NUR 230 FINAL EXAM QUESTIONS
AND ANSWERS
When performing hand hygiene using an antiseptic hand rub, the nurse would continue
to rub for how long?
Until the antiseptic has evaporated from the skin
For several minutes to allow the antiseptic to work
For about five seconds after applying the antiseptic
Until the hands are completely covered with the antiseptic - ANSWER-Until the
antiseptic has evaporated from the skin
The nurse is required to wear a gown, gloves, goggles, and mask as personal protective
equipment (PPE) when caring for an assigned patient. Which of the following would the
nurse put on first?
Gown
Gloves
Mask
Goggles - ANSWER-Gown
There is some question about the use of appropriate transmission-based precautions
when caring for a patient. Some of the nurses are wearing PPEs and others are not.
Which of the following would be most appropriate?
Consulting the agency's infection control manual
Asking the physician about the patient's condition.
Checking the medication record for use of antibiotics
Checking with the other staff nurses on the unit. - ANSWER-Consulting the agency's
infection control manual
The nurse is removing a gown after providing care to a patient. Which of the following
would the nurse do first?
Unfasten the ties at the neck and back
Pull the gown away from the body
Allow the gown to fall away from the shoulders
Turn the gown inside out - ANSWER-Unfasten the ties at the neck and back
The nurse would appropriately choose an antiseptic hand rub to perform hand hygiene
for which situation?
When hands are not visibly soiled
When body fluids are on the hands
Before eating
After using the restroom - ANSWER-When hands are not visibly soiled
A nursing instructor is preparing to teach a class on asepsis and hand hygiene. Which
of the following would the instructor include?
,The sink is considered a contaminated surface.
Antiseptic hand rubs are less effective than soap and water
Bar soap is preferred over liquid soap for hand washing
A forceful stream of water helps remove microorganisms from the hand - ANSWER-The
sink is considered a contaminated surface.
A nurse is providing nail care to clients admitted to a health care facility. The nurse
should know that which clients are most susceptible to nail problems?
Patients with diabetes
Patients with fever
Patients with diarrhea
Patients with sinusitis - ANSWER-Patients with diabetes
The nurse is caring for a client who has an infection spread by respiratory droplets and
is under droplet precautions. The client asks, "Can my spouse visit me?" Which
response is correct?
"Yes, as long as your spouse wears a mask and stays at least 3 feet away from you."
"No, the chance of spreading your infection to the community is too great."
"Yes, but only if your spouse stays outside of the room and speaks to you from the
doorway."
"No, the supplies used for this type of infection are too expensive to provide to family
members." - ANSWER-"Yes, as long as your spouse wears a mask and stays at least 3
feet away from you."
When accessing a client's central line, a drop of the client's blood falls on the nurse's
gloved hand. What is the appropriate action by the nurse?
Perform hand hygiene after removing the gloves
Report the incident to the supervisor immediately
Have the patient tested for HIV and hepatitis C.
Follow agency policy of exposure to communicable infections - ANSWER-Perform hand
hygiene after removing the gloves
A nurse is caring for a female client with diarrhea. What instruction should the nurse
give the client with regard to perineal hygiene?
Clean the perineal area from the front to the back
Bathe with a mild soap and water
Wash the perineal area with cold water
Wash hands with cold water after visiting the toilet - ANSWER-Clean the perineal area
from the front to the back
The nurse is reviewing discharge instructions for a client who was prescribed an
antibiotic. Which statement by the client would require further teaching?
"Once I start feeling better, I should stop taking the antibiotic."
"If I develop a rash, I will contact my healthcare provider."
"I have a bacterial infection that requires an antibiotic."
I should avoid sharing my antibiotic with my spouse." - ANSWER-"Once I start feeling
,better, I should stop taking the antibiotic."
The nurse is assisting a patient with daily hygiene practices. What is the most important
benefit of this interaction as it related to nursing care?
The nurse has the opportunity to observe the patient.
The patient is well groomed.
The nurse has an opportunity to influence the patient's hygiene practices.
The patient is ready to receive visitors. - ANSWER-The nurse has the opportunity to
observe the patient.
The patient is well groomed.
Prior to giving a patient a bed bath, why would the nurse review the patient's chart?
To check for physical limitations
To check for medications
To check for skin alterations
To check for hygiene preferences - ANSWER-To check for physical limitations
When giving a bed bath, to what area of the body would the nurse pay special attention
to observe for redness or skin breakdown?
The sacral area
The head
The lower legs
The chest - ANSWER-The sacral area
The nurse is performing perineal care for a male patient. What part of the perineum
would the nurse clean first?
The tip of the penis
The base of the penis
The anal area
The scrotum - ANSWER-The tip of the penis
The nurse is providing perineal care for an uncircumcised male patient. Which of the
following is a recommended guideline for this action?
Retract the foreskin when washing the prepuce of adolescents and older.
Retract the foreskin, wash the area, and allow the foreskin to dry five minutes before
pulling it back.
Retract the foreskin when washing the prepuce.
Do not retract the foreskin as this may cause edema and tissue injury. - ANSWER-
Retract the foreskin when washing the prepuce of adolescents and older.
The nurse is performing perineal care for an unconscious female patient. Which of the
following is a recommended guideline for this procedure?
Spread the labia and move the washcloth from the pubic area to the anal area.
Always proceed from the most contaminated area to the least contaminated area
Use a clean washcloth for each stroke
Spread the labia and move the washcloth from the anal area to the pubic area. -
, ANSWER-Spread the labia and move the washcloth from the pubic area to the anal
area.
The nurse is providing oral care for a patient who is unconscious following a moving
vehicle accident. Which of the following is a recommended guideline in this procedure?
Put a towel across the chest and an emesis basin underneath the chin.
Insert a folded gauze pad between the patient's molars to keep the mouth open.
Explain the procedure to the patient in a loud voice to stimulate the senses
Position the patient on the side with the head of the bed as high as tolerated -
ANSWER-Put a towel across the chest and an emesis basin underneath the chin.
How would the nurse remove the top linens when making an occupied bed?
Have the patient hold onto the bath blanket and reach under it to remove the linens
Fan-fold the linens at the bottom of the bed and remove them to the chair
Arrange the patient's gown for privacy, and roll the linens to the bottom of the bed.
Have the patient hold onto the bath blanket and reach under it to remove all linens
except the top sheet. - ANSWER-Have the patient hold onto the bath blanket and reach
under it to remove the linens
A group of nursing students are reviewing information about asepsis in preparation for a
test. The students demonstrate understanding of the topic when they identify which of
the following as the primary rationale for asepsis?
Break the chain of infection
Maintain skin integrity
Enhance wound healing
Control the amount of body fluids - ANSWER-Break the chain of infection
The nurse is monitoring a patient following oral surgery and prepares to deliver nutrition
ordered by the primary health care provider. Which of the following is the best method
of delivering nutrition on a short term basis when oral feedings are not appropriate?
Nasogastric tube feeding
Gastrostomy tube feeding
Total parenteral nutrition (TPN)
Peripheral parenteral nutrition (PPN) - ANSWER-Nasogastric tube feeding
The nurse is caring for a patient with a feeding tube and is carefully monitoring the
patient for potential complications. What is the most serious complication of tube
feedings?
Aspirated stomach content
Fluid imbalance
Tube displacement
Dehydration - ANSWER-Aspirated stomach content
A nurse aspirates fluid through a gastrostomy tube and checks the fluid for color and
consistency. Which of the following would the nurse identify as a normal finding
suggesting gastric placement of the tube?
AND ANSWERS
When performing hand hygiene using an antiseptic hand rub, the nurse would continue
to rub for how long?
Until the antiseptic has evaporated from the skin
For several minutes to allow the antiseptic to work
For about five seconds after applying the antiseptic
Until the hands are completely covered with the antiseptic - ANSWER-Until the
antiseptic has evaporated from the skin
The nurse is required to wear a gown, gloves, goggles, and mask as personal protective
equipment (PPE) when caring for an assigned patient. Which of the following would the
nurse put on first?
Gown
Gloves
Mask
Goggles - ANSWER-Gown
There is some question about the use of appropriate transmission-based precautions
when caring for a patient. Some of the nurses are wearing PPEs and others are not.
Which of the following would be most appropriate?
Consulting the agency's infection control manual
Asking the physician about the patient's condition.
Checking the medication record for use of antibiotics
Checking with the other staff nurses on the unit. - ANSWER-Consulting the agency's
infection control manual
The nurse is removing a gown after providing care to a patient. Which of the following
would the nurse do first?
Unfasten the ties at the neck and back
Pull the gown away from the body
Allow the gown to fall away from the shoulders
Turn the gown inside out - ANSWER-Unfasten the ties at the neck and back
The nurse would appropriately choose an antiseptic hand rub to perform hand hygiene
for which situation?
When hands are not visibly soiled
When body fluids are on the hands
Before eating
After using the restroom - ANSWER-When hands are not visibly soiled
A nursing instructor is preparing to teach a class on asepsis and hand hygiene. Which
of the following would the instructor include?
,The sink is considered a contaminated surface.
Antiseptic hand rubs are less effective than soap and water
Bar soap is preferred over liquid soap for hand washing
A forceful stream of water helps remove microorganisms from the hand - ANSWER-The
sink is considered a contaminated surface.
A nurse is providing nail care to clients admitted to a health care facility. The nurse
should know that which clients are most susceptible to nail problems?
Patients with diabetes
Patients with fever
Patients with diarrhea
Patients with sinusitis - ANSWER-Patients with diabetes
The nurse is caring for a client who has an infection spread by respiratory droplets and
is under droplet precautions. The client asks, "Can my spouse visit me?" Which
response is correct?
"Yes, as long as your spouse wears a mask and stays at least 3 feet away from you."
"No, the chance of spreading your infection to the community is too great."
"Yes, but only if your spouse stays outside of the room and speaks to you from the
doorway."
"No, the supplies used for this type of infection are too expensive to provide to family
members." - ANSWER-"Yes, as long as your spouse wears a mask and stays at least 3
feet away from you."
When accessing a client's central line, a drop of the client's blood falls on the nurse's
gloved hand. What is the appropriate action by the nurse?
Perform hand hygiene after removing the gloves
Report the incident to the supervisor immediately
Have the patient tested for HIV and hepatitis C.
Follow agency policy of exposure to communicable infections - ANSWER-Perform hand
hygiene after removing the gloves
A nurse is caring for a female client with diarrhea. What instruction should the nurse
give the client with regard to perineal hygiene?
Clean the perineal area from the front to the back
Bathe with a mild soap and water
Wash the perineal area with cold water
Wash hands with cold water after visiting the toilet - ANSWER-Clean the perineal area
from the front to the back
The nurse is reviewing discharge instructions for a client who was prescribed an
antibiotic. Which statement by the client would require further teaching?
"Once I start feeling better, I should stop taking the antibiotic."
"If I develop a rash, I will contact my healthcare provider."
"I have a bacterial infection that requires an antibiotic."
I should avoid sharing my antibiotic with my spouse." - ANSWER-"Once I start feeling
,better, I should stop taking the antibiotic."
The nurse is assisting a patient with daily hygiene practices. What is the most important
benefit of this interaction as it related to nursing care?
The nurse has the opportunity to observe the patient.
The patient is well groomed.
The nurse has an opportunity to influence the patient's hygiene practices.
The patient is ready to receive visitors. - ANSWER-The nurse has the opportunity to
observe the patient.
The patient is well groomed.
Prior to giving a patient a bed bath, why would the nurse review the patient's chart?
To check for physical limitations
To check for medications
To check for skin alterations
To check for hygiene preferences - ANSWER-To check for physical limitations
When giving a bed bath, to what area of the body would the nurse pay special attention
to observe for redness or skin breakdown?
The sacral area
The head
The lower legs
The chest - ANSWER-The sacral area
The nurse is performing perineal care for a male patient. What part of the perineum
would the nurse clean first?
The tip of the penis
The base of the penis
The anal area
The scrotum - ANSWER-The tip of the penis
The nurse is providing perineal care for an uncircumcised male patient. Which of the
following is a recommended guideline for this action?
Retract the foreskin when washing the prepuce of adolescents and older.
Retract the foreskin, wash the area, and allow the foreskin to dry five minutes before
pulling it back.
Retract the foreskin when washing the prepuce.
Do not retract the foreskin as this may cause edema and tissue injury. - ANSWER-
Retract the foreskin when washing the prepuce of adolescents and older.
The nurse is performing perineal care for an unconscious female patient. Which of the
following is a recommended guideline for this procedure?
Spread the labia and move the washcloth from the pubic area to the anal area.
Always proceed from the most contaminated area to the least contaminated area
Use a clean washcloth for each stroke
Spread the labia and move the washcloth from the anal area to the pubic area. -
, ANSWER-Spread the labia and move the washcloth from the pubic area to the anal
area.
The nurse is providing oral care for a patient who is unconscious following a moving
vehicle accident. Which of the following is a recommended guideline in this procedure?
Put a towel across the chest and an emesis basin underneath the chin.
Insert a folded gauze pad between the patient's molars to keep the mouth open.
Explain the procedure to the patient in a loud voice to stimulate the senses
Position the patient on the side with the head of the bed as high as tolerated -
ANSWER-Put a towel across the chest and an emesis basin underneath the chin.
How would the nurse remove the top linens when making an occupied bed?
Have the patient hold onto the bath blanket and reach under it to remove the linens
Fan-fold the linens at the bottom of the bed and remove them to the chair
Arrange the patient's gown for privacy, and roll the linens to the bottom of the bed.
Have the patient hold onto the bath blanket and reach under it to remove all linens
except the top sheet. - ANSWER-Have the patient hold onto the bath blanket and reach
under it to remove the linens
A group of nursing students are reviewing information about asepsis in preparation for a
test. The students demonstrate understanding of the topic when they identify which of
the following as the primary rationale for asepsis?
Break the chain of infection
Maintain skin integrity
Enhance wound healing
Control the amount of body fluids - ANSWER-Break the chain of infection
The nurse is monitoring a patient following oral surgery and prepares to deliver nutrition
ordered by the primary health care provider. Which of the following is the best method
of delivering nutrition on a short term basis when oral feedings are not appropriate?
Nasogastric tube feeding
Gastrostomy tube feeding
Total parenteral nutrition (TPN)
Peripheral parenteral nutrition (PPN) - ANSWER-Nasogastric tube feeding
The nurse is caring for a patient with a feeding tube and is carefully monitoring the
patient for potential complications. What is the most serious complication of tube
feedings?
Aspirated stomach content
Fluid imbalance
Tube displacement
Dehydration - ANSWER-Aspirated stomach content
A nurse aspirates fluid through a gastrostomy tube and checks the fluid for color and
consistency. Which of the following would the nurse identify as a normal finding
suggesting gastric placement of the tube?
