NURA 303 EXAM 2 QUESTIONS
COMPLETE WITH OUTLINED
ANSWERS
\.A nurse is following the principles of medical asepsis when performing patient care in a
hospital setting. Which nursing action performed by the nurse follows these recommended
guidelines?
A. The nurse carries the patients' soiled bed linens close to the body to prevent spreading
microorganisms into the air
B. The nurse places soiled bed linens and hospital gowns on the floor when making the bed
C. The nurse moves the patient table away from the nurse's body when wiping it off after a meal
D. The nurse cleans the most soiled items in the patient's bathroom first and follows with the
cleaner items - Answer- c. According to the principles of medical asepsis, the nurse should
move equipment away from the body when brushing, scrubbing, or dusting articles to prevent
contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled
items away from the body to prevent them from touching the clothing. The nurse should not
put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least
soiled areas first and then move to the more soiled ones to prevent having the cleaner areas
soiled by the dirtier areas.
\.A school nurse is performing an assessment of a student who states, "I'm too tired to keep my
head up in class." The student has a low-grade fever. The nurse would interpret these findings as
indicating which stage of infection?
A. Incubation period
B. Prodromal stage
C. Full stage of illness
,D. Convalescent period - Answer- b. During the prodromal stage, the person has vague signs
and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of
infection during the incubation period, and they are more specific during the full stage of illness
before disappearing by the convalescent period.
\.A nurse is caring for patients in an isolation ward. In which situations would the nurse
appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply.
A. Providing a bed bath for a patient
B. Visibly soiled hands after changing the bedding of a patient
C. Removing gloves when patient care is completed
D. Inserting a urinary catheter for a female patient
E. Assisting with a surgical placement of a cardiac stent
F. Removing old magazines from a patient's table - Answer- a, c, d, f. It is recommended to
use an alcohol-based handrub in the following situations: before direct contact with patients;
after direct contact with patient skin; after contact with body fluids if hands are not visibly
soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters,
or invasive devices that do not require surgical placement; before donning sterile gloves prior to
an invasive procedure; if moving from a contaminated body site to a clean body site; and after
contact with objects contaminated by the patient. Keep in mind that handrubs are not
appropriate for use with C. difficile infection.
\.A nurse is performing hand hygiene after providing patient care. The nurse's hands are not
visibly soiled. Which steps in this procedure are performed correctly? Select all that apply.
A. Removes all jewelry including a platinum wedding band
B. Washes hands to 1 in above the wrists
C. Uses approximately one teaspoon of liquid soap
D. Keeps hands higher than elbows when placing under faucet
E. Uses friction motion when washing for at least 20 seconds
F. Rinses thoroughly with water flowing toward fingertips - Answer- b, c, e, f. Proper hand
hygiene includes removing jewelry (with the exception of a plain wedding band), wetting the
,hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid
soap, using friction motion for at least 20 seconds, washing to 1 in above the wrists with a
friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward
fingertips.
\.The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile
dressing change, a procedure that requires surgical asepsis. Which action by the nurse is
appropriate?
A. Keep splashes on the sterile field to a minimum
B. Cover the nose and mouth with gloved hands if a sneeze is imminent
C. Use forceps soaked in a disinfectant
D. Consider the outer 1 in of the sterile field as contaminated - Answer- d. Considering the
outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as
from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves.
Forceps soaked in disinfectant are not considered sterile.
\.The nurse caring for patients in a hospital setting institutes CDC standard precaution
recommendations for which category of patients?
A. Only patients with diagnosed infections
B. Only patients with visible blood, body fluids, or sweat
C. Only patients with nonintact skin
D. All patients receiving care in hospitals - Answer- d. Standard precautions apply to all
patients receiving care in hospitals, regardless of their diagnosis or possible infection status.
These recommendations include blood; all body fluids, secretions, and excretions except sweat;
nonintact skin; and mucous membranes.
\.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 - Answer- 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 - Answer-
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) - Answer- d. To add a sterile
solution to a sterile field, the nurse would open the solution container according to directions
COMPLETE WITH OUTLINED
ANSWERS
\.A nurse is following the principles of medical asepsis when performing patient care in a
hospital setting. Which nursing action performed by the nurse follows these recommended
guidelines?
A. The nurse carries the patients' soiled bed linens close to the body to prevent spreading
microorganisms into the air
B. The nurse places soiled bed linens and hospital gowns on the floor when making the bed
C. The nurse moves the patient table away from the nurse's body when wiping it off after a meal
D. The nurse cleans the most soiled items in the patient's bathroom first and follows with the
cleaner items - Answer- c. According to the principles of medical asepsis, the nurse should
move equipment away from the body when brushing, scrubbing, or dusting articles to prevent
contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled
items away from the body to prevent them from touching the clothing. The nurse should not
put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least
soiled areas first and then move to the more soiled ones to prevent having the cleaner areas
soiled by the dirtier areas.
\.A school nurse is performing an assessment of a student who states, "I'm too tired to keep my
head up in class." The student has a low-grade fever. The nurse would interpret these findings as
indicating which stage of infection?
A. Incubation period
B. Prodromal stage
C. Full stage of illness
,D. Convalescent period - Answer- b. During the prodromal stage, the person has vague signs
and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of
infection during the incubation period, and they are more specific during the full stage of illness
before disappearing by the convalescent period.
\.A nurse is caring for patients in an isolation ward. In which situations would the nurse
appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply.
A. Providing a bed bath for a patient
B. Visibly soiled hands after changing the bedding of a patient
C. Removing gloves when patient care is completed
D. Inserting a urinary catheter for a female patient
E. Assisting with a surgical placement of a cardiac stent
F. Removing old magazines from a patient's table - Answer- a, c, d, f. It is recommended to
use an alcohol-based handrub in the following situations: before direct contact with patients;
after direct contact with patient skin; after contact with body fluids if hands are not visibly
soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters,
or invasive devices that do not require surgical placement; before donning sterile gloves prior to
an invasive procedure; if moving from a contaminated body site to a clean body site; and after
contact with objects contaminated by the patient. Keep in mind that handrubs are not
appropriate for use with C. difficile infection.
\.A nurse is performing hand hygiene after providing patient care. The nurse's hands are not
visibly soiled. Which steps in this procedure are performed correctly? Select all that apply.
A. Removes all jewelry including a platinum wedding band
B. Washes hands to 1 in above the wrists
C. Uses approximately one teaspoon of liquid soap
D. Keeps hands higher than elbows when placing under faucet
E. Uses friction motion when washing for at least 20 seconds
F. Rinses thoroughly with water flowing toward fingertips - Answer- b, c, e, f. Proper hand
hygiene includes removing jewelry (with the exception of a plain wedding band), wetting the
,hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid
soap, using friction motion for at least 20 seconds, washing to 1 in above the wrists with a
friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward
fingertips.
\.The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile
dressing change, a procedure that requires surgical asepsis. Which action by the nurse is
appropriate?
A. Keep splashes on the sterile field to a minimum
B. Cover the nose and mouth with gloved hands if a sneeze is imminent
C. Use forceps soaked in a disinfectant
D. Consider the outer 1 in of the sterile field as contaminated - Answer- d. Considering the
outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as
from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves.
Forceps soaked in disinfectant are not considered sterile.
\.The nurse caring for patients in a hospital setting institutes CDC standard precaution
recommendations for which category of patients?
A. Only patients with diagnosed infections
B. Only patients with visible blood, body fluids, or sweat
C. Only patients with nonintact skin
D. All patients receiving care in hospitals - Answer- d. Standard precautions apply to all
patients receiving care in hospitals, regardless of their diagnosis or possible infection status.
These recommendations include blood; all body fluids, secretions, and excretions except sweat;
nonintact skin; and mucous membranes.
\.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 - Answer- 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 - Answer-
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) - Answer- d. To add a sterile
solution to a sterile field, the nurse would open the solution container according to directions
