1. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST?
a. Institute seizure precautions
b. Assess neurologic status
c. Place in respiratory isolation
d. Assess vital signs
2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client?
a. Reverse isolation
b. Respiratory isolation
c. Standard precautions
d. Contact isolation
3. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions?
a. A diagnosis of AIDS and cytomegalovirus
b. A positive PPD with an abnormal chest x-ray
c. A tentative diagnosis of viral pneumonia
d. Advanced carcinoma of the lung
4. Which of the following is the FIRST priority in preventing infections when providing care for a client?
a. Handwashing
b. Wearing gloves
c. Using a barrier between client’s furniture and nurse’s bag
d. Wearing gowns and goggles
5. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible?
a. Hands.
b. Droplet nuclei.
c. Milk products.
d. Eating utensils.
6. A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action?
a. Order a stat admission CBC.
b. Place a urine collection bag and specimen cup at the bedside.
c. Place a cooling mattress on his bed.
d. Pad the side rails of his bed.
7. A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement?
a. “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water.”
b. “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
c. “I must wear my Jobst elastic garment all day and can only remove it when I’m going to bed.”
d. “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”
8. An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is
a. limit visits by staff.
b. encourage family phone calls.
c. position in a bright, busy area.
d. speak soothingly and provide quiet music.
9. Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure?
a. She says to her husband, “Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food.”
b. “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”
c. “I understand it will be several weeks before all the radiation leaves my body.”
d. “I brought several craft projects to do while the radium is inserted.”
10. The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff?
a. The nurse aide is not wearing gloves when feeding an elderly client.
b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.
c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.
11. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to:
a. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing.
b. congratulate the nurse on the use of good technique.
c. discuss dressing change technique with the nurse at a later date.
d. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
12. Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is:
a. Correct illumination of the environment.
b. amount of regular exercise.
c. the resting pulse rate.
d. status of salt intake.
13. Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis?
a. “If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.”
b. “If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline.”
c. “If I question the sterility of any dressing material, I should not use it.”
d. “I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.”
14. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?
a. Masks should be worn with all client contact.
b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
c. Isolation gowns are not needed.
d. A private room is always indicated.
15. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?
a. Masks should be worn with all client contact.
b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
c. Isolation gowns are not needed.
d. A private room is always indicated.
16. The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions?
a. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood.
b. An aide wears gloves to feed a helpless client.
c. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy.
d. A pregnant worker refuses to care for a client known to have AIDS.
17. Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism?
a. Bathing together.
b. Coughing on each other.
c. Sharing pacifiers.
d. Eating off the same plate.
18. Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client:
a. verbalizes the role of sexual activity in spread of the disorder.
b. states he will make arrangements to drop his college classes.
c. acknowledges the need to avoid all contact sports.
d. says he will avoid close contact with his three-year-old niece.
19. Which question is least useful in the assessment of a client with AIDS?
a. Are you a drug user?
b. Do you have many sex partners?
c. What is your method of birth control?
d. How old were you when you became sexually active?
20. Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse’s preoperative goals for Mrs. M. would include:
a. independently ambulating around the unit.
b. reading the routine preoperative education materials.
c. maneuvering safely after orientation to the room.
d. using a bedpan for elimination needs.
Answers and Rationale
1. Answer C. The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.
2. Answer D. Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient”s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia.
3. Answer B. The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.
4. Answer A. Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.
5. Answer B. Hands are the primary method of transmission of the common cold. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils.
6. Answer D. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.
7. Answer B. Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage must be reported immediately.
8. Answer D. The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Putting the client in a bright, busy area would probably add to his confusion. The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.
9. Answer B. The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours after insertion), the client is no longer contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place.
10. Answer C. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask, gown, and gloves.
11. Answer D. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing and before donning the sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. However, the nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.
12. Answer A. To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate. The amount of regular exercise is not the most important factor to assess. It is only indirectly related. The resting pulse rate is not related to preventing falls. The salt intake is not directly related to preventing falls.
13. Answer C. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. The 4 X 4s should be soaked prior to donning the sterile gloves. Once the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a need for further instruction.
14. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client’s hygiene is poor.
15. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client’s hygiene is poor.
16. Answer C. Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an instrument such as a hemostat should be used to recap. The hand should never be used. Gloves are not necessary when feeding, since there is no contact with mucus membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin. Masks and protective eye wear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions.
17. Answer A. Direct contact is the mode of transmission for staphylococcus. Staph is not spread by coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not spread through oral secretions.
18. Answer A. The AIDS virus is spread through direct contact with body fluids such as blood and through sexual intercourse. Casual contact with other people does not pose a risk of transmission of AIDS. Unless the client is feeling very ill, there is no need for him to drop his college classes. Contact sports are not contraindicated unless there is a significant chance of bleeding and direct contact with others. Casual contact with other people does not pose a risk of transmission of AIDS. There is no need to limit casual contact with children.
19. Answer D. Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for AIDS. Birth control methods are important to prevent a baby from being born with the AIDS virus. The age at which sexual activity began it not relevant as it does not usually provide information that identifies the presence of risk factors for AIDS.
20. Answer C. Independently ambulating around the unit is not appropriate because the unit environment can change and injury could result. Assistance is necessary because of the client’s visual deficit. It is unlikely the client can see well enough to read the materials. Maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely. Using the bedpan is an unnecessary restriction on the client as she can be oriented to the bathroom or to call for assistance.
I got 13 .... :] thanks a lot for this practice questions I've learned a lot.... Godbless! ^_^
ReplyDeletegot 16 right, very helpful
ReplyDelete14/20
ReplyDelete14/20
ReplyDeleteDid you write these questions or did you find them through other material?
ReplyDeleteIf you found that where are they from?
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