NURA 303 Exam 2
QUESTIONS ANIONSD CORRECT ANSWERS | ALREADY GRADED A+ WITH
COMPLETE SOLUTION
In addition to standard precautions, the nurse would initiate droplet precautions for which
patients? Select all that apply.
A. A patient diagnosed with rubella
B. A patient diagnosed with diphtheria
C. A patient diagnosed with varicella
D. A patient diagnosed with tuberculosis
E. A patient diagnosed with MRSA
F. An infant diagnosed with adenovirus infection - a, b, f. Rubella, diphtheria, and adenovirus
infection are illnesses transmitted by large-particle droplets and require droplet precautions in
addition to standard precautions. Airborne precautions are used for patients who have infections
spread through the air with small particles; for example, tuberculosis, varicella, and rubeola.
Contact precautions are used for patients who are infected or colonized by a multidrug-resistant
organism (MDRO), such as MRSA.
A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is
scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an
instrument in the sterile field. What is the appropriate nursing action in this situation?
A. Ask another nurse to hold the hand of the patient and continue setting up the field
B. Remove the instrument that was touched by the patient and continue setting up the sterile field
C. Discard the supplies and prepare a new sterile field with another person holding the patient's
hand
D. No action is necessary since the patient has touched his or her own sterile field - c. If the
patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile
field. If the patient is confused, the nurse should have someone assist by holding the patient's
hand and reinforcing what is happening.
,A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an
appropriate action when performing this task?
A. Place the bottle cap on the table with the edges down
B. Hold the bottle inside the edge of the sterile field
C. Hold the bottle with the label side opposite the palm of the hand
D. Pour the solution from a height of 4 to 6 in (10 to 15 cm) - d. To add a sterile solution to a
sterile field, the nurse would open the solution container according to directions and place the
cap on the table away from the field with the edges up. The nurse would then hold the bottle
outside the edge of the sterile field with the label side facing the palm of the hand and prepare to
pour from a height of 4 to 6 in (10 to 15 cm).
A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?
A. Remove gown, goggles, mask, gloves, and exit the room
B. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles
C. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene
D. Remove goggles, mask, gloves, and gown, and perform hand hygiene - c. If an
impervious gown has been tied in front of the body at the waist, the nurse should untie the waist
strings before removing gloves. Gloves are always removed first because they are most likely to
be contaminated, followed by the goggles, gown, and mask, and hands should be washed
thoroughly after the equipment has been removed and before leaving the room.
A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when
administering the patient's medications. What would be the first action of the nurse following the
exposure?
A. Report the incident to the appropriate person and file an incident report
B. Wash the exposed area with warm water and soap
C. Consent to PEP at appropriate time
D. Set up counseling sessions regarding safe practice to protect self - b. When a needlestick
injury occurs, the nurse should wash the exposed area immediately with warm water and soap,
report the incident to the appropriate person and complete an incident injury report, consent to
and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe
practice to protect self and others.
,The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would
the nurse consider most at risk for developing this type of infection?
A. A 60-year-old patient who smokes two packs of cigarettes daily
B. A 40-year-old patient who has a white blood cell count of 6,000/mm3
C. A 65-year-old patient who has an indwelling urinary catheter in place
D. A 60-year-old patient who is a vegetarian and slightly underweight - c. Indwelling urinary
catheters have been implicated in most HAIs. Cigarette smoking, a normal white blood cell
count, and a vegetarian diet have not been implicated as risk factors for HAIs.
A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open
reddened area over his sacrum. What risk factor would be a priority concern for the nurse when
caring for this patient?
A. Imbalanced nutrition
B. Impaired physical mobility
C. Chronic pain
D. Infection - d. The priority risk factor in this situation is the possibility of an infection
developing in the open skin area. The other risk factors may be potential problems for this patient
and may also require nursing interventions after the first diagnosis is addressed.
A nurse teaches a patient at home to use clean technique when changing a wound dressing. What
would be a consideration when preparing this teaching plan?
A. It is the personal preference of the nurse whether or not to use clean technique
B. The use of clean technique is safe for the home setting
C. Surgical asepsis is the only safe method to use in a home setting
D. It is grossly negligent to recommend clean technique for changing a wound dressing - b.
In the home setting, where the patient's environment is more controlled, medical asepsis is
usually recommended, with the exception of self-injection. This is the appropriate procedure for
the home and is not a personal preference or a negligent action
, A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C.
difficile infection. Which nursing action related to this activity promotes safe, effective patient
care?
A. The nurse puts on PPE after entering the patient room
B. The nurse works from "clean" areas to "dirty" areas during bath
C. The nurse personalizes the care by substituting glasses for goggles
D. The nurse removes PPE after the bath to talk with the patient in the room - b. When using
PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE before entering the
patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or
anteroom just before exiting.
A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when
planning a patient's personal hygiene?
A. When the patient had his or her most recent bath
B. The patient's usual hygiene practices and preferences
C. Where the bathing fits in the nurse's schedule
D. The time that is convenient for the patient care assistant - b. Bathing practices and
cleansing habits and rituals vary widely. The patient's preferences should always be taken into
consideration, unless there is a clear threat to health. The patient and nurse should work together
to come to a mutually agreeable time and method to accomplish the patient's personal hygiene.
The availability of staff to assist may be important, but the patient's preferences are a higher
priority.
A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an
essential part of nursing care. What are some of the benefits of providing this care? Select all that
apply.
A. It promotes the patient's sense of well-being.
B. It prevents deterioration of the oral cavity.
C. It contributes to decreased incidence of aspiration pneumonia.
D. It eliminates the need for flossing.
E. It decreases oropharyngeal secretions.
QUESTIONS ANIONSD CORRECT ANSWERS | ALREADY GRADED A+ WITH
COMPLETE SOLUTION
In addition to standard precautions, the nurse would initiate droplet precautions for which
patients? Select all that apply.
A. A patient diagnosed with rubella
B. A patient diagnosed with diphtheria
C. A patient diagnosed with varicella
D. A patient diagnosed with tuberculosis
E. A patient diagnosed with MRSA
F. An infant diagnosed with adenovirus infection - a, b, f. Rubella, diphtheria, and adenovirus
infection are illnesses transmitted by large-particle droplets and require droplet precautions in
addition to standard precautions. Airborne precautions are used for patients who have infections
spread through the air with small particles; for example, tuberculosis, varicella, and rubeola.
Contact precautions are used for patients who are infected or colonized by a multidrug-resistant
organism (MDRO), such as MRSA.
A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is
scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an
instrument in the sterile field. What is the appropriate nursing action in this situation?
A. Ask another nurse to hold the hand of the patient and continue setting up the field
B. Remove the instrument that was touched by the patient and continue setting up the sterile field
C. Discard the supplies and prepare a new sterile field with another person holding the patient's
hand
D. No action is necessary since the patient has touched his or her own sterile field - c. If the
patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile
field. If the patient is confused, the nurse should have someone assist by holding the patient's
hand and reinforcing what is happening.
,A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an
appropriate action when performing this task?
A. Place the bottle cap on the table with the edges down
B. Hold the bottle inside the edge of the sterile field
C. Hold the bottle with the label side opposite the palm of the hand
D. Pour the solution from a height of 4 to 6 in (10 to 15 cm) - d. To add a sterile solution to a
sterile field, the nurse would open the solution container according to directions and place the
cap on the table away from the field with the edges up. The nurse would then hold the bottle
outside the edge of the sterile field with the label side facing the palm of the hand and prepare to
pour from a height of 4 to 6 in (10 to 15 cm).
A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?
A. Remove gown, goggles, mask, gloves, and exit the room
B. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles
C. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene
D. Remove goggles, mask, gloves, and gown, and perform hand hygiene - c. If an
impervious gown has been tied in front of the body at the waist, the nurse should untie the waist
strings before removing gloves. Gloves are always removed first because they are most likely to
be contaminated, followed by the goggles, gown, and mask, and hands should be washed
thoroughly after the equipment has been removed and before leaving the room.
A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when
administering the patient's medications. What would be the first action of the nurse following the
exposure?
A. Report the incident to the appropriate person and file an incident report
B. Wash the exposed area with warm water and soap
C. Consent to PEP at appropriate time
D. Set up counseling sessions regarding safe practice to protect self - b. When a needlestick
injury occurs, the nurse should wash the exposed area immediately with warm water and soap,
report the incident to the appropriate person and complete an incident injury report, consent to
and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe
practice to protect self and others.
,The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would
the nurse consider most at risk for developing this type of infection?
A. A 60-year-old patient who smokes two packs of cigarettes daily
B. A 40-year-old patient who has a white blood cell count of 6,000/mm3
C. A 65-year-old patient who has an indwelling urinary catheter in place
D. A 60-year-old patient who is a vegetarian and slightly underweight - c. Indwelling urinary
catheters have been implicated in most HAIs. Cigarette smoking, a normal white blood cell
count, and a vegetarian diet have not been implicated as risk factors for HAIs.
A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open
reddened area over his sacrum. What risk factor would be a priority concern for the nurse when
caring for this patient?
A. Imbalanced nutrition
B. Impaired physical mobility
C. Chronic pain
D. Infection - d. The priority risk factor in this situation is the possibility of an infection
developing in the open skin area. The other risk factors may be potential problems for this patient
and may also require nursing interventions after the first diagnosis is addressed.
A nurse teaches a patient at home to use clean technique when changing a wound dressing. What
would be a consideration when preparing this teaching plan?
A. It is the personal preference of the nurse whether or not to use clean technique
B. The use of clean technique is safe for the home setting
C. Surgical asepsis is the only safe method to use in a home setting
D. It is grossly negligent to recommend clean technique for changing a wound dressing - b.
In the home setting, where the patient's environment is more controlled, medical asepsis is
usually recommended, with the exception of self-injection. This is the appropriate procedure for
the home and is not a personal preference or a negligent action
, A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C.
difficile infection. Which nursing action related to this activity promotes safe, effective patient
care?
A. The nurse puts on PPE after entering the patient room
B. The nurse works from "clean" areas to "dirty" areas during bath
C. The nurse personalizes the care by substituting glasses for goggles
D. The nurse removes PPE after the bath to talk with the patient in the room - b. When using
PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE before entering the
patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or
anteroom just before exiting.
A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when
planning a patient's personal hygiene?
A. When the patient had his or her most recent bath
B. The patient's usual hygiene practices and preferences
C. Where the bathing fits in the nurse's schedule
D. The time that is convenient for the patient care assistant - b. Bathing practices and
cleansing habits and rituals vary widely. The patient's preferences should always be taken into
consideration, unless there is a clear threat to health. The patient and nurse should work together
to come to a mutually agreeable time and method to accomplish the patient's personal hygiene.
The availability of staff to assist may be important, but the patient's preferences are a higher
priority.
A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an
essential part of nursing care. What are some of the benefits of providing this care? Select all that
apply.
A. It promotes the patient's sense of well-being.
B. It prevents deterioration of the oral cavity.
C. It contributes to decreased incidence of aspiration pneumonia.
D. It eliminates the need for flossing.
E. It decreases oropharyngeal secretions.
