PN 2006 Final Exam 2025 Graded A+

The nurse works in a small rural hospital with a wide variety of clients. Of the clients admitted this afternoon, the nurse recognizes that the individual with which of the following conditions is most susceptible to infection? a. Burns b. Diabetes c. Pulmonary emphysema d. Peripheral vascular disease - ANSWER-a. Burns The nursing assistant is learning how to use protective equipment when caring for a client in isolation. The nursing assistant is instructed in the correct sequence for putting on the protective equipment. Which of the following describes the correct sequence? a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves. b. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves. c. Wash her hands, put on the gown, apply gloves, and then put on mask and eyewear. d. Put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves. - ANSWER-a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves. The client has a large, deep abdominal incision that requires a dressing. The incision is packed with sterile 1.75-cm packing and covered with a dry, 10 × 10-cm gauze. When changing the dressing, the nurse accidentally drops the packing onto the client's abdomen. Which of the following actions should the nurse take? a. Add alcohol to the packing and insert it into the incision. b. Throw the packing away, and prepare a new one. c. Pick up the packing with sterile forceps, and gently place it into the incision. d. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves. - ANSWER-b. Throw the packing away, and prepare a new one. The client requires a sterile dressing change. Which of the following is an appropriate intervention for the nurse to implement in maintaining sterile asepsis? a. Put sterile gloves on before opening sterile packages. b. Check integrity of sterile packages prior to use. c. Place the cap of the sterile solution well within the sterile field. d. Place sterile items on the very edge of the sterile drape. - ANSWER-b. Check integrity of sterile packages prior to use. PN 2006 PN 2006 Which one of the following indicates that the nurse is using surgical aseptic technique? a. Inserting an intravenous catheter b. Placing soiled linen in moisture-resistant bags c. Disposing of syringes in puncture-proof containers d. Washing hands before changing a dressing - ANSWER-a. Inserting an intravenous catheter The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? a. Clean forceps may be used to move items on the sterile field. b. Sterile fields may be prepared well in advance of the procedures. c. The first small amount of sterile solution should be poured and discarded. d. Wrapped sterile packages should be opened starting with the flap closest to the nurse. - ANSWER-c. The first small amount of sterile solution should be poured and discarded. The nurse suspects that an older adult client may have pneumonia. Older adult clients may react differently to infectious processes, so the nurse is alert to atypical signs and symptoms, such as which one of the following? a. Hypotension b. Confusion c. Erythema d. Chills - ANSWER-b. Confusion The nurse is preparing to assist with a sterile procedure in the surgical suite. Which of the following is an appropriate technique that the nurse includes in the surgical scrub? a. Keeping the hands below the elbows throughout the scrub b. Using a brush on the palms and dorsal surface of the hands c. Maintaining a scrub for two to six minutes d. Washing well around all artificial nails - ANSWER-c. Maintaining a scrub for two to six minutes The patient is in isolation in a negative-pressure room for active tuberculosis. He coughs and spews large amounts of blood-tinged sputum but is too weak to cover his mouth and nose with a tissue. Which is the most important intervention for the nurse to implement for self-protection while providing nursing care? a. Cover the patient's mouth and nose snugly with a surgical mask. b. Wear an N-95 mask, gloves, face shield, and isolation gown. c. Place tissues and a contaminated waste container within reach. d. Use a properly fitted surgical mask and gloves to help with tissues. - ANSWER-b. Wear an N-95 mask, gloves, face shield, and isolation gown. PN 2006 PN 2006 The nurse completes preparation of the sterile field to change a patient's dressing when the patient's dinner tray arrives. Which action should the nurse take? a. Use the sterile field on another patient in another room. b. Change the dressing using clean technique to save time. c. Set the tray aside and proceed with the dressing change. d. Cover the setup with a sterile drape and let the patient eat. - ANSWER-c. Set the tray aside and proceed with the dressing change. The nurse is preparing a sterile field with several items on it. Which action should the nurse implement to maintain a sterile field? a. Flip sterile objects onto the sterile field. b. Put fluid holders near the edge of the field. c. Wear sterile gloves to open sterile packs. d. Open the inner flaps of the sterile packages first. - ANSWER-b. Put fluid holders near the edge of the field. The nurse is getting ready to provide a sterile dressing change. Which nursing action is consistent with principles used to prepare a sterile field? a. Identify that items below waist height are contaminated. b. Use opened packages of dressing supplies within the same shift. c. Identify that sterile drapes have a 5.08 cm 2-inch contaminated border. d. Replace bottle caps if the inside of the cap is not touched. - ANSWER-a. Identify that items below waist height are contaminated. The nurse assists the health care provider during the insertion of a central venous catheter. Which is the most effective intervention for the nurse to implement to prevent patient infection? a. Adhere to the principles of surgical asepsis. b. Close the door of the sterile procedure room. c. Sterilize working surfaces for the procedure. d. Restrict foot traffic into sterile procedure room. - ANSWER-a. Adhere to the principles of surgical asepsis. The nurse evaluates the handwashing technique of nursing assistive personnel (NAP). Which behavior by NAP requires additional training by the nurse? a. Rubs sudsy hands for 5 to 10 seconds b. Uses warm running water and soap c. Dries the hands from the fingers to the wrists d. Keeps the hands and forearms below the elbows - ANSWER-a. Rubs sudsy hands for 5 to 10 seconds PN 2006 PN 2006 While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile package to the floor. Which reaction allows the nurse to maintain safe practice? a. Inspect the package for tears. b. Brush away the visible debris. c. Record the procedure as clean. d. Replace the sterile package. - ANSWER-d. Replace the sterile package. The nurse is caring for a patient who is 4 years old and in isolation. Which approach should the nurse implement to reduce the patient's anxiety? a. Put the child in a room with a locked door. b. Ask the parents to keep the child in the room. c. Explain isolation to the child by using a cartoon. d. Put the mask, gown, and gloves on in view of the child. - ANSWER-d. Put the mask, gown, and gloves on in view of the child. The nurse sets up a sterile field and notes several tiny holes in the sterile drape of the table that served as the wrap for the pack. What does the nurse do to facilitate completion of the procedure? a. Uses a sterile towel to cover the existing holes b. Replaces the entire sterile field and the supplies c. Moves the sterile supplies to a replacement drape d. Avoids using any of the sterile items near the holes - ANSWER-b. Replaces the entire sterile field and the supplies The nurse helps the health care provider get supplies and monitor the patient during an emergency insertion of a femoral line at the patient's bedside. Which nursing behavior helps to maintain the sterile environment? a. Avoid reaching over the field. b. Wear a sterile cap and booties. c. Use sterile examination gloves. d. Place a face mask on the patient. - ANSWER-a. Avoid reaching over the field. The nurse is preparing to put on sterile gloves. What should the nurse do to begin this procedure? a. Pull the first glove up and over the nondominant hand. b. Place the fingers of the dominant hand under the cuff of the first glove. c. Let the cuff of the glove roll up over the hand for more coverage. d. Hold the inside surface of th