Fundamentals of Nursing N192 Exam
Questions And 100% Correct Answers.
1. A nurse is following the principles of medical asepsis when performing patient care in a hospital
setting. Which nursing action performed by the nurse follows these recommended guidelines? - Answer
1. c. According to the principles of medical asepsis, the nurse should move equipment away from the
body when brushing, scrubbing, or dusting articles to prevent contaminated particles from settling on
the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from
touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated.
The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent
having the cleaner areas soiled by the dirtier areas.
2. A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up
in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which
stage of infection? - Answer 2. b. During the prodromal stage, the person has vague signs and
symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the
incubation period, and they are more specific during the full stage of illness, before disappearing by the
convalescent period.
3. A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately
use an alcohol-based handrub to decontaminate the hands? Select all that apply. - Answer 3. a, c, d, f.
It is recommended to use an alcohol-based handrub in the following situations: before direct contact
with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly
soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or
invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive
procedure; if moving from a contaminated body site to a clean body site; and after contact with objects
contaminated by the patient.
4. A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly
soiled. Which steps in this procedure are performed correctly? Select all that apply. - Answer 4. b, e, f.
Proper hand hygiene includes removing jewelry with the exception of a plain wedding band, wetting the
hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap,
using friction motion for at least 15 seconds, washing to one inch above the wrists with a friction motion
for at least 15 seconds, and rinsing thoroughly with water flowing toward fingertips.
5. The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing
change, a procedure that requires surgical asepsis. The nurse must: - Answer 5. d. Considering the
,outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from
splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps
soaked in disinfectant are not considered sterile.
6. The nurse caring for patients in a hospital setting institutes CDC standard precaution
recommendations for which category of patients? - Answer 6. d. Standard precautions apply to all
patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These
recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin;
and mucous membranes.
7. In addition to standard precautions, the nurse would initiate droplet precautions for which patients?
Select all that apply. - Answer 7. a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses
transmitted by large-particle droplets and require droplet precautions in addition to standard
precautions. Airborne precautions are used for patients who have infections spread through the air with
small particles, for example, tuberculosis, varicella, and rubeola. Contact precautions are used for
patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.
8. A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is
scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an
instrument in the sterile field. What is the appropriate nursing action in this situation? - Answer 8. c. If
the patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile field. If
the patient is confused, the nurse should have someone assist by holding the patient's hand and
reinforcing what is happening.
9. A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an
appropriate action when performing this task? - Answer 9. d. To add a sterile solution to a sterile field,
the nurse would open the solution container according to directions and place the cap on the table away
from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile
field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches
(10 to 15 cm).
10. A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? -
Answer 10. c. If an impervious gown has been tied in front of the body at the waist, the nurse should
untie the waist strings before removing gloves. Gloves are always removed first because they are most
likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed
thoroughly after the equipment has been removed and before leaving the room.
, 11. A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when
administering the patient's medications. What would be the priority action of the nurse following the
exposure? - Answer 11. b. When a needlestick injury occurs, the nurse should wash the exposed area
immediately with warm water and soap, report the incident to the appropriate person and complete an
incident injury report, consent to and await the results of blood tests, consent to postexposure
prophylaxis, and attend counseling sessions regarding safe practice to protect self and others.
12. The nurse assesses patients to determine their risk for health care-associated infections. Which
hospitalized patient is most at risk for developing this type of infection? - Answer 12. c. Indwelling
urinary catheters have been implicated in most health care-associated infections. Cigarette smoking, a
normal white blood cell count, and a vegetarian diet have not been implicated as risk factors for HAIs.
13. A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open
reddened area over his sacrum. What is a priority nursing diagnosis for this patient? - Answer 13. d.
The priority diagnosis in this situation is the possibility of an infection developing in the open skin area.
The others may be potential or probable diagnoses for this patient and may also require nursing
interventions after the first diagnosis is addressed.
14. A nurse teaches a patient at home to use clean technique when changing a wound dressing. This
practice is considered: - Answer 14. b. In the home setting, where the patient's environment is more
controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the
appropriate procedure for the home and is neither unethical nor grossly negligent.
15. A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C.
difficile infection. Which nursing action related to this activity promotes safe, effective patient care? -
Answer 15. b. When using PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE
before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the
doorway or anteroom.
1. A nurse is scheduling hygiene for patients on her unit. What is the most important consideration when
planning a patient's personal hygiene? - Answer . b. Bathing practices and cleansing habits and rituals
vary widely. The patient's preferences should always be taken into consideration, unless there is a clear
threat to health. The patient and nurse should work together to come to a mutually agreeable time and
method to accomplish the patient's personal hygiene. The availability of staff to assist may be important,
but the patient's preferences are a higher priority..
2. A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential
part of nursing care. What are some of the benefits of providing this care? Select all that apply. - Answer
