1.
Which element in the circular chain of infection can be eliminated by preserving skin integrity?
Correct Answer
D. Portal of entry
Explanation
In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.
2.
Which of the following will probably result in a break in sterile technique for respiratory isolation?
Correct Answer
C. Opening the door of the patient’s room leading into the hospital corridor
Explanation
Respiratory isolation, like strict isolation, requires that the door to the door patient’s room remain closed. However, the patient’s room should be well ventilated, so opening the window or turning on the ventricular is desirable. The nurse does not need to wear gloves for respiratoryisolation, but good hand washing is important for all types of isolation.
3.
Which of the following patients is at greater risk for contracting an infection?
Correct Answer
A. A patient with leukopenia
Explanation
Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. None of the other situations would put the patient at risk for contracting an infection; taking broad-spectrum antibiotics might actually reduce the infection risk.
4.
Effective hand washing requires the use of:
Correct Answer
A. Soap or detergent to promote emulsification
Explanation
Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns.
5.
After routine patient contact, hand washing should last at least:
Correct Answer
A. 30 seconds
Explanation
Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of pathogen transmission.
6.
Which of the following procedures always requires surgical asepsis?
Correct Answer
B. Urinary catheterization
Explanation
The urinary system is normally free of microorganisms except at the urinary meatus. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state.
7.
Sterile technique is used whenever:
Correct Answer
C. Invasive procedures are performed
Explanation
All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strictisolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms.
8.
Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
Correct Answer
C. Placing a sterile object on the edge of the sterile field
Explanation
The edges of a sterile field are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated.
9.
A natural body defense that plays an active role in preventing infection is:
Correct Answer
B. Body hair
Explanation
Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.
10.
All of the following statement are true about donning sterile gloves except:
Correct Answer
D. The inside of the glove is considered sterile
Explanation
The inside of the glove is always considered to be clean, but not sterile.
11.
When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
Correct Answer
A. Waist tie and neck tie at the back of the gown
Explanation
The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again.
12.
Which of the following nursing interventions is considered the most effective form or universal precautions?
Correct Answer
B. Discard all used uncapped needles and syringes in an impenetrable protective container
Explanation
According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.
13.
All of the following measures are recommended to prevent pressure ulcers except:
Correct Answer
A. Massaging the reddened are with lotion
Explanation
Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.
14.
Which of the following blood tests should be performed before a blood transfusion?
Correct Answer
B. Blood typing and cross-matching
Explanation
Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.
15.
The primary purpose of a platelet count is to evaluate the:
Correct Answer
A. Potential for clot formation
Explanation
Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.
16.
Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
Correct Answer
D. 25,000/mm³
Explanation
Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis.
17.
After 5 days of diuretic therapy with 20mg of furosemide (Lasix)
daily, a patient begins to exhibit fatigue, muscle cramping and muscle
weakness. These symptoms probably indicate that the patient is
experiencing:
Correct Answer
A. Hypokalemia
Explanation
Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing.
18.
Which of the following statements about chest X-ray is false?
Correct Answer
A. No contradictions exist for this test
Explanation
Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.
19.
The most appropriate time for the nurse to obtain a sputum specimen for culture is:
Correct Answer
A. Early in the morning
Explanation
Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.
20.
A patient with no known allergies is to receive penicillin every 6
hours. When administering the medication, the nurse observes a fine
rash on the patient’s skin. The most appropriate nursing action would
be to:
Correct Answer
A. Withhold the moderation and notify the pHysician
Explanation
Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top priority in such a potentially life-threatening situation.
21.
All of the following nursing interventions are correct when using the Z-track method of drug injection except:
Correct Answer
D. Rub the site vigorously after the injection to promote absorption
Explanation
The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.
22.
The correct method for determining the vastus lateralis site for I.M. injection is to:
Correct Answer
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh
Explanation
The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.
23.
The mid-deltoid injection site is seldom used for I.M. injections because it:
Correct Answer
A. Can accommodate only 1 ml or less of medication
Explanation
The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).
24.
The appropriate needle size for insulin injection is:
Correct Answer
D. 25G, 5/8” long
Explanation
A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
25.
The appropriate needle gauge for intradermal injection is:
Correct Answer
D. 26G
Explanation
Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
26.
Parenteral penicillin can be administered as an:
Correct Answer
A. IM injection or an IV solution
Explanation
Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.
27.
The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
Correct Answer
D. 600 mg
Explanation
gr 10 x 60mg/gr 1 = 600 mg
28.
The physician orders an IV solution of dextrose 5% in water at
100ml/hour. What would the flow rate be if the drop factor is 15 gtt =
1 ml?
Correct Answer
C. 25 gtt/minute
Explanation
100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
29.
Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
Correct Answer
A. Hemoglobinuria
Explanation
Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia.
30.
Which of the following conditions may require fluid restriction?
Correct Answer
C. Renal Failure
Explanation
In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.
31.
All of the following are common signs and symptoms of phlebitis except:
Correct Answer
D. Frank bleeding at the insertion site
Explanation
Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.
32.
The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:
Correct Answer
D. Ask the patient to demonstrate the procedure
Explanation
Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.
33.
Which of the following types of medications can be administered via gastrostomy tube?
Correct Answer
D. Most tablets designed for oral use, except for extended-duration compounds
Explanation
Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.
34.
A patient who develops hives after receiving an antibiotic is exhibiting drug:
Correct Answer
D. Allergy
Explanation
A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater than that of their separate effects.
35.
A patient has returned to his room after femoral arteriography. All
of the following are appropriate nursing interventions except:
Correct Answer
D. Order a hemoglobin and hematocrit count 1 hour after the arteriograpHy
Explanation
A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.
36.
The nurse explains to a patient that a cough:
Correct Answer
A. Is a protective response to clear the respiratory tract of irritants
Explanation
Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs.
37.
An infected patient has chills and begins shivering. The best nursing intervention is to:
Correct Answer
C. Provide additional bedclothes
Explanation
In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.
38.
A clinical nurse specialist is a nurse who has:
Correct Answer
D. Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.
Explanation
A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.
39.
The purpose of increasing urine acidity through dietary means is to:
Correct Answer
D. Inhibit the growth of microorganisms
Explanation
Microorganisms usually do not grow in an acidic environment.
40.
Clay colored stools indicate:
Correct Answer
D. Bile obstruction
Explanation
Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool – for example, drugs containing iron turn stool black.; beets turn stool red.
41.
In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
Correct Answer
D. Evaluation
Explanation
In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.
42.
All of the following are good sources of vitamin A except:
Correct Answer
A. White potatoes
Explanation
The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.
43.
Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
Correct Answer
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
Explanation
Maintaing the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.
44.
The ELISA test is used to:
Correct Answer
D. All of the above
Explanation
The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)
45.
The two blood vessels most commonly used for TPN infusion are the: .
Correct Answer
A. Subclavian and jugular veins
Explanation
Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis.
46.
Effective skin disinfection before a surgical procedure includes which of the following methods?
Correct Answer
D. Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery
Explanation
Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away.
47.
When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
Correct Answer
C. Leg muscles
Explanation
The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.
48.
Thrombophlebitis typically develops in patients with which of the following conditions?
Correct Answer
C. An impaired or traumatized blood vessel wall
Explanation
The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls.
49.
In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
Correct Answer
A. Respiratory acidosis, ateclectasis, and hypostatic pneumonia
Explanation
Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
50.
Immobility impairs bladder elimination, resulting in such disorders as
Correct Answer
B. Urine retention, bladder distention, and infection
Explanation
The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.