Fundamentals Of Nursing NCLEX Quiz 11

1. A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions?

A clean gown and gloves must be worn when in contact with the client.

Everyone who enters the room must wear a N-95 respirator mask.

All linen and trash must be marked as contaminated and send to biohazard waste.

Place the client in a room with a client with an upper respiratory infection.

A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. A respirator mask is required only with airborne precautions. not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections.

Explanation

A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. A respirator mask is required only with airborne precautions. not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections.

2. A newly hired at Nurseslabs Medical Center is assigned in the OR Department. Which action demonstrates a break in sterile technique?

Remaining 1 foot away from nonsterile areas

Placing sterile items on the sterile field

Avoiding the border of the sterile drape

Reaching 1 foot over the sterile field

Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique. healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb. place sterile items needed for the procedure on the sterile drape. and avoid coming in contact with the 1-inch border of the sterile drape.

Explanation

Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique. healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb. place sterile items needed for the procedure on the sterile drape. and avoid coming in contact with the 1-inch border of the sterile drape.

3. For a morbidly obese patient. which intervention should the nurse choose to counteract the pressure created by the skin folds?

Cover the mattress with a sheepskin.

Keep the linens wrinkle free.

Separate the skin folds with towels.

Apply petrolatum barrier creams.

Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence.

Explanation

Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence.

4. A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection?

Fever

Intact skin

Inflammation

Lethargy

Intact skin is considered a primary defense against infection. Fever. the inflammatory response. and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.

Explanation

Intact skin is considered a primary defense against infection. Fever. the inflammatory response. and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.

5. The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed?

Bathe the patient’s entire body using 8 to 10 washcloths.

Assist the patient to a chair and provide bathing supplies.

Saturate a towel and blanket in a plastic bag. and then bathe the patient.

Assist the patient to the bathtub and provide a bath chair.

A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag. saturates them with a commercially prepared mixture of moisturizer. non rinse cleaning agent. and water; warms in them in a microwave. and then uses them to bathe the patient. A bag bath is a modification of the towel bath. in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub.

Explanation

A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag. saturates them with a commercially prepared mixture of moisturizer. non rinse cleaning agent. and water; warms in them in a microwave. and then uses them to bathe the patient. A bag bath is a modification of the towel bath. in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub.

6. A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One:

Admitted with unstable diabetes mellitus.

Who underwent surgical repair of a perforated bowel.

With a stage 3 sacral pressure ulcer.

Admitted with a urinary tract infection.

The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore. this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound. such as a stage 3 pressure ulcer. or with a client who has a urinary tract infection.

Explanation

The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore. this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound. such as a stage 3 pressure ulcer. or with a client who has a urinary tract infection.

7. Which of the following incidents requires the nurse to complete an occurrence report?

Medication given 30 minutes after scheduled dose time

Patient’s dentures lost after transfer

Worn electrical cord discovered on an IV infusion pump

Prescription without the route of administration

You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. A medication can be administered within a half-hour of the administration time without an error in administration; therefore. an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary.

Explanation

You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. A medication can be administered within a half-hour of the administration time without an error in administration; therefore. an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary.

8. Nurse Berta is facilitating a monthly mothers' class at a small village. As a knowledgeable nurse. she must know that a mother who breastfeeds her child passes on which antibody through breast milk?

IgA

IgE

IgG

IgM

Antibodies. which are also called immunoglobulins. take five basic forms. indicated as IgG. IgA. IgM. IgD and IgE. All have been detected in human milk. but by far the most abundant type is IgA. particularly the form known as secretory IgA. which is found in great amounts throughout the gut and respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues.

Explanation

Antibodies. which are also called immunoglobulins. take five basic forms. indicated as IgG. IgA. IgM. IgD and IgE. All have been detected in human milk. but by far the most abundant type is IgA. particularly the form known as secretory IgA. which is found in great amounts throughout the gut and respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues.

9. The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove:

Transient flora from the skin.

Resident flora from the skin.

All microorganisms from the skin.

Media for bacterial growth.

There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g.. when you touch a soiled dressing). You can remove these with hand washing. Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans. microbes must be able to use the body’s precise balance of food. moisture. nutrients. electrolytes. pH. temperature. and light. Food. water. and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms. except perhaps briefly when an antiseptic agent is used for cleansing.

Explanation

There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g.. when you touch a soiled dressing). You can remove these with hand washing. Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans. microbes must be able to use the body’s precise balance of food. moisture. nutrients. electrolytes. pH. temperature. and light. Food. water. and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms. except perhaps briefly when an antiseptic agent is used for cleansing.

10. The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting:

Separates the health record according to discipline

Organizes documentation around the patient’s problems

Highlights the patient’s concerns. problems. and strengths

Is designed to streamline documentation

In source-oriented charting. each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient’s problems. Focus charting highlights the patient’s concerns. problems. and strengths. Charting by exception is a unique charting system designed to streamline documentation.

Explanation

In source-oriented charting. each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient’s problems. Focus charting highlights the patient’s concerns. problems. and strengths. Charting by exception is a unique charting system designed to streamline documentation.