NCLEX Practice Exam for Fundamentals of Nursing #03

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Published on February 4, 2017 by NCLEX Exams

NCLEX Practice Exam for Fundamentals of Nursing #03 In Text Mode: All questions and answers are given for reading and answering at your own pace.

Question 1. Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A). Irrigate the patient with 1% Neosporin solution three times a daily.
B). Maintain the drainage tubing and collection bag level with the patient’s bladder.
C). Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity.
D). Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity.

Question 1 Answer: C). Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity.
Question 1 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.

Question 2. Which of the following will probably result in a break in sterile technique for respiratory isolation?
A). Failing to wear gloves when administering a bed bath.
B). Opening the patient’s window to the outside environment.
C). Opening the door of the patient’s room leading into the hospital corridor.
D). Turning on the patient’s room ventilator.

Question 2 Answer: C). Opening the door of the patient’s room leading into the hospital corridor.
Question 2 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.

Question 3. The ELISA test is used to:
A). Test blood to be used for transfusion for HIV antibodies.
B). Screen blood donors for antibodies to human immunodeficiency virus (HIV).
C). All of the above.
D). Aid in diagnosing a patient with AIDS.

Question 3 Answer: C). All of the above.
Question 3 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)

Question 4. Which of the following types of medications can be administered via gastrostomy tube?
A). Enteric-coated tablets that are thoroughly dissolved in water.
B). Capsules whole contents are dissolve in water.
C). Any oral medications.
D). Most tablets designed for oral use, except for extended-duration compounds.

Question 4 Answer: D). Most tablets designed for oral use, except for extended-duration compounds.
Question 4 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.

Question 5. 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?
A). 50 gtt/minute.
B). 13 gtt/minute.
C). 5 gtt/minute.
D). 25 gtt/minute.

Question 5 Answer: D). 25 gtt/minute.
Question 5 Explanation: 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

Question 6. The appropriate needle size for insulin injection is:
A). 22G, 1” long.
B). 22G, 1 ½” long.
C). 25G, 5/8” long.
D). 18G, 1 ½” long.

Question 6 Answer: C). 25G, 5/8” long.
Question 6 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.

Question 7. The purpose of increasing urine acidity through dietary means is to:
A). Inhibit the growth of microorganisms.
B). Decrease burning sensations.
C). Change the urine’s color.
D). Change the urine’s concentration.

Question 7 Answer: A). Inhibit the growth of microorganisms.
Question 7 Explanation: Microorganisms usually do not grow in an acidic environment.

Question 8. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
A). Cheyne-Strokes respirations and spontaneous pneumothorax.
B). Appneustic breathing, atypical pneumonia and respiratory alkalosis.
C). Respiratory acidosis, ateclectasis, and hypostatic pneumonia.
D). Kussmail’s respirations and hypoventilation.

Question 8 Answer: C). Respiratory acidosis, ateclectasis, and hypostatic pneumonia.
Question 8 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.

Question 9. All of the following nursing interventions are correct when using the Z-track method of drug injection except:
A). Use a needle that’s a least 1” long.
B). Prepare the injection site with alcohol.
C). Aspirate for blood before injection.
D). Rub the site vigorously after the injection to promote absorption.

Question 9 Answer: D). Rub the site vigorously after the injection to promote absorption.
Question 9 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.

Question 10. An infected patient has chills and begins shivering. The best nursing intervention is to:
A). Provide increased ventilation.
B). Provide increased cool liquids.
C). Provide additional bedclothes.
D). Apply iced alcohol sponges.

Question 10 Answer: C). Provide additional bedclothes.
Question 10 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.

Question 11. The two blood vessels most commonly used for TPN infusion are the:
A). Brachial and subclavian veins.
B). Brachial and femoral veins.
C). Subclavian and jugular veins.
D). Femoral and subclavian veins.

Question 11 Answer: C). Subclavian and jugular veins.
Question 11 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.

Question 12. A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:
A). Order a hemoglobin and hematocrit count 1 hour after the arteriography.
B). Check the pressure dressing for sanguineous drainage.
C). Assess a vital signs every 15 minutes for 2 hours.
D). Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours.

Question 12 Answer: A). Order a hemoglobin and hematocrit count 1 hour after the arteriography.
Question 12 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.

Question 13. After routine patient contact, hand washing should last at least:
A). 3 minutes.
B). 30 seconds.
C). 2 minute.
D). 1 minute.

Question 13 Answer: B). 30 seconds.
Question 13 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.

Question 14. 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:
A). Dysphagia.
B). Hypokalemia.
C). Anorexia.
D). Hyperkalemia.

Question 14 Answer: B). Hypokalemia.
Question 14 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.

Question 15. Which of the following conditions may require fluid restriction?
A). Renal Failure.
B). Fever.
C). Dehydration.
D). Chronic Obstructive Pulmonary Disease.

Question 15 Answer: A). Renal Failure.
Question 15 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.

Question 16. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
A). Touching the outside wrapper of sterilized material without sterile gloves.
B). Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container.
C). Placing a sterile object on the edge of the sterile field.
D). Using sterile forceps, rather than sterile gloves, to handle a sterile item.

Question 16 Answer: C). Placing a sterile object on the edge of the sterile field.
Question 16 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.

Question 17. Effective hand washing requires the use of:
A). Soap or detergent to promote emulsification.
B). Hot water to destroy bacteria.
C). All of the above.
D). A disinfectant to increase surface tension.

Question 17 Answer: A). Soap or detergent to promote emulsification.
Question 17 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.

Question 18. In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
A). Analysis.
B). Assessment.
C). Evaluation.
D). Planning.

Question 18 Answer: C). Evaluation.
Question 18 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.

Question 19. Which of the following procedures always requires surgical asepsis?
A). Vaginal instillation of conjugated estrogen.
B). Nasogastric tube insertion.
C). Urinary catheterization.
D). Colostomy irrigation.

Question 19 Answer: C). Urinary catheterization.
Question 19 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.

Question 20. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
A). Distended neck veins.
B). Hemoglobinuria.
C). Chest pain.
D). Urticaria.

Question 20 Answer: B). Hemoglobinuria.
Question 20 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.

Question 21. All of the following are common signs and symptoms of phlebitis except:
A). Edema and warmth at the IV insertion site.
B). Frank bleeding at the insertion site.
C). A red streak exiting the IV insertion site.
D). Pain or discomfort at the IV insertion site.

Question 21 Answer: B). Frank bleeding at the insertion site.
Question 21 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.

Question 22. Clay colored stools indicate:
A). Bile obstruction.
B). An effect of medication.
C). Upper GI bleeding.
D). Impending constipation.

Question 22 Answer: A). Bile obstruction.
Question 22 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.

Question 23. The nurse explains to a patient that a cough:
A). Is a protective response to clear the respiratory tract of irritants.
B). Can be inhibited by “splinting” the abdomen.
C). Is induced by the administration of an antitussive drug.
D). Is primarily a voluntary action.

Question 23 Answer: A). Is a protective response to clear the respiratory tract of irritants.
Question 23 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.

Question 24. All of the following are good sources of vitamin A except:
A). Apricots.
B). Carrots.
C). White potatoes.
D). Egg yolks.

Question 24 Answer: C). White potatoes.
Question 24 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.

Question 25. The appropriate needle gauge for intradermal injection is:
A). 22G.
B). 26G.
C). 20G.
D). 25G.

Question 25 Answer: B). 26G.
Question 25 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.

Question 26. The correct method for determining the vastus lateralis site for I.M. injection is to:
A). Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest.
B). Palpate a 1” circular area anterior to the umbilicus.
C). Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm.
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.

Question 26 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.
Question 26 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.

Question 27. The primary purpose of a platelet count is to evaluate the:
A). Potential for clot formation.
B). Presence of cardiac enzymes.
C). Presence of an antigen-antibody response.
D). Potential for bleeding.

Question 27 Answer: A). Potential for clot formation.
Question 27 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.

Question 28. Which of the following statements about chest X-ray is false?
A). Eating, drinking, and medications are allowed before this test.
B). A signed consent is not required.
C). Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist.
D). No contradictions exist for this test.

Question 28 Answer: D). No contradictions exist for this test.
Question 28 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.

Question 29. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
A). 7,000/mm³.
B). 25,000/mm³.
C). 10,000/mm³.
D). 4,500/mm³.

Question 29 Answer: B). 25,000/mm³.
Question 29 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.

Question 30. When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
A). Waist tie and neck tie at the back of the gown.
B). Inside of the gown.
C). Waist tie in front of the gown.
D). Cuffs of the gown.

Question 30 Answer: A). Waist tie and neck tie at the back of the gown.
Question 30 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.

Question 31. Effective skin disinfection before a surgical procedure includes which of the following methods?
A). Shaving the site on the day before surgery.
B). Applying a topical antiseptic to the skin on the evening before surgery.
C). Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery.
D). Having the patient take a tub bath on the morning of surgery.

Question 31 Answer: C). Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery.
Question 31 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.

Question 32. The mid-deltoid injection site is seldom used for I.M. injections because it:
A). Can accommodate only 1 ml or less of medication.
B). Does not readily parenteral medication.
C). Can be used only when the patient is lying down.
D). Bruises too easily.

Question 32 Answer: A). Can accommodate only 1 ml or less of medication.
Question 32 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).

Question 33. Which of the following patients is at greater risk for contracting an infection?
A). A patient receiving broad-spectrum antibiotics.
B). A patient with leukopenia.
C). A postoperative patient who has undergone orthopedic surgery.
D). A newly diagnosed diabetic patient.

Question 33 Answer: B). A patient with leukopenia.
Question 33 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.

Question 34. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
A). 600 mg.
B). 60 mg.
C). 0.6 mg.
D). 10 mg.

Question 34 Answer: A). 600 mg.
Question 34 Explanation: gr 10 x 60mg/gr 1 = 600 mg

Question 35. All of the following measures are recommended to prevent pressure ulcers except:
A). Providing meticulous skin care.
B). Massaging the reddened are with lotion.
C). Using a water or air mattress.
D). Adhering to a schedule for positioning and turning.

Question 35 Answer: B). Massaging the reddened are with lotion.
Question 35 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.

Question 36. A clinical nurse specialist is a nurse who has:
A). Received credentials from the Philippine Nurses’ Association.
B). Completed a master’s degree in the prescribed clinical area and is a registered professional nurse..
C). Graduated from an associate degree program and is a registered professional nurse.
D). Been certified by the National League for Nursing.

Question 36 Answer: B). Completed a master’s degree in the prescribed clinical area and is a registered professional nurse..
Question 36 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.

Question 37. 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:
A). Apply corn starch soaks to the rash.
B). Administer the medication with an antihistamine.
C). Administer the medication and notify the physician.
D). Withhold the moderation and notify the physician.

Question 37 Answer: D). Withhold the moderation and notify the physician.
Question 37 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.

Question 38. A natural body defense that plays an active role in preventing infection is:
A). Body hair.
B). Hiccupping.
C). Rapid eye movements.
D). Yawning.

Question 38 Answer: A). Body hair.
Question 38 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.

Question 39. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
A). Leg muscles.
B). Back muscles.
C). Upper arm muscles.
D). Abdominal muscles.

Question 39 Answer: A). Leg muscles.
Question 39 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.

Question 40. Parenteral penicillin can be administered as an:
A). IM injection or an IV solution.
B). Intradermal or subcutaneous injection.
C). IM or a subcutaneous injection.
D). IV or an intradermal injection.

Question 40 Answer: A). IM injection or an IV solution.
Question 40 Explanation: Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.

Question 41. The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:
A). Demonstrate the procedure to the patient and encourage to ask questions.
B). Have the patient repeat the nurse’s instructions using her own words.
C). Ask the patient if he/she has used ear drops before.
D). Ask the patient to demonstrate the procedure.

Question 41 Answer: D). Ask the patient to demonstrate the procedure.
Question 41 Explanation: Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.

Question 42. Sterile technique is used whenever:
A). Protective isolation is necessary.
B). Terminal disinfection is performed.
C). Invasive procedures are performed.
D). Strict isolation is required.

Question 42 Answer: C). Invasive procedures are performed.
Question 42 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.

Question 43. Which element in the circular chain of infection can be eliminated by preserving skin integrity?
A). Portal of entry.
B). Host.
C). Reservoir.
D). Mode of transmission.

Question 43 Answer: A). Portal of entry.
Question 43 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.

Question 44. The most appropriate time for the nurse to obtain a sputum specimen for culture is:
A). Early in the morning.
B). After aerosol therapy.
C). After the patient eats a light breakfast.
D). After chest physiotherapy.

Question 44 Answer: A). Early in the morning.
Question 44 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.

Question 45. A patient who develops hives after receiving an antibiotic is exhibiting drug:
A). Idiosyncrasy.
B). Allergy.
C). Synergism.
D). Tolerance.

Question 45 Answer: B). Allergy.
Question 45 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.

Question 46. Which of the following nursing interventions is considered the most effective form or universal precautions?
A). Follow enteric precautions.
B). Discard all used uncapped needles and syringes in an impenetrable protective container.
C). Cap all used needles before removing them from their syringes.
D). Wear gloves when administering IM injections.

Question 46 Answer: B). Discard all used uncapped needles and syringes in an impenetrable protective container.
Question 46 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.

Question 47. Thrombophlebitis typically develops in patients with which of the following conditions?
A). Increases partial thromboplastin time.
B). Chronic Obstructive Pulmonary Disease (COPD).
C). Acute pulsus paradoxus.
D). An impaired or traumatized blood vessel wall.

Question 47 Answer: D). An impaired or traumatized blood vessel wall.
Question 47 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.

Question 48. Immobility impairs bladder elimination, resulting in such disorders as
A). Urine retention, bladder distention, and infection.
B). Increased urine acidity and relaxation of the perineal muscles, causing incontinence.
C). Diuresis, natriuresis, and decreased urine specific gravity.
D). Decreased calcium and phosphate levels in the urine.

Question 48 Answer: A). Urine retention, bladder distention, and infection.
Question 48 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.

Question 49. Which of the following blood tests should be performed before a blood transfusion?
A). Blood typing and cross-matching.
B). Prothrombin and coagulation time.
C). Complete blood count (CBC) and electrolyte levels..
D). Bleeding and clotting time.

Question 49 Answer: A). Blood typing and cross-matching.
Question 49 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.

Question 50. All of the following statement are true about donning sterile gloves except:
A). The inside of the glove is considered sterile.
B). The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove..
C). The first glove should be picked up by grasping the inside of the cuff..
D). The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist.

Question 50 Answer: A). The inside of the glove is considered sterile.
Question 50 Explanation: The inside of the glove is always considered to be clean, but not sterile.

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