HCAL Exam 1
What is the most accurate conclusion by the nurse about a patient's immune system when assessing
well-healing wounds that were contaminated during a car crash? - Answer-Innate immunity is being
effective.
Which patient finding should the nurse report to the provider? - Answer-Monocytes 5.1 × 109/L
Match the type of immunity with the source from which it is obtained. - Answer-Natural active-Disease
Artificial active-Immunization
Natural passive-Breast milk
Artificial passive-Serum injection
The nurse will anticipate administering a prescribed antibiotic to a patient with which infection? -
Answer-Staphylococcus aureus
Which actions will the nurse avoid to prevent indirect transmission of pathogens when caring for a
patient with an infection? - Answer-Handling medical equipment
Changing patient linens
Removing food trays
Disposing of tissues
,Which statement by the patient on droplet precautions indicates understanding of how to prevent the
spread of infection? - Answer-I'll cover my mouth whenever coughing or sneezing
Which clinical manifestations of sepsis differentiate it from a systemic infection? - Answer-Oliguria
Hypotension
Confusion
Hypothermia
Low platelets
Which patient assessment indicates the patient has a chronic infection? - Answer-Persistent fatigue
Match the situation with its definition. - Answer-Isolation-Separates those with disease from those
without disease
Quarantine-Restricts movement of those exposed to an infectious agent
Protective isolation-Prevents exposure of person with compromised immunity from others
Which action by the nurse contributed to a patient developing a health care-associated infection (HAI)? -
Answer-Use of alcohol-based hand cleaner prior to inserting an indwelling urinary catheter
Which action will the nurse take when caring for a patient with drug-resistant Clostridium difficile (C-
Diff) to prevent spreading the infection to other patients? - Answer-Teach the patient to wash hands
after toileting.
The nurse will take which action when caring for the patient admitted with influenza? - Answer-Place in
a single room on droplet precautions
, Which action will the nurse take when implementing standard precautions? - Answer-Donning gloves
prior to administering a patient intramuscular injection
Which collaborative intervention does the nurse determine to implement for the patient with an
infection, pain, and fever? - Answer-Acetaminophen
Which intervention does the nurse determine addresses the collaborative goal of "eradication of the
pathogenic agent"? - Answer-Oseltamivir prescribed for influenza
Which action does the nurse determine to take based on findings of a localized, purulent, infected leg
lesion? - Answer-Prepare the patient for incision and drainage.
When assessing a patient with a respiratory infection, the nurse will anticipate which abnormal findings?
- Answer-Lung crackles
Wheezes
Greenish sputum
Heart rate 102 bpm
Oral temperature 101°F
What conclusion can be drawn by the nurse when a patient shows no improvement in assessment
baseline after two weeks of treatment for an infection? - Answer-Collaborative interventions were
ineffective.
Which statement by a patient can the nurse determine indicates the need for further teaching about a
prescribed anti-infective medication? - Answer-"I can miss a dose as long as I take it the next time the
dose is due."
What is the most accurate conclusion by the nurse about a patient's immune system when assessing
well-healing wounds that were contaminated during a car crash? - Answer-Innate immunity is being
effective.
Which patient finding should the nurse report to the provider? - Answer-Monocytes 5.1 × 109/L
Match the type of immunity with the source from which it is obtained. - Answer-Natural active-Disease
Artificial active-Immunization
Natural passive-Breast milk
Artificial passive-Serum injection
The nurse will anticipate administering a prescribed antibiotic to a patient with which infection? -
Answer-Staphylococcus aureus
Which actions will the nurse avoid to prevent indirect transmission of pathogens when caring for a
patient with an infection? - Answer-Handling medical equipment
Changing patient linens
Removing food trays
Disposing of tissues
,Which statement by the patient on droplet precautions indicates understanding of how to prevent the
spread of infection? - Answer-I'll cover my mouth whenever coughing or sneezing
Which clinical manifestations of sepsis differentiate it from a systemic infection? - Answer-Oliguria
Hypotension
Confusion
Hypothermia
Low platelets
Which patient assessment indicates the patient has a chronic infection? - Answer-Persistent fatigue
Match the situation with its definition. - Answer-Isolation-Separates those with disease from those
without disease
Quarantine-Restricts movement of those exposed to an infectious agent
Protective isolation-Prevents exposure of person with compromised immunity from others
Which action by the nurse contributed to a patient developing a health care-associated infection (HAI)? -
Answer-Use of alcohol-based hand cleaner prior to inserting an indwelling urinary catheter
Which action will the nurse take when caring for a patient with drug-resistant Clostridium difficile (C-
Diff) to prevent spreading the infection to other patients? - Answer-Teach the patient to wash hands
after toileting.
The nurse will take which action when caring for the patient admitted with influenza? - Answer-Place in
a single room on droplet precautions
, Which action will the nurse take when implementing standard precautions? - Answer-Donning gloves
prior to administering a patient intramuscular injection
Which collaborative intervention does the nurse determine to implement for the patient with an
infection, pain, and fever? - Answer-Acetaminophen
Which intervention does the nurse determine addresses the collaborative goal of "eradication of the
pathogenic agent"? - Answer-Oseltamivir prescribed for influenza
Which action does the nurse determine to take based on findings of a localized, purulent, infected leg
lesion? - Answer-Prepare the patient for incision and drainage.
When assessing a patient with a respiratory infection, the nurse will anticipate which abnormal findings?
- Answer-Lung crackles
Wheezes
Greenish sputum
Heart rate 102 bpm
Oral temperature 101°F
What conclusion can be drawn by the nurse when a patient shows no improvement in assessment
baseline after two weeks of treatment for an infection? - Answer-Collaborative interventions were
ineffective.
Which statement by a patient can the nurse determine indicates the need for further teaching about a
prescribed anti-infective medication? - Answer-"I can miss a dose as long as I take it the next time the
dose is due."
