NUR 105 Midterm Exam 2025

1. To assess the apical pulse, the nurse should place the stethoscope at which location on the left side of the client's chest? - Correct Ans-a. Between the 5th and 6th ribs An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? - Correct Ans-Health care-associated infection The nurse prepared the sterile tray for in dwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next? - Correct Ans-Change into a new pair of gloves Which includes practices used to render and keep objects and areas free from microorganisms? - Correct Ans-Surgical asepsis Which are basic principles of surgical asepsis? - Correct Ans-consider the outer inch edge of a sterile field to be contaminated never turn the back on a sterile field only a sterile object can touch another sterile object The nurse determines that the sterile field has been contaminated when which action occurs? - Correct Ans-the nurse turns his or her back to the field The nurse prepared for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take? - Correct Ans-Take a few steps around the table to pick up the additional supplies A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review? - Correct Ans-"Any items coming into contact with a sterile field must be sterile" The nurse performs hand hygiene using an alcohol-based hand rub after exiting a clients room. The nurse does not touch another surface or client until what has occurred? - Correct Ans-The antiseptic has evaporated from the skin A nurse is preparing to perform hand hygiene using an alcohol-based hand rub. Place the following steps in the correct order - Correct Ans-1 remove jewelry 2 check the product later for the correct amount to use 3 apply the product 4 rub hands together, covering all surfaces of the hands and fingers 5 ensure that the hands are dry NUR 105 NUR 105 A nurse is preparing to perform hand hygiene using an alcohol-based hand rub. When applying the product, the nurse would place the product at which location? - Correct Ans-in the palm of one hand A nurse demonstrated the correct use of hand hygiene using an alcohol-based hand rub for which situation? - Correct Ans-before entering a clients room after removing gloves after applying a clean, dry dressing The nurse is preparing to perform hand-washing. Place the following steps in the correct order - Correct Ans-a. turn on the faucet and adjust the force and temperature of the water b. wet the hands and wrists c. apply soap d. wash the palms and backs of the hands for at least 20 seconds e. pat the hands dry with a paper towel f. turn the faucet off with a paper towel When washing the hands with soap and water what is an appropriate action for the nurse to perform? - Correct Ans-keep the hands below the elbow The nurse uses soap and water for hand hygiene. Which action demonstrates proper hand-washing? - Correct Ans-using a rubbing, circular motion The nurse is performing hand washing using soap and water after providing client care. The nurse has performed hand hygiene using soap and water. What action would the nurse take next? - Correct Ans-Dry the hands with a paper towel A group of students are demonstrating the skill for hand washing. What would indicate a need for additional teaching? - Correct Ans-The students wash their hands for 15 seconds prior to drying them The nurse is required to wear a gown, gloves, goggles, and mask as PPE when caring for an assigned client. What should the nurse put on first? - Correct Ans-Gown The charge nurse observes a new nurse not wearing PPE entering a client's room. The client is on a transmission-based precautions. What is the charge nurse's best response? - Correct Ans-Reinforce teaching that transmission-based precautions must be observed The nurse is removing a gown after providing care to a client. Which action would the nurse take first? - Correct Ans-Unfasten the ties at the neck and back NUR 105 NUR 105 The charge nurse notices that when caring for a client, some nurses are wearing PPE and other nurses are not. Which action would be most appropriate for the nurse to take? - Correct Ans-consult the agency's infection control manual Place in the correct order the steps for removing a gown - Correct Ans-a. unfasten the ties b. touching only the inside of the gown, pull away from the torso c. keeping the hands on the inner surface of the gown, pull gown from arms d. turn gown inside out e. fold or roll the gown into a bundle f. discard the gown 1. What is the best source for the nurse to determine the type of transmission precautions a client needs? - Correct Ans-a. Client's medical record 1. The client asks the nurse why the nurse wears a disposable gown every time she enters the client's room. What is the nurse's best response? - Correct Ans-a. "I am required to wear a gown for certain infections that are easily passed to others" 1. The nurse removes PPE after caring for a client on transmission-based precautions. Which action by the nurse is correct? - Correct Ans-a. Touch the inside of the gown and pull it away from the torso 1. The nurse prepares to wear PPE when entering a client's room. What action does the nurse take first? - Correct Ans-a. Perform hand hygiene 1. The charge nurse confronts a new nurse about not wearing gloves into a client's room. The client is not on transmission-based precautions. How does the new nurse best respond? - Correct Ans-a. "Can you show me the hospital policy for when to wear gloves?" 1. PPE is used in health care facilities for primarily which reason? - Correct Ans-a. To protect both the staff and clients from becoming infected by one another 1. Which item would the nurse remove first when removing PPE? - Correct Ans-a. Gloves 1. The new nurse notes a health care provider enter a client's room without the correct PPE. What does the nurse say to the health care provider? - Correct Ans-a. "I notice you did not wear the required PPE" 1. The nurse is wearing a gown and gloves as part of using PPE. The gown is tied in the front at the waist and at the neck. Which action would the nurse take first? - Correct Ans-a. Unfasten the gown at the waist NUR 105 NUR 105 1. The nurse is wearing a gown as part of using PPE and is preparing to put on clean disposable gloves. Which placement indicates that the nurse has put on the gloves properly? - Correct Ans-a. The glove ends extend to cover the gown's cuffs 1. The nurse wears PPE when entering the client's room. What is the nurse's goal in wearing PPE? - Correct Ans-a. To prevent infection transmission 1. The nurse prepares to enter a client's room where goggles are required but are not available. Which action by the nurse is best? - Correct Ans-a. Wear a face shield as part of the protective equipment 1. The nurse notes that a health care provider failed to observe transmission precautions in a client's room and is entering another client's room. What is the nurse's next action? - Correct Ans-a. Remind the health care provider about the transmission precautions 1. The nurse has just measured an adult client's oral temperature and obtained a result of 102.4 F (39.1 C). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate? - Correct Ans-a. "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return" 1. The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? - Correct Ans-a. An electronic thermometer with rectal probe b. Disposable probe cover a. Water-soluble lubricating gel 1. The nurse is teaching the unlicensed assistive personnel (UAP) the proper technique to take an axillary temperature. Where would the nurse teach the UAP to place the probe? - Correct Ans-a. The deepest area of the axilla 1. The nurse is providing care for a 3-year-old toddler and needs to take the child's temperature rectally. How far should the nurse insert the probe into the rectum? - Correct Ans-a. 1 in (2.5 cm) 1. The nurse is taking a rectal temperature on a client. The client reports dizziness and then faints. What actions should the nurse take? - Correct Ans-a. Assess the heart rate b. Remove the thermometer probe c. Notify the health care provider d. Assess the blood pressure 1. The nurse has taken a client's temperature using a tympanic thermometer. What should the nurse do next? - Correct Ans-a. Discard the probe cover