Asepsis

Question 1

The nurse recognizes which term to identify the second line of defense that leads to local capillary dilation and leukocyte infiltration?
a. Normal flora
b. Inflammatory response
c. Immune response
d. Humoral immunity

Answer 1

b. Inflammatory response

Question 2

The nurse knows that the antigen-antibody reaction is an example of what type of immunity?
a. Humoral
b. Cellular
c. Innate
d. Passive

Answer 2

a. Humoral

Question 3

The nurse uses what term to identify a disease-causing organism?
a. Pathogen
b. Normal flora
c. Germ
d. Microorganism

Answer 3

a. Pathogen

Question 4

The nurse is explaining to the patient why antibiotics are being administered. The answer would be correct if the nurse stated antibiotics are effective against which microorganisms?
a. Viruses
b. Fungi
c. Parasites
d. Bacteria

Answer 4

d. Bacteria

Question 5

The nurse anticipates that what medication category would be correct to treat athletes foot?
a. Antiviral
b. Antibiotic
c. Antihelminth
d. Antifungal

Answer 5

d. Antifungal

Question 6

The nurse recognizes that the stethescope most correctly represents which possible link in the chain of infection?
a. Source
b. Portal of exit
c. Portal of entry
d. Mode of transmission

Answer 6

d. Mode of transmission

Question 7

The nurse is teaching a group of patients about the diseases that are transmitted by ticks. Which term would the nurse use when identifying the function of a tick in spreading disease?
a. Vectors
b. Bacteria
c. Viruses
d. Fungi

Answer 7

a. Vectors

Question 8

What response would the nurse provide to correctly identify the most effective method to prevent hospital-acquired infections?
a. Use of sterile technique
b. Isolation protocols
c. Antibiotic use
d. Handwashing

Answer 8

d. Handwashing

Question 9

The nurse correctly identifies which patient as having the greatest risk for infection.
a. An 80-year-old male with an enlarged prostate
b. A 24-year-old female long-distance runner
c. A 50-year-old obese male
d. A 40-year-old sexually active female

Answer 9

a. An 80-year-old male with an enlarged prostate

Question 10

The nurse understands that which set of vital signs most likely indicates infection?
a. T: 98.6 F, P: 75 beats/min, R: 18 breaths/min, BP: 120/80 mm Hg
b. T: 99 F, P: 80 beats/min, R: 18 breaths/min, BP: 110/70 mm Hg
c. T: 100. 5 F, P: 96 beats/min, R: 22 breaths/min, BP: 150/100 mm Hg
d. T: 98.9 F, P: 66 beats/min, R: 18 breaths/min, BP: 98/62 mm Hg

Answer 10

c. T: 100. 5 F, P: 96 beats/min, R: 22 breaths/min, BP: 150/100 mm Hg

Question 11

A patient admitted after abdominal surgery has a Nursing diagnosis of risk for infection. The nurse identifies which goal to be most appropriate?
a. Patient will ambulate length of hallway this shift
b. Patient will consume 20% of meals by the end of the week.
c. Patient’s incision will be without signs or symptoms of infection at discharge
d. Patient will verbalize need to stop antibiotics medication when symptom free.

Answer 11

c. Patient’s incision will be without signs or symptoms of infection at discharge

Question 12

The nurse is caring for a patient who is comatose. When performing oral hygiene, which interval is most appropriate?
a. Every shift
b. Twice daily
c. Every 4 hours
d. Daily

Answer 12

c. Every 4 hours

Question 13

The nurse knows which skill does not require the use of sterile technique?
a. NG tube insertion
b. Foley catheterization
c. Tracheostomy care
d. PICC line insertion

Answer 13

a. NG tube insetion

Question 14

The nurse recognizes which situation to be inappropriate to use alcohol-based hand sanitizer?
a. Patient with pneumonia
b. Patient with C-Diff
c. Status post-appendectomy
d. Patient with HIV

Answer 14

b. Patien with C-Diff

Question 15

The nurse is preparing to perform suctioning on a new tracheostomy with the potential for forceful expulsioin of secretions and identifie what PPE should be worn?
a. Gloves and eyewear
b. Gloves, gown, and mask
c. Eyewear and gown
d. Eyewear, mask, gown, and gloves

Answer 15

d. Eyewear, mask, gown, and gloves

Question 16

Which isolation precaution should the nurse implement for the patient who has been diagnosed with hepatitis A?
a. Airborne
b. Contact
c. Droplet
d. Protective

Answer 16

b. Contact

Question 17

When the patient is diagnosed with pertussis, which isolation precaution should the nurse implement?
a. Droplet
b. Airborne
c. Contact
d. Protective

Answer 17

a. Droplet

Question 18

When teaching a student nurse about removing PPE, the nurse would include which correct order of equipment removal?
a. Gloves, eyewear, gown, and mask
b. Mask, eyewear, gown, and gloves
c. Gown, mask, eyewear, and gloves
d. Gloves, gown, mask, and eyewear

Answer 18

a. Gloves, eyewear, gown, and mask

Question 19

When the nurse is wearing sterile gloves, which action would result in the gloves becoming nonsterile?
a. Fold gloved hands until procedure begins
b. Change a dressing using aseptic technique
c. Place sterile hands below waist
d. Use correct protocol when donning sterile gloves

Answer 19

c. Place sterile hands below waist

Question 20

The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply)
a. Decreased cough reflex
b. Decreased lung elasticity
c. Increased activity of the cilia
d. Abnormal swallowing reflex
e. Increased sputum production

Answer 20

a. Decreased cough reflex
b. Decreased lung elasticity
d Abnormal swallowing reflex

Question 21

The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which statement by the patient indicates further education is needed? (Select all that apply).
a. “I should take antibiotics everytiime I am sick.”
b. “I should take all antibiotic as prescribed.”
c. “I should save all unused antibiotics.”
d. “I should stop taking antibiotics when I feel better.”
e. “If I develop a rash while taking these I will call the provider.”

Answer 21

a. “I should take antibiotics everytiime I am sick.”
c. “I should save all unused antibiotics.”
d. “I should stop taking antibiotics when I feel better.”

Question 22

The nurse is providing which statements by the student nurse regarding handwashing indicate a need for further education?
a. Wash hands first, then wrists.
b. Rinse from fingertips to wrists.
c. Dry using a scrubbing motion.
d. Turn off faucet with clean, dry paper towel
e. Dry hands in the same order as washing them.

Answer 22

a. Wash hands first, then wrists.
b. Rinse from fingertips to wrists.
c. Dry using a scrubbing motion.

Question 23

The nurse knows that standard precautions are indicated for which group(s) of patients?
a. All patients
b. Patients with HIV
c. Patients with MRSA
d. Patients with Tuberculosis
e. Patients who are bleeding

Answer 23

a. All patients
e. Patients who are bleeding

Question 24

The patient is on protective precautions. The nurse knows which statements are true regarding these precautions? (Select all that apply)
a. A Positive-pressure room with a HEPA filtration system is required.
b. Special respirator masks should be available, and one size fits all.
c. No live plants are allowed in the room.
d. The patient may eat any foods desired.
e. Everyone entering the room wears a mask

Answer 24

c. No live plants are allowed in the room.
e. Everyone entering the room wears a mask

Question 25

Which of the following is a vector-borne disease? a. Rocky mountain spotted fever b. Pneumonia c. Salmonella d. Hepatitis

Answer 25

a. Rocky mountain spotted fever

Question 26

The patient has a 6-inch laceration on his right forearm. An infection develops at the site. Which of the following is a sign of a local inflammatory response observed by the nurse? a. Blanching of the skin b. Edema at the site c. Decrease in temperature d. Increase in the number of WBC's

Answer 26

b. Edema at the site

Question 27

An adult female patient has been undergoing diagnostic testing since admission to the medical unit in the hospital. The results of blood testing are sent back to the unit. On reviewing the results, the nurse reports which abnormal finding to the physician? a. WBCs 14,000 cells/mm3 b. Lymphocytes 2000 cells/mm3 c. Neutrophils 65% d. Hemoglobin 14 g/dl

Answer 27

a. WBCs 14,000 cells/mm3

Question 28

A nurse is observing a new staff member work with a patient. Of the following activities, which one has the greatest possibility of contributing to an HAI and requires correction? a. Washing hands before applying a dressing b. Taping a plastic bag at the bed rail for tissue disposal c. Placing a urinary catheter bag on the bed with the patient d. Using an antiseptic to cleanse the skin before starting an intravenous line.

Answer 28

c. Placing a urinary catheter bag on the bed with the patient

Question 29

The nurse works in a small rural hospital with a wide variety of patients. Of the patients admitted this afternoon, the nurse recognizes that the individual with the highest susceptibility to infection is the individual with which of the following? a. Burns b. Diabetes c. Pulmonary emphysema d. Peripheral vascular disease

Answer 29

a. Burns

Question 30

The nurse employs surgical septic technique when a. disposing of syringes in puncture-proof containers b. placing soiled linens in moisture-resistant bags. c. Washing hands before changing a dressing d. Inserting an intravenous catheter

Answer 30

d. Inserting an intravenous catheter

Question 31

The patient has a large, deep abdominal incission that requires a dressing. When changing the dressing, the nurse accidentally drops the packing onto the patient's abdomien. The nurse should do which of the following? a. Throw the packing away and prepare new one b. Add alcohol to the packing and insert it into the incisioin c. Pick up the packing with sterile forceps and gently place it into the incision. d. Rinse the packing with sterile water and put the packing into the incision with sterile gloves

Answer 31

a. Throw the packing away and prepare new one

Question 32

An adult patient has a viral infection. Which of the following vital signs is typical during the early stage of an infection? a. Increased blood pressure b. Normal temperature c. Decreased respiratory rate d. Increased oxygen saturation

Answer 32

a. increased blood pressure

Question 33

The nurse recognizes that special care must be taken in the handling of which of the following to prevent the transmission of hepatitis C? a. Feces b. Blood c. Saliva d. Vaginal secretions

Answer 33

b. blood

Question 34

The parent of a preschool-aged child asks the nurse how chickenpox is transmitted. The nurse identifies that the virus is transmitted. a. by a vector organism b. through the air in droplets after sneezing or coughing c. through person-to-person contact d. by contact with contaminated objects

Answer 34

b. through the air in droplets after sneezing or coughing

Question 35

The nurse is aware that is important to break the chain of infection. Which of the following is an example of a nursing intervention that is implemented to control the portal of exit of infection for a patient? a. Using hand sanitizer b. Wearing disposable gloves c. Changing soiled dressings d. Administering vaccines

Answer 35

b. Wearing disposable gloves

Question 36

The single most important technique to prevent and control the transmission of infection is a. handwashing b. the use of disposable gloves c. the use of isolation precautions d. sterilization of equipment

Answer 36

a. handwashing

Question 37

A patient with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this patient to the unit will require the implementation by the staff of a. droplet precautions b. airborne precautions c. contact precautions d. protective isolation

Answer 37

b. airborne precautions

Question 38

The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with surgical asepsis? a. Clean forceps may be used to move items on the sterile field. b. Sterile fields may be prepared well in advance of the procedure. c. Sterile items are kept well within a 1-inch border of the filed. d. Wrapped sterile packages should be opened, starting with the flap closest to the nurse.

Answer 38

c. Sterile items are kept well within a 1-inch border of the filed.

Question 39

The nurse suspects that an older adult patient may be experiencing hypostatic pneumonia. Older adult patients may react differently to infectious processes, so the nurse is alert to an atypical sign, such as which of the following? a. hypotension b. confusion c. erythema d. chills

Answer 39

b. confusion

Question 40

A patient requires a sterile dressing change for a midabdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to a. put sterile gloves on before opening sterile packages b. place the cap of the sterile solution well within the sterile field. c. place sterile items on the edge of the sterile drape. d. discard packages that may have been in contact with the area below waist level.

Answer 40

d. discard packages that may have been in contact with the area below waist level.

Question 41

The nurse is preparing to assist with a dressing change. An appropriate technique that the nurse includes in performing correct hand hygiene is to a. wash the wrists, then the hands b. use a brush on the palms of the hands c. maintain the scrub for at least 1 minute d. wash well around watches and other jewelry

Answer 41

a. wash the wrists, then the hands

Question 42

A patient is found to have MRSA. An appropriate isolation procedure for the nurse to implement when working with this patient is to a. leave all linen in the patients room b. use personal protective equipment for contact precautions c. wipe the stethoscope off before removing it from the room. d. identify on the patient's door that droplet precautions are in place.

Answer 42

b. use personal protective equipment for contact precautions

Question 43

The nurse is observing the student put on sterile gloves. Which one of the following actions has contaminated the gloves? a. keeping the package above the waist level. b. pulling the inner package edges apart with the thumbs and fingers. c. grasping the second glove by the cuff d. adjusting the gloves by pinching and shifting with the other hand.

Answer 43

c. grasping the second glove by the cuff

Question 44

In evaluating the infection control measures used by the patient and family in the home, which finding indicates that additional teaching is required? a. Using antimicrobial soaps and disinfectants b. Sharing a towel in the bathroom c. Disposing of sharps in a jar with a screw-top lid d. Avoiding breathing directly on others.

Answer 44

b. Sharing a towel in the bathroom

Question 45

The unit manager observes the new staff nurse performs the following actions for a patient with isolation precautions. Which of the following actions should the unit manager address and correct with the new nurse? a. keeping a thermometer, stethoscope, and blood pressure cuff in the patient's room. b. documenting the precautions required in the patient's record. c. using a particulate respirator mask for the patient who has tuberculosis d. coming out of the bathroom in the PPE to quickly get another dressing.

Answer 45

d. coming out of the bathroom in the PPE to quickly get another dressing.