PN 2006 Final Exam
a. Burns - ANS The nurse works in a small rural hospital with a wide variety of clients. Of the clients
admitted this afternoon, the nurse recognizes that the individual with which of the following
conditions is most susceptible to infection?
a. Burns
b. Diabetes
c. Pulmonary emphysema
d. Peripheral vascular disease
a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves. - ANS The
nursing assistant is learning how to use protective equipment when caring for a client in isolation.
The nursing assistant is instructed in the correct sequence for putting on the protective equipment.
Which of the following describes the correct sequence?
a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves.
b. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves.
c. Wash her hands, put on the gown, apply gloves, and then put on mask and eyewear.
d. Put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves.
b. Throw the packing away, and prepare a new one. - ANS The client has a large, deep abdominal
incision that requires a dressing. The incision is packed with sterile 1.75-cm packing and covered
with a dry, 10 × 10-cm gauze. When changing the dressing, the nurse accidentally drops the packing
onto the client's abdomen. Which of the following actions should the nurse take?
a. Add alcohol to the packing and insert it into the incision.
b. Throw the packing away, and prepare a new one.
c. Pick up the packing with sterile forceps, and gently place it into the incision.
d. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves.
b. Check integrity of sterile packages prior to use. - ANS The client requires a sterile dressing change.
Which of the following is an appropriate intervention for the nurse to implement in maintaining
sterile asepsis?
,a. Put sterile gloves on before opening sterile packages.
b. Check integrity of sterile packages prior to use.
c. Place the cap of the sterile solution well within the sterile field.
d. Place sterile items on the very edge of the sterile drape.
a. Inserting an intravenous catheter - ANS Which one of the following indicates that the nurse is
using surgical aseptic technique?
a. Inserting an intravenous catheter
b. Placing soiled linen in moisture-resistant bags
c. Disposing of syringes in puncture-proof containers
d. Washing hands before changing a dressing
c. The first small amount of sterile solution should be poured and discarded. - ANS The nurse
recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent
with sterile asepsis?
a. Clean forceps may be used to move items on the sterile field.
b. Sterile fields may be prepared well in advance of the procedures.
c. The first small amount of sterile solution should be poured and discarded.
d. Wrapped sterile packages should be opened starting with the flap closest to the nurse.
b. Confusion - ANS The nurse suspects that an older adult client may have pneumonia. Older adult
clients may react differently to infectious processes, so the nurse is alert to atypical signs and
symptoms, such as which one of the following?
a. Hypotension
b. Confusion
c. Erythema
d. Chills
, c. Maintaining a scrub for two to six minutes - ANS The nurse is preparing to assist with a sterile
procedure in the surgical suite. Which of the following is an appropriate technique that the nurse
includes in the surgical scrub?
a. Keeping the hands below the elbows throughout the scrub
b. Using a brush on the palms and dorsal surface of the hands
c. Maintaining a scrub for two to six minutes
d. Washing well around all artificial nails
b. Wear an N-95 mask, gloves, face shield, and isolation gown. - ANS The patient is in isolation in a
negative-pressure room for active tuberculosis. He coughs and spews large amounts of blood-tinged
sputum but is too weak to cover his mouth and nose with a tissue. Which is the most important
intervention for the nurse to implement for self-protection while providing nursing care?
a. Cover the patient's mouth and nose snugly with a surgical mask.
b. Wear an N-95 mask, gloves, face shield, and isolation gown.
c. Place tissues and a contaminated waste container within reach.
d. Use a properly fitted surgical mask and gloves to help with tissues.
c. Set the tray aside and proceed with the dressing change. - ANS The nurse completes preparation
of the sterile field to change a patient's dressing when the patient's dinner tray arrives. Which action
should the nurse take?
a. Use the sterile field on another patient in another room.
b. Change the dressing using clean technique to save time.
c. Set the tray aside and proceed with the dressing change.
d. Cover the setup with a sterile drape and let the patient eat.
b. Put fluid holders near the edge of the field. - ANS The nurse is preparing a sterile field with several
items on it. Which action should the nurse implement to maintain a sterile field?
a. Flip sterile objects onto the sterile field.
b. Put fluid holders near the edge of the field.
c. Wear sterile gloves to open sterile packs.
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