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Fundamentals Exam 2 CH 31 Test Bank 2024/2025 Questions With Completed & Verified Solution.
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Fundamentals Exam 2 CH 31 Test Bank 2024/2025 Questions With Completed & Verified Solution.
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Fundamentals Exam 2 CH 31 Test BankQuestions
The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis?
1. Disinfecting an item before adding it to a sterile field
2. Allowing sterile gloved hands to fall below the waist
3. Suctioning the oral cavity of an unconscious client
4. Touching only the inside surface of the first glove while pulling it onto the hand
Touching only the inside surface of the first glove while pulling it onto the hand
Rationale 1: Disinfecting an item is an example of medical asepsis, not surgical asepsis.
Rationale 2: If sterile gloved hands fall below the waist, they are considered to be unsterile.
Rationale 3: Suctioning the oral cavity of a client is considered contaminating.
Rationale 4: Touching only the inside surface of the first glove while pulling it onto the hand is
the correct technique when applying sterile gloves. This prevents contamination of the outside
of the glove, which must remain sterile.
The nurse is using medical asepsis when providing client care. Which action did the nurse
demonstrate?
1. Administering parenteral medications
2. Changing a dressing
3. Performing a urinary catheterization
4. Using personal protective equipment
Using personal protective equipment
Rationale 1: Administering parenteral medications requires surgical asepsis.
,Rationale 2: Changing a dressing requires surgical asepsis.
Rationale 3: Performing a urinary catheterization requires surgical asepsis.
Rationale 4: Using personal protective equipment demonstrates medical asepsis.
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The nurse is reviewing the care needs for a group of assigned clients. Which client should the
nurse recognize as being most at risk for a nosocomial infection?
1. A client in the emergency department with abdominal pain
2. A 19-year-old woman in her first trimester of pregnancy
3. A 72-year-old male client with COPD
4. An 86-year-old female client on steroid therapy
An 86-year-old female client on steroid therapy
Rationale 1: A client in the emergency department with abdominal pain has just arrived in the
facility, and not enough time has elapsed for this client to be considered to have a nosocomial
infection. If this client has an infection, it would be community acquired.
Rationale 2: The 19-year-old female who is pregnant is at a low risk.
Rationale 3: The 72-year-old male with COPD is at a lower risk for infection than the 82-year-old
because the older client has a weakened immune system because of taking steroids.
, Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th 706
Rationale 4: The client most at risk for a nosocomial infection is the client who is 86 years old
and on steroid therapy. The very old and very young are most susceptible to infections. The
86-year-old client is also on steroid therapy, which compromises the immune system.
The nurse is preparing discharge teaching for a client recovering from surgery. What instruction
is the most important for the nurse to give this client who has a surgical wound?
1. Adjust the diet so it contains more fruits and vegetables.
2. Apply lubricating lotion to the edges of the wound.
3. Notify the physician of any edema, heat, or tenderness at the wound site.
4. Thoroughly irrigate the wound with hydrogen peroxide.
Notify the physician of any edema, heat, or tenderness at the wound site.
Rationale 1: Increasing intake of fruits and vegetables would increase vitamin C, which helps
with wound healing, but more protein would be the best choice.
Rationale 2: Applying lubricating lotion to the edges of a wound would impede the healing
process.
Rationale 3: A client being discharged with an open surgical wound has to be instructed on the
detection of infection because the skin is the first line of defense. Signs such as edema, heat,
and tenderness would indicate a local infection.
Rationale 4: Irrigating with hydrogen peroxide would break down good granulating tissue, so this
would not increase healing.
A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this
client?
1. Edema, rubor, heat, and pain
2. Fever, malaise, anorexia, nausea, and vomiting
3. Palpitations, irritability, and heat intolerance
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