Fundamentals Of Nursing NCLEX Quiz 32
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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:
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Interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing.
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Congratulate the nurse on the use of good technique.
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Discuss dressing change technique with the nurse at a later date.
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Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
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All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.
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- 2.
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:
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Correct illumination of the environment.
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Amount of regular exercise.
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The resting pulse rate.
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Status of salt intake.
Correct Answer
A. Correct illumination of the environment.Explanation
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.Rate this question:
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- 3.
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?
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“If I drop the 4 X 4s on the floor. I can use them as long as they are not soiled.”
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“If I drop the 4 X 4s on the floor. I can use them if I rinse them with sterile normal saline.”
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“If I question the sterility of any dressing material. I should not use it.”
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“I should put on my sterile gloves. then open the bottle of saline to soak the 4 X 4s.”
Correct Answer
A. “If I question the sterility of any dressing material. I should not use it.”Explanation
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.Rate this question:
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- 4.
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?
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Masks should be worn with all client contact.
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Gloves should be worn for contact with nonintact skin. mucous membranes. or soiled items.
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Isolation gowns are not needed.
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A private room is always indicated.
Correct Answer
A. Gloves should be worn for contact with nonintact skin. mucous membranes. or soiled items.Explanation
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. non intact 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.Rate this question:
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- 5.
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?
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A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood.
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An aide wears gloves to feed a helpless client.
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An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy.
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A pregnant worker refuses to care for a client known to have AIDS.
Correct Answer
A. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy.Explanation
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 mucous 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.Rate this question:
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- 6.
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?
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Bathing together.
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Coughing on each other.
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Sharing pacifiers.
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Eating off the same plate.
Correct Answer
A. Bathing together.Explanation
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.Rate this question:
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- 7.
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:
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Verbalizes the role of sexual activity in spread of the disorder.
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States he will make arrangements to drop his college classes.
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Acknowledges the need to avoid all contact sports.
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Says he will avoid close contact with his three-year-old niece.
Correct Answer
A. Verbalizes the role of sexual activity in spread of the disorder.Explanation
HIV 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 HIV. 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 HIV . There is no need to limit casual contact with children.Rate this question:
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- 8.
Which question is least useful in the assessment of a client with AIDS?
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Are you a drug user?
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Do you have many sex partners?
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What is your method of birth control?
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How old were you when you became sexually active?
Correct Answer
A. How old were you when you became sexually active?Explanation
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.Rate this question:
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- 9.
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:
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Independently ambulating around the unit.
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Reading the routine preoperative education materials.
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Maneuvering safely after orientation to the room.
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Using a bedpan for elimination needs.
Correct Answer
A. Maneuvering safely after orientation to the room.Explanation
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.Rate this question:
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- 10.
A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to:
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Prevent metabolic breakdown of xanthine to uric acid
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Prevent uric acid from precipitating in the ureters
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Enhance the production of uric acid to ensure adequate excretion of urine
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Ensure that the chemotherapy doesn’t adversely affect the bone marrow
Correct Answer
A. Prevent metabolic breakdown of xanthine to uric acidExplanation
The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.Rate this question:
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Mar 21, 2023Quiz Edited by
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Aug 29, 2017Quiz Created by
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