1-5
When a patient in the ambulatory clinic is diagnosed as having pneumococcal pneumonia, the
nurse is aware that this infection is:
viral and will not respond to antibiotics.
bacterial and should respond to treatment with antibiotics.
fungal and is caused by the alteration of the normal flora of the lung.
resultant from a resistant organism and extreme caution must be taken.
ANS: B bacterial and should respond to treatment with antibiotics.
Health personnel should wash their hands with soap and water at the beginning of the shift
for:
10 seconds.
15 seconds.
1 minute.
2 minutes.
ANS: B
15 seconds
A nurse is using personal protective equipment (PPE) before entering the room of a patient with diarrhea and vomiting who is being treated for an intestinal infection. The nurse most likely needs to use which combination of PPE?
Gown, gloves, and mask
Gown, gloves, and goggles (or glasses)
Shoe covers, gown, and gloves
Reusable gown and mask
ANS: B
Gown, gloves, and goggles (or glasses)
The nurse encourages the 84-year-old patient who is recovering from a hip replacement to:
cough frequently to make up for the loss of cilia.
restrict fluid to prevent pulmonary congestion.
keep the bed flat to aid in lung expansion.
encourage bed rest.
ANS: A
cough frequently to make up for the loss of cilia.
The situation in which protective eyewear is required is:
suctioning a tracheotomy.
applying a dressing on the leg.
changing a baby’s diaper.
gathering the linens off a contaminated bed.
ANS: A
suctioning a tracheotomy.
The nurse explains to the patient who has pneumococcal pneumonia that the lungs serve as
the:
mode of transfer.
transmission of the disease.
reservoir.
organisms that cause the infection.
ANS: C
reservoir.
An organism that is included in the extended-spectrum beta-lactamase producing pneumonia (ESBL) group is:
Staphylococcus aureus.
Clostridium difficile.
Enterococcus.
Escherichia coli.
ANS: D
Escherichia coli.
When removing a used face mask, the nurse correctly:
a. lowers it below his chin to use the next time he enters that patient’s room.
b. removes the mask first before removing any other PPE.
c. unties the bottom ties first, then the top, and disposes of the mask without touching
it.
d. discards the mask only if it is wet; otherwise, he folds and stores it to reuse the next time.
ANS: C
unties the bottom ties first, then the top, and disposes of the mask without touching
it.
A patient is sent home with an open wound that is still infected and being treated with wet-to- dry dressing changes four times a day. Before discharge, in order to prevent infecting other family members, the nurse would teach the patient to:
be the only person to perform the dressing changes, thus eliminating the risk of infection to other family members.
wash hands thoroughly before the dressing change.
use gowns, gloves, and masks for any family contact with him.
maintain medical asepsis and proper handling of the contaminated dressings.
ANS: D
maintain medical asepsis and proper handling of the contaminated dressings.
To prevent a urinary infection in an elderly patient who is in traction for a broken femur, the nurse would:
request a Foley catheter to be inserted.
encourage fluid intake to keep urine dilute.
encourage intake of apple juice to keep urine acidic.
offer a urinal every 2 hours.
ANS: B
encourage fluid intake to keep urine dilute.
The patient inquires about how his body will kill pathogens unassisted by antibiotics. The nurse responds that a process called phagocytosis will:
stimulate the body to make more white blood cells.
create antibodies against the pathogen.
engulf and destroy the pathogen.
stimulate the production of interferons.
ANS: C
engulf and destroy the pathogen.
The nurse explains that medical asepsis differs from surgical asepsis in that medical asepsis:
kills all organisms.
is confined to the patient’s room.
uses sterile attire to protect the patient.
uses sterile equipment before contact with the patient.
ANS: B
is confined to the patient’s room.
The nurse uses the Standard Precautions, as outlined by the Centers for Disease Control and Prevention (CDC), when:
there is a suspicion of or risk of infection.
preventing transmission of respiratory and wound infections.
caring for patients who have wounds draining body fluids.
caring for all patients.
ANS: D
caring for all patients.
The nurse instructing a patient in the home use of disinfectant would include the information that the disinfectant can be used to:
decrease organisms on the patient’s body but take care not to use it around the patient’s eyes or in the mouth.
sterilize instruments with a bacteriostatic disinfectant.
thoroughly clean and rinse all soap off the equipment before disinfecting it.
first remove all organic matter prior to disinfecting.
ANS: C
thoroughly clean and rinse all soap off the equipment before disinfecting it.
Fecal matter has contaminated the patient’s bed sheet. The nurse should:
place a folded clean, dry sheet or plastic-backed protector over the soiled sheet
until it dries and then change the sheet.
don non-sterile gloves and gown, remove the soiled sheet, replace it with a clean
one, and then dispose of the sheet in a plastic bag to prevent skin or clothing
contact.
c. remove the soiled sheet without exposure of skin or clothing to the sheet and rinse
it in the patient’s bathroom sink to dilute or remove as much feces as possible.
d. use PPE to remove the sheet and place it in a pillowcase on the floor; then replace it with a clean sheet.
ANS: B
don non-sterile gloves and gown, remove the soiled sheet, replace it with a clean one, and then dispose of the sheet in a plastic bag to prevent skin or clothing contact.
he nurse explains that the immunizations against hepatitis B will:
stimulate the body to make antibodies the hepatitis B antigen.
offer immediate protection from hepatitis B by the injection of ready-made
antibodies.
introduce live antigens into the body that will stimulate the production of
antibodies.
offer protection against hepatitis A, C, and D, in addition to hepatitis B.
ANS: A
stimulate the body to make antibodies the hepatitis B antigen.
When the nurse performs a procedure using sterile technique in the patient’s unit, it means that:
the equipment and supplies used are disposable and clean.
all organisms have been killed or removed from materials that come in contact with
the patient.
the nurse will do a 10-minute surgical scrub before beginning the procedure.
the nurse will be required to don a sterile gown, mask, and eye shields.
ANS: B
all organisms have been killed or removed from materials that come in contact with
the patient.
When the nurse is using a syringe and needle to give a patient an injection, he or she should:
never recap the needle afterwards to avoid risk of needle stick.
carefully break the needle from the syringe, using the needle cover to prevent reuse
of a used syringe and needle.
throw the needle and syringe immediately in a covered garbage can with a red
plastic liner to indicate the materials are biohazards.
recap the needle and place it carefully on the patient’s table until leaving the room,
then discard it in a garbage container in the nurses’ medication room.
ANS: A
never recap the needle afterwards to avoid risk of needle stick.
The nurse is aware that the use of ethylene oxide gas is reserved for the sterilization of:
dressings.
surgical instruments.
heat-sensitive items.
floors and walls.
ANS: C
Heat-sensitive items.
The nurse explains that the body’s normal flora serve as:
aids to digestion and blood production.
prevention to the colonizing of pathogens.
managers of fluid balance of the body.
cell rebuilders.
ANS: B
prevention to the colonizing of pathogens.
A mother and her 2-week-old infant, who is breast-fed, have been exposed to chickenpox. Although the mother had chickenpox as a child, she is concerned about her baby. The nurse explains:
the infant is at risk because the baby has not been immunized against the disease.
both infant and mother are at risk because the mother’s immunity was acquired too
long ago to be effective.
the baby should receive immune globulin to protect him from the infection.
neither are at risk, because the mother has naturally acquired immunity, and she passes antibodies to the baby through the breast milk.
ANS: D
neither are at risk, because the mother has naturally acquired immunity, and she passes antibodies to the baby through the breast milk.
A nurse teaching family members about hand hygiene in the home would emphasize:
keeping fingernails short and avoiding wearing rings.
washing hands up to the elbows for 2 minutes the first time in the day, and for 1
minute after a diaper change.
using disposable gloves after hand hygiene when feeding the infant.
that home care requires less attention to medical asepsis, so hand hygiene is
necessary only after toileting or handling soiled diapers.
ANS: A
keeping fingernails short and avoiding wearing rings.
The nurse using protective non-sterile gloves in the provision of patient care will wash his or her hands after removal of the gloves in order to:
avoid transfer of organisms.
diminish possibility of latex allergy.
keep skin of hands from cracking and drying.
enhance the ease of donning a fresh pair of gloves.
A
avoid transfer of organisms.
The nurse recommends a good agent for disinfecting contaminated areas in the home is:
a. to cover the area with boiling water and let air dry.
a 1:10 solution of chlorine bleach.
a 1:2 solution of alcohol.
to soak in a solution of povidone-iodine for 30 minutes and rinse with hot water.
ANS: B
a 1:10 solution of chlorine bleach.
A patient has been diagnosed with Creutzfeldt-Jakob disease (mad cow disease). The nurse recognizes this disease is caused by a:
a. prion.
b. virus.
c. protozoa. d. fungus.
A. Prion