Which term is used to describe the nares of a patient after a nasal
culture is positive for MRSA?
a. Reservoir
b. Portal of entry
c. Susceptible host
d. Mode of transmission
Which mode of transmission is demonstrated when the nurse spreads an infection with the hands
after neglecting to perform hand hygiene?
a. Direct
b. Automatic
c. Spontaneous
d. Uninterrupted
Which is an example of normal flora?
a. The patient has a tapeworm living in the large intestine.
b. The patient's colon contains bacteria to help assist digestion.
c. The patient's incision is infected with Staphylococcus bacteria.
d. The patient has a viral infection causing nasal congestion and sore throat.
Which term is used to describe the body's protection against whooping cough after receiving the
pertussis vaccination?
a. Natural passive immunity
b. Natural active immunity
c. Acquired active immunity
d. Acquired passive immunity
Which is an example of suprainfection?
a. The patient develops Clostridium difficile diarrhea after taking broad-spectrum
antibiotics.
b. The immunocompromised patient develops an upper respiratory despite protective
isolation precautions.
c. The bacteria in the patient's wound are resistant to cephalosporin and penicillin
antibiotics.
d. The patient's upper respiratory infection progresses to pneumonia with right-sided
pleural effusion.
6. The patient's urine cultures tested positive for Escherichia coli (E. coli) following urinary
catheterization. Which term describes this type of infection?
a. Protozoan
b. Endogenous
c. Diagnostic
d. Bactericidal
Which action of the nurse will minimize the onset and spread of infection?
a. Insert indwelling urinary catheters to prevent incontinence.
b. Use aseptic technique when providing mouth care to the patient.
c. Keep the patient's mucus membranes dry to prevent maceration.
d. Use masks and gowns sparingly to reduce the patient's sense of isolation.
The nurse maintains a sterile field when inserting a urinary catheter into the patient's bladder.
Which term best describes the infection control practice of the nurse?
a. Pathogenesis
b. Bacteriostasis
c. Medical asepsis
d. Surgical asepsis
9. Which assessment finding indicates that the patient is at high risk for infection?
a. The patient is allergic to penicillin, iodine. and watermelon.
b. The patient has a urinary catheter draining clear yellow urine.
c. The patient's white blood cell count is 7500/mm3
this morning.
d. The patient follows a kosher diet and refuses to eat pork or shrimp.
10. Which is an appropriate goal for the diagnosis risk for infection related to aspiration of fluids into
the airway?
a. The patient will respond positively to IV antibiotic therapy.
b. The nurse will elevate the head of the patient's bed at mealtimes.
c. The patient will remain afebrile with clear lung sounds bilaterally.
d. The nurse will have suction equipment available when feeding the patient.
11. The nurse is caring for a patient with pneumonia with a congested cough, fever, and wheezing.
Which is the priority nursing diagnosis for the patient?
a. Risk for infection related to congested cough and wheezing
b. Deficient diversional activity related to boredom due to hospitalization
c. Risk for imbalanced body temperature related to increased metabolic rate
d. Ineffective airway clearance related to inability to clear secretions from airway
Which action demonstrates disinfection?
a. Washing the hands with warm water and antimicrobial liquid soap
b. Cleaning the patient's mouth with a swab soaked in chlorhexidine solution
c. Cleaning the stethoscope with isopropyl alcohol after each use with patients
d. Using an alcohol-based hand sanitizer after performing physical assessments
Which laboratory result indicates to the nurse that antibiotic therapy is effectively treating the
patient's infection?
a. The patient's urinalysis tested positive for nitrites and leukocytes.
b. The patient's wound culture showed a positive result for Candida albicans.
c. The patient's white blood cell count has increased from 12,000 to 25,000/mm3
.
d. The patient's erythrocyte sedimentation rate (ESR) dropped from 56 to 33
mm/hour.
Which action of the nurse demonstrates the use of standard precautions?
a. The nurse uses gloves when performing oral care for the patient.
b. The nurse puts on a surgical mask before entering the patient's room.
c. The patient is placed in a private room with negative-pressure airflow.
d. The nurse uses sterile gloves when emptying the patient's urinary catheter bag.
Which protective apparel must the nurse wear to start an intravenous line for the patient?
a. Gloves only
b. Sterile gloves only
c. Gloves and a mask
d. Gloves and a gown
The nurse is caring for a patient with the nursing diagnosis risk for latex allergy response related to
multiple food allergies. Which is the priority intervention of the nurse?
a. Recommend that the patient wear a medical alert bracelet at home.
b. Ensure that a medical plan is in place if an allergic response occurs.
c. Lightly powder inside of the gloves before putting them on the hands.
d. Provide written information about latex allergy prevention to the patient.
The nurse disposes of gauze dressings that are saturated with drainage from a MRSA-positive
wound. Which action is appropriate?
a. The gauze dressings are placed in a red medical waste disposal bag.
b. The gauze dressings are placed in the wall-mounted sharps disposal box.
c. The gauze dressings are left in the wastepaper basket in the patient's room.
d. The gauze dressings are flushed down the disposal system in the utility room.
Which action by the nurse demonstrates correct hand-hygiene practice?
a. Letting hand sanitizer dry for a full minute before applying gloves
b. Keeping hands and wrists above the level of the elbows while washing
c. Scrubbing hands and nails for at least 15 seconds using plenty of soap
d. Making sure that the water is hot before wetting the hands and wrists
Which action of the nurse is appropriate after leaving the room of the patient with Clostridium
difficile?
a. Wash hands thoroughly for 20 seconds with antibacterial soap and water.
b. Vigorously rub a quarter-sized dollop of hand sanitizer into both hands.
c. Perform a sterile scrub procedure using chlorhexidine soap solution.
d. Scrub the hands for 2 minutes keeping hands above the level of the elbows.
Which precautions are appropriate for a patient with a methicillin-resistant Staphylococcus aureus
(MRSA) wound infection?
a. Contact
b. Airborne
c. Droplet
d. Standard
Which item of protective apparel is removed first when the nurse leaves the room of the patient with
Clostridium difficile?
a. Gown
b. Mask
c. Gloves
d. Eyewear
MULTIPLE RESPONSE
1. Which actions of the nurse cause a break in the sterile procedure? (Select all that apply.)
a. Dropping a sterile instrument onto the sterile field
b. Spilling sterile saline solution onto the sterile field
c. Reaching over the sterile field to pick up an instrument
d. Keeping the top of the table above waist level
e. Placing instruments in the center of the sterile field
Which assessment findings indicate to the nurse that the patient's incision has become infected?
(Select all that apply.)
a. The incision site is red and warm to the touch.
b. Thick yellow-green drainage is noted at the site.
c. The patient's white blood cell count is 5300/mm3
.
d. The wound edges are well approximated with sutures.
e. The patient received prophylactic antibiotics before surgery.
A nurse is preparing a teaching plan for patients about the hepatitis B virus. The nurse informs them that this virus may be transmitted by?
a. mosquitoes
b. droplet nuclei
c. blood products
d. improperly handled food.
Which statement about caring for patients is true?
a. Basically all patients are the same.
b. Each patient has a unique background.
c. Caring for patients requires very little experience.
d. Standard solutions exist for most patient's health care problems.
Which statement is part of Leininger's Transcultural View of Caring?
a. Caring and curing are basically synonymous.
b. Caring acts are independent of patient values.
c. Care uses a standardized approach for all patients.
d. Care is tailored to meet the needs of the individual patient.
Which activity best demonstrates the caring role of a nurse?
a. Assessing the patient's entire health history
b. Administering antibiotic medications on time
c. Inserting a urinary catheter using aseptic technique
d. Maintaining privacy when conversing with the patient
Which nursing goal is consistent with Watson's Transpersonal Theory of Caring?
a. The nurse will develop a therapeutic relationship with the patient.
b. The nurse will tell the patient what needs to be done to resolve health problems.
c. The nurse will be viewed as the authority when it comes to health care issues.
d. The nurse will exclude the family from health discussions to protect privacy.
The nurse helps the patient set small, achievable goals and celebrates with the patient when the
goals are met. Which caring behavior is demonstrated by the nurse?
a. Human respect
b. Encouraging manner
c. Healing environment
d. Affiliation needs
Which action by the nurse facilitates mutual problem solving?
a. The nurse refers the newly widowed patient to a local bereavement support group.
b. The nurse elevates the head of the bed and administers oxygen when the patient
becomes short of breath.
c. The nurse asks the patient which high-fiber foods are preferred to prevent
constipation.
d. The nurse assesses the patient's oral mucus membranes for ulcerations, bleeding,
or dryness.
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