NS 2 QUIZ 2 FUNDA & HA

1. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis.
Which of the following nursing measures should the nurse do FIRST?
A. Institute seizure precautions C. Place in respiratory isolation
B. Assess neurologic status D. Assess vital signs
Answer C. The initial therapeutic management of acute bacterial meningitis includes isolation
precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses
should take necessary precautions to protect themselves and others from possible infection.
2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type
of isolation is MOST appropriate for this client?
A. Reverse isolation C. Standard precautions
B. Respiratory isolation D. Contact isolation
Answer D. Contact or Body Substance Isolation (BSI) involves the use of barrier protection
(e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with
any body fluid is expected. When determining the type of isolation to use, one must consider
the mode of transmission. The hands of personnel continues to be the principal mode of
transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is
limited to the sputum in this example, precautions are taken if contact with the patient"s
sputum is expected. A private room and BSI, along with good hand washing techniques, are
the best defense against the spread of MRSA pneumonia
3. Several clients are admitted to an adult medical unit. The nurse would ensure airborne
precautions for a client with which of the following medical conditions?
A. A diagnosis of AIDS and cytomegalovirus
B. A positive x-ray for a suspicious tuberculin lesion
C. A tentative diagnosis of viral pneumonia
D. Advanced carcinoma of the lung
Answer B. The client who must be placed in airborne precautions is the client with a positive
PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.
4. Which of the following is the FIRST priority in preventing infections when providing care for a client?
A. Handwashing
B. Wearing gloves
C. Using a barrier between client's furniture and nurse's bag
D. Wearing gowns and goggles
Answer A. Handwashing remains the most effective way to avoid spreading infection. However,
too often nurses do not practice good handwashing techniques and do not teach families to do
so. Nurses need to wash their hands before and after touching the client and before entering
the nursing bag.
5. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected
during a pre-employment physical. Although frightened about her diagnosis, she is anxious to
cooperate with the therapeutic regimen. The teaching plan includes information regarding the
most common means of transmitting the tubercle bacillus from one individual to another. Which
contamination is usually responsible?
A. Hands. C. Milk products.
B. Droplet nuclei. D. Eating utensils.
Answer B. Hands are the primary method of transmission of the common cold. The most
frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is
present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected
person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with
contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid,
or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous
microbes can be transmitted via reservoirs such as linens or eating utensils.
6. You are aware that standard precautions apply to the following except:
A. Blood and blood products
B. Bodily fluids, secretions, excretions including sweat
C. Bodily fluids, secretions, excretions excluding sweat
D. Non-intact skin, and mucous membranes
Answer: C. Sweat is included in applying the standard precautions.
7. When wearing a disposable mask, one must know to follow the following except:
A. Keep talking to a minimum while wearing a mask to reduce respiratory airflow.
B. A mask that has become moist does not provide a barrier to microorganisms and is
ineffective and is discarded.
C. A mask that has become moist does not provide a barrier to microorganisms and should be
air dried to reuse.
D. A properly applied mask fits snugly over the mouth and nose so pathogens and body fluids
cannot enter or escape
E. through the sides.
Answer: C. Masks that are moist are ineffective and should be discarded.
8. The nurse in charge is evaluating the infection control procedures on the unit. Which finding
indicates a break in technique and the need for education of staff?
A. The nurse aide is not wearing gloves when feeding an elderly client.
B. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to
another department for testing.
C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client
care.
D. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict
isolation.
Answer C. There is no need to wear gloves when feeding a client. However, universal precautions
(treating all blood and body fluids as if they are infectious) should be observed in all situations. A
client with active tuberculosis should be on respiratory precautions. Having the client wear a mask
when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis
should not give direct client care or handle client-care equipment until the condition resolves.
Strict isolation requires the use of mask, gown, and gloves.
9. 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:
A. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to
remove the old dressing.
B. congratulate the nurse on the use of good technique.
C. discuss dressing change technique with the nurse at a later date.
D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of
the dirty dressing and gloves.
Answer D. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile
gloves does not put the client in danger so discussion of this can wait until later. The staff nurse
is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The
nurse should wash her hands after removing the soiled dressing and before donning sterile gloves
to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing
and before donning the sterile gloves to clean and dress the wound. Not doing this compromises
client safety and should be brought to the immediate attention of the nurse. The staff nurse is
doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However,
the use of sterile gloves does not put the client in danger so discussion of this can wait until later.
However, the nurse should wash her hands after removing the soiled dressing and before donning
sterile gloves to clean and dress the wound. Not doing this compromises client safety and should
be brought to the immediate attention of the nurse.
10.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?
A. "If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled."
B. "If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline."
C. "If I question the sterility of any dressing material, I should not use it."
D. "I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s."
Answer C. 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.
11.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?
A. Masks should be worn with all client contact.
B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
C. Isolation gowns are not needed.
D. A private room is always indicated.
Answer B. 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, nonintact 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.
12.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?
A. Masks should be worn with all client contact.
B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
C. Isolation gowns are not needed.
D. A private room is always indicated.
Answer B. 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, nonintact 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.
13.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?
A. A lab technician rests his hand on the desk to steady it while recapping the needle after
drawing blood.
B. An aide wears gloves to feed a helpless client.
C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction
a tracheostomy.
D. A pregnant worker refuses to care for a client known to have AIDS.
Answer C. 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 mucus 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.
14.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?
A. Bathing together. C. Sharing pacifiers.
B. Coughing on each other. D. Eating off the same plate.
Answer A. 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.
15.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:
A. verbalizes the role of sexual activity in spread of the disorder.
B. states he will make arrangements to drop his college classes.
C. acknowledges the need to avoid all contact sports.
D. says he will avoid close contact with his three-year-old niece.
Answer A. The AIDS virus 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 AIDS. 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 AIDS.
There is no need to limit casual contact with children.
16.If an infectious disease can be transmitted directly from one person to another, it is:
A. A susceptible host
B. A communicable disease
C. A portal of entry to a host
D. A portal of exit from the reservoir

B - If an infectious disease is transmitted directly from one person to another, it is a communicable

disease. Portals of entry and exit are the mechanisms of disease transmission. A susceptible host
is a person who can acquire an infection.
17. A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client
seems angry but knows this is a normal response to isolation. The best intervention is to:

A. Provide a dark, quiet room to calm the client.

B. Explain the isolation procedures and provide meaningful stimulation.
C. Reduce the level of precautions to keep the client from becoming angry.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection.

B - When a client is in isolation, the nurse should take measures to improve the client's stimulation
and make sure to explain the isolation procedures. Darkening the room can increase the sense of
isolation. The nurse should not change the isolation level but should provide plenty of emotional
support and make time for the client to prevent a sense of isolation. As long as family and
caregivers follow infection precautions, there is no reason to limit contact with these individuals.
(BONUS)

18.In what situation does a nurse needs to wear a gown?

A. The client's hygiene is poor.

B. The client has acquired immunodeficiency syndrome (AIDS) or hepatitis.
C. The nurse is assisting with medication administration.
D. Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.

D - Gowns should be worn when there is a possibility that blood or body fluids could get on the
nurse's clothes or when the client is on contact isolation status. The other options are not
appropriate uses of gowns.

19.To remove a glove that is contaminated, what should the nurse do first?
A. Rinse the glove before removing it to minimize contamination.
B. Pull the glove off the back of the hand until it slides off the entire hand and discard it.
C. Grasp the outside of the cuff or palm of the glove and pull it away from the hand without
touching the wrist or fingers.
D. Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the
hand by the other gloved hand.

C - When the outside of the cuff is grasped with the contaminated gloved hand, then dirty to dirty
remains intact. Pulling the glove away from the hand entirely without touching the wrist or fingers
further minimizes the contamination by the gloved hand. If the nurse puts the gloved thumb inside
the glove, the nurse has contaminated the bare hand with a contaminated thumb. Pulling the
glove off by holding it at the back sounds good and could minimize contamination, but it is very
difficult to remove a glove this way without the risk of tearing the glove and creating contamination
through the tear. If excessive secretions are present on gloves, then a towel or the drape could
be used to wipe off excessive secretions before an attempt is made to remove the gloves.

20.What is the single most effective method by which the nurse can break the chain of infection?
A. Give all clients antibiotics.
B. Wear gloves when caring for all clients.
C. Wash hands between procedures and clients.
D. Make sure housekeeping staff are using the right chemicals.
C - Adequate hand washing will remove bacteria and wastes or contaminates to minimize cross
contamination between clients. Use of alcohol-based waterless antiseptics between clients is also
effective if the guidelines for using these cleansers are followed. Giving all clients antibiotics is
impractical and is a source of new superinfections when persons who do not need antibiotics are
given them and then the bacteria mutate to become resistant to older drugs. It would be both
unethical and costly to try to control infections by treating everyone in the facility. Although
wearing gloves to perform procedures that carry the risk of direct contact with contaminated
material is a correct method of bacterial control, wearing gloves at all times is impractical,
expensive, and unrealistic. Housekeeping staff are trained to use the correct agents for
decontamination and disinfection of all surfaces that place clients at risk.

21.The nurse has just admitted a client to rule out active hepatitis B. The client is confused, spitting
and scratching everyone who enters the room. The nurse should:
A. Wait an hour until the client calms down and then use gloves when touching the client.
B. Use gloves, mask, face shield, and gown when entering the room to perform the initial
assessment.
C. Administer a sedative and then perform the assessment after the client is asleep; no
precautions would be needed.
D. Realize that isolation equipment might further confuse the client and avoid using a face
mask and shield but use gown and gloves.
B - Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination
by spitting (saliva can be a source of bacterial contamination) and scratching others, which can
break the skin and become a source of risk. All of the barriers listed would minimize cross
contamination from the client to the nurse. Even though gloves may be all that is needed because
of limited contact with the client, after an hour the client will remain confused and may not
understand. The client may become aggressive again and spit or scratch, and other barriers are
needed to stop that source of possible risks. A sedative may be given if needed, but trying to
perform an assessment when the client is asleep is not appropriate and will prevent the nurse
from successfully establishing rapport with the client. Although masks and shields might be
frightening to some confused clients, if the client is spitting and body fluids could be exchanged,
a barrier should still be used.
22.For which airborne disease(s) would the nurse be required to use gloves, respiratory devices,
and gown when in close contact with the client?
A. Herpes simplex, scabies
B. Viral pneumonia, atelectasis
C. Chickenpox, pulmonary tuberculosis
D. Multidrug-resistant respiratory syncytial virus
C - Airborne precautions are required for chickenpox and tuberculosis, because in these diseases
small particles float in the air and a barrier is required to prevent contamination of the nurse. A
respiratory protection device is form-fitted to the face to prevent the escape of air around the seal.
Gloves and gown are also worn to prevent contamination and transport of infective particles to
other clients. For viral pneumonia a regular mask is used as a barrier because the particles do not
float in the air and are more likely to be found on surfaces unless coughing or spitting is occurring.
Atelectasis is the collapse of alveoli, and airborne precautions are not needed. Herpes and scabies
are spread by contact, and gloves and gown would be necessary; masks would not be needed.
For multidrug-resistant respiratory syncytial virus the protection of the client would be as
important as preventing the spread of these disorders. Therefore, gown, gloves, and mask would
be used as in reverse isolation to prevent cross contamination of the client.
23.Before the nurse washes the hands when leaving an isolation room, what is the last thing that
is removed?
A. Mask C. Goggles
B. Gown D. Head cover
A - Remove goggles by touching only the ear pieces. Next remove the gown and the nurse should
untie the neck ties and allow the gown to fall from shoulders and only touch the inside of the
gown. The mask is removed last by removing the elastic from the ears or untying the bottom mask
string followed by the top mask string. In both cases the nurse's hands only touch the ties of the
mask. Head covers are usually not worn in isolation rooms as a barrier.
24.What part of a sterile glove is considered contaminated once the glove is applied by the open
gloving method?
A. The inner cuff of each glove
B. The back of the gloved hands
C. Any surface that the powder from the gloves touches
D. The outer part of the glove that touched the inner wrapper
A - The cuff is folded and touched to apply the glove; thus, it becomes contaminated during
application of the glove. Usually the cuff will fall down over the wrist, but if it does not, then it is
considered unsterile and should not be touched during the procedure. All of the outer part of the
glove is sterile unless it has been contaminated. The inner wrapper that held the sterile glove is
not contaminated unless one touches it. Therefore, the outer part of the glove can touch it without
contamination. The powder is sterile and will not contaminate anything it touches.

25.The nurse has redressed a client's wound and now plans to administer a medication to the
client. It is important to:
A. Leave the gloves on to administer the medication
B. Remove gloves and perform hand hygiene before leaving the room
C. Remove gloves and perform hand hygiene before administering the medication
D. Leave the medication on the bedside table to avoid having to remove gloves before leaving
the client's room
C. Remove gloves and perform hand hygiene before administering the medication

26. A nurse is working with a patient who has a contagious condition. In recalling the chain of
infection, the nurse knows that an environment favorable for the growth and reproduction of
an infectious agent is referred to as ____.
a. a reservoir c. a vector
b. a susceptible host d. a portal of entry
A . a reservoir which is any environment that is favorable for the growth and reproduction of an
infectious agent

27.A nurse is volunteering in an indigent clinic. She is seeing a patient whom she suspects has
active tuberculosis. In this disease process, which of the following body systems serves as both
the reservoir and portal of entry for this infection?
A. the hematologic system C. the respiratory system
B. the gastrointestinal system D. the integumentary system
C . Tuberculosis (TB) is a bacterial infection that mainly infects the respiratory system caused by
the organism Mycobacterium tuberculosis. It is spread via inhalation of droplets that contain the
bacteria that are released during coughing, sneezing, etc. There are two forms of TB: latent and
active. Patients are contagious only during an active TB infection, and they usually feel sick during
this time. Those with latent infection are not infectious and do not feel ill. The respiratory system
is where this organism best grows and reproduces (a reservoir) and how one becomes infected
with the organism via inhalation (portal of entry).

Case Scenario:
A 52-year-old female client comes to the clinic for her routine physical examination. She has a
history of hypertension and hyperlipidemia. She is currently taking medications for both
conditions. The nurse is performing a health assessment on the client.

28.During the client's health assessment, which of the following should the nurse prioritize first?
A. Collecting a thorough health history.
B. Assessing vital signs and overall appearance.
C. Inspecting the client's skin for abnormalities.
D. Assessing the client's cardiovascular system.
Answer: b. Assessing vital signs and overall appearance.
Rationale: Assessing vital signs and overall appearance are essential components of the initial
assessment because they provide an indication of the client's physiological status and overall
health. Vital signs and overall appearance include assessment of the client's body temperature,
blood pressure, pulse, respiratory rate, and general appearance.

29.Which of the following is an example of subjective data that the nurse can obtain during the
client's health history?
A. Blood pressure. B. Heart rate.
 C. Family medical history. D. Body mass index.
Answer: c. Family medical history.
Rationale: Subjective data are information that the client provides about their symptoms, feelings, and
experiences. Family medical history is an example of subjective data that can provide valuable
information about the client's genetic predisposition to certain health conditions.

30.What is the purpose of the inspection phase of a health assessment?

A. To measure the client's vital signs.
B. To observe the client's body movements.
C. To assess the client's skin for abnormalities.
D. To palpate the client's abdomen.
Answer: b. To observe the client's body movements.
Rationale: The inspection phase of a health assessment involves observing the client's body for
any visible abnormalities, such as asymmetry, lesions, or deformities. It also involves observing
the client's body movements, gait, and posture.

31.Which of the following is an example of an objective data that the nurse can obtain during the
health assessment?
A. The client's report of feeling dizzy.
B. The client's report of chest pain.
C. The client's blood pressure reading.
D. The client's description of a rash.
Answer: c. The client's blood pressure reading.
Rationale: Objective data are measurable and observable signs or symptoms, such as vital signs
or laboratory values. Blood pressure readings are an example of objective data that can provide
valuable information about the client's cardiovascular health.

32.What is the purpose of auscultation during a health assessment?

A. To measure the client's vital signs.
B. To assess the client's skin for abnormalities.
C. To listen to the client's heart, lungs, and abdomen.
D. To palpate the client's abdomen.
Answer: c. To listen to the client's heart, lungs, and abdomen.
Rationale: Auscultation involves listening to the sounds produced by the body's internal organs,
such as the heart, lungs, and abdomen. The purpose of auscultation is to detect any abnormal
sounds or rhythms that may indicate underlying health problems.

Case Scenario:
Aljun, a 28-year-old man, comes to the clinic for a routine check-up. During the assessment, the
nurse performs a physical assessment on Aljun using the IPPA method.
33.During the physical assessment, the nurse inspects Aljun's skin. What is the appropriate
distance to observe skin color and texture?
A. 1 inch C. 3 inches
B. 2 inches D. 4 inches
Answer: b. 2 inches
Rationale: The appropriate distance to observe skin color and texture during inspection is 2 inches.
This distance allows the nurse to accurately assess the skin's color, texture, and any abnormalities.

34.During the physical assessment, the nurse palpates Aljun's abdomen. What is the appropriate
technique for palpating the abdomen?
A. Light palpation, using one hand C. Light palpation, using two hands
B. Deep palpation, using one hand D. Deep palpation, using two hands
Answer: a. Light palpation, using one hand
Rationale: The appropriate technique for palpating the abdomen is light palpation, using one hand.
This technique allows the nurse to detect any tenderness, masses, or organ enlargement.
35.During the physical assessment, the nurse performs percussion on Aljun's lungs. Which area
of the chest should the nurse percuss?
A. Over the sternum C. Over the lung fields
B. Over the scapula D. Over the liver
Answer: c. Over the lung fields
Rationale: The appropriate area to percuss on the chest is over the lung fields. This technique
allows the nurse to detect any changes in sound, which may indicate underlying lung problems.
36.During the physical assessment, the nurse auscultates Aljun's heart sounds. Which area of the
chest should the nurse place the stethoscope to listen to the heart sounds?
A. Over the upper left sternal border C. Over the apex of the heart
B. Over the upper right sternal border D. Over the lower left sternal border
Answer: c. Over the apex of the heart
Rationale: The appropriate area to auscultate for heart sounds is over the apex of the heart, which
is located in the left lower chest. This technique allows the nurse to detect any abnormalities in
heart sounds, such as murmurs or gallops.

37.During the physical assessment, the nurse inspects Aljun's eyes. Which technique should the
nurse use to inspect the internal structures of the eye?
A. Direct inspection C. Transillumination
B. Indirect inspection D. Palpation
Answer: b. Indirect inspection
Rationale: The appropriate technique for inspecting the internal structures of the eye is indirect
inspection, using an ophthalmoscope. This technique allows the nurse to visualize the retina, optic
disc, and blood vessels.

Cultural and Spiritual Assessment

Case Scenario:
Maria Agwanta a 63-year-old Filipino immigrant, is admitted to the hospital for management of
diabetes and hypertension. During the admission process, the nurse is performing a cultural and
spiritual nursing assessment on Maria.

38.What is the primary goal of a cultural and spiritual nursing assessment?

A. To identify the client's cultural and spiritual beliefs and practices.
B. To provide spiritual care to the client.
C. To assess the client's physical health status.
D. To ensure that the client's cultural and spiritual needs are met.
Answer: a. To identify the client's cultural and spiritual beliefs and practices.
Rationale: The primary goal of a cultural and spiritual nursing assessment is to identify the client's
cultural and spiritual beliefs and practices, which can have a significant impact on their health
beliefs, behaviors, and decision-making. By understanding the client's cultural and spiritual
background, nurses can provide culturally sensitive care and avoid misunderstandings and
conflicts.

39.During a cultural and spiritual nursing assessment, which of the following is an example of a
cultural factor that may affect a client's health beliefs?
A. Gender. C. Religion.
B. Age. D. Marital status.
Answer: c. Religion.
Rationale: Cultural factors that may affect a client's health beliefs include their religion, ethnicity,
language, customs, and traditions. Religion, in particular, can influence a client's views on health,
illness, and healthcare practices.

40.What is the role of the nurse in addressing a client's spiritual needs?

A. To provide religious counseling to the client.
B. To respect the client's spiritual beliefs and practices.
C. To encourage the client to convert to a different religion.
D. To discourage the client from expressing their spiritual beliefs.
Answer: b. To respect the client's spiritual beliefs and practices.
Rationale: The role of the nurse in addressing a client's spiritual needs is to respect the client's
spiritual beliefs and practices, regardless of their own personal beliefs. The nurse should provide
a safe and supportive environment that allows the client to express their spiritual needs and
preferences.

41.Which of the following is an example of a spiritual need that a client may have?
A. The need for pain management. C. The need for forgiveness.
B. The need for social support. D. The need for nutrition.
Answer: c. The need for forgiveness
Rationale: Spiritual needs are related to a client's sense of meaning, purpose, and connection to
something greater than themselves. Examples of spiritual needs include the need for forgiveness,
the need for hope, the need for acceptance, and the need for inner peace.
42.Which of the following is an example of a culturally sensitive nursing intervention?
A. Encouraging the client to adopt Western healthcare practices.
B. Providing educational materials in the client's native language.
C. Disregarding the client's cultural preferences and beliefs.
D. Ignoring the client's family members during care.
Answer: b. Providing educational materials in the client's native language.
Rationale: A culturally sensitive nursing intervention is one that respects and accommodates the client's
cultural preferences and beliefs. Providing educational materials in the client's native language is an
example of a culturally sensitive intervention that can improve the client's understanding and
adherence to healthcare practices. Encouraging the client to adopt Western healthcare practices,
disregarding the client's cultural preferences, and ignoring their family members are not culturally
sensitive interventions and can lead to misunderstandings and conflicts.

Assessment of Integumentary System

Case Scenario:
Minerva, a 35-year-old woman, comes to the clinic complaining of a rash on her arms and legs.
During the assessment, the nurse performs an integumentary system assessment on Minerva.

43.What is the purpose of an integumentary system assessment?

A. To assess the client's cognitive function.
B. To identify potential skin problems and abnormalities.
C. To evaluate the client's respiratory status.
D. To measure the client's fluid and electrolyte balance.
Answer: b. To identify potential skin problems and abnormalities.
Rationale: The integumentary system assessment is performed to identify potential skin problems and
abnormalities, such as rashes, lesions, bruising, or discoloration. This assessment is important for
detecting skin cancer, infections, or other conditions that may affect the client's overall health.

44.During the integumentary system assessment, the nurse assesses Minerva's skin turgor. What
does skin turgor assess?
A. The skin's color and texture.
B. The skin's moisture content.
C. The skin's elasticity and hydration.
D. The skin's sensitivity and pain level.
Answer: c. The skin's elasticity and hydration.
Rationale: Skin turgor is the skin's elasticity and hydration, which can be assessed by pinching the
skin and observing how quickly it returns to its normal position. This assessment is useful in
evaluating the client's hydration status, as well as detecting any signs of dehydration or fluid
overload.

45.Minerva has a raised, red rash on her arms and legs. What type of skin lesion is this?
A. Papule. C. Vesicle.
B. Macule. D. Pustule.
Answer: a. Papule.
Rationale: A papule is a raised, solid lesion that is less than 1 cm in diameter. It is usually red or
pink in color and may be accompanied by itching or inflammation. Papules can be caused by a
variety of skin conditions, including acne, eczema, or insect bites.

46.During the integumentary system assessment, the nurse notes that Minerva has dry, flaky skin
on her arms and legs. What condition could this indicate?
A. Eczema. C. Seborrheic dermatitis.
B. Psoriasis. D. Contact dermatitis.
Answer: a. Eczema.
Rationale: Dry, flaky skin is a common symptom of eczema, which is a chronic inflammatory skin
condition. Eczema can cause itching, redness, and swelling, and is often triggered by
environmental factors such as dry weather, irritants, or allergens.
47.During the integumentary system assessment, the nurse notes that Minerva has a mole on her
arm that has changed in color and size since her last visit. What should the nurse do?
A. Document the finding and inform the healthcare provider.
B. Ignore the finding, as moles are a common skin condition.
C. Apply a topical cream to the mole to reduce inflammation.
D. Schedule a follow-up appointment in six months.
Answer: a. Document the finding and inform the healthcare provider.
Rationale: Changes in the color, size, or shape of a mole can indicate a potential skin cancer, such
as melanoma. It is important for the nurse to document the finding and inform the healthcare
provider, who may order further diagnostic tests or refer the client to a dermatologist. Ignoring
the finding or applying a topical cream could delay diagnosis and treatment of a potentially serious
condition. Scheduling a followup

Assessment of Head, Eyes, Ears, Nose and Throat

Case Scenario:
Darcy, a 45-year-old woman, comes to the clinic complaining of a headache and ear pain.
During the assessment, the nurse performs a head, eyes, ears, nose, and throat (HEENT)
assessment on Darcy.

48.During the HEENT assessment, the nurse inspects Darcy's eyes. What is the purpose of this
assessment?
A. To assess the client's visual acuity.
B. To evaluate the client's cognitive function.
C. To identify potential eye problems and abnormalities.
D. To measure the client's fluid and electrolyte balance.
Answer: c. To identify potential eye problems and abnormalities.
Rationale: The HEENT assessment includes an inspection of the eyes to identify potential eye
problems and abnormalities, such as redness, swelling, or discharge. This assessment is important
for detecting eye conditions, such as conjunctivitis or glaucoma, that may affect the client's vision
and overall health.

49.During the HEENT assessment, the nurse examines Darcy's ears. What is the purpose of this
assessment?
A. To assess the client's hearing acuity.
B. To evaluate the client's cognitive function.
C. To identify potential ear problems and abnormalities.
D. To measure the client's fluid and electrolyte balance.
Answer: a. To assess the client's hearing acuity.
Rationale: The HEENT assessment includes an examination of the ears to assess the client's
hearing acuity and identify potential ear problems and abnormalities, such as infection or blockage.
This assessment is important for detecting hearing loss or other conditions that may affect the
client's communication and overall health.

50.During the HEENT assessment, the nurse inspects Darcy's nose. What is the purpose of this
assessment?
A. To assess the client's sense of smell.
B. To evaluate the client's cognitive function.
C. To identify potential nose problems and abnormalities.
D. To measure the client's fluid and electrolyte balance.
Answer: c. To identify potential nose problems and abnormalities.
Rationale: The HEENT assessment includes an inspection of the nose to identify potential nose
problems and abnormalities, such as nasal congestion, discharge, or deviation. This assessment
is important for detecting conditions, such as sinusitis or nasal polyps, that may affect the client's
breathing and overall health.

51.During the HEENT assessment, the nurse palpates Darcy's sinuses. What is the purpose of this
assessment?
A. To assess the client's cognitive function.
B. To identify potential sinus problems and abnormalities.
C. To evaluate the client's visual acuity.
D. To measure the client's fluid and electrolyte balance.
Answer: b. To identify potential sinus problems and abnormalities.

Rationale: The HEENT assessment includes a palpation of the sinuses to identify potential sinus
problems and abnormalities, such as tenderness, swelling, or blockage. This assessment is
important for detecting conditions, such as sinusitis or allergies, that may affect the client's
breathing and overall health.

52.During the HEENT assessment, the nurse inspects Darcy's throat. What is the purpose of this
assessment?
A. To assess the client's cognitive function.
B. To evaluate the client's respiratory status.
C. To identify potential throat problems and abnormalities.
 D. To measure the client's fluid and electrolyte balance.
Answer: c. To identify potential throat problems and abnormalities.
Rationale: The HEENT assessment includes an inspection of the throat to identify potential throat
problems and abnormalities, such as redness, swelling,

Assessment of the Respiratory System

Case Scenario:
VR, a 55-year-old man, comes to the clinic complaining of shortness of breath and chest pain.
During the assessment, the nurse performs a respiratory system assessment on VR.

53.During the respiratory system assessment, the nurse assesses VR's respiratory rate. What is
the normal range for adult respiratory rate?
A. 8-10 breaths per minute C. 22-28 breaths per minute
B. 12-20 breaths per minute D. 30-40 breaths per minute
Answer: b. 12-20 breaths per minute
Rationale: The normal range for adult respiratory rate is 12-20 breaths per minute. This
assessment is important to identify any alterations in respiratory rate, which may indicate
respiratory distress or failure.

54.During the respiratory system assessment, the nurse auscultates VR's lungs. What is the
purpose of this assessment?
A. To assess for chest wall abnormalities
B. To evaluate the client's cognitive function
C. To identify potential lung problems and abnormalities
D. To measure the client's fluid and electrolyte balance
Answer: c. To identify potential lung problems and abnormalities
Rationale: The respiratory system assessment includes auscultation of the lungs to identify
potential lung problems and abnormalities, such as wheezing, crackles, or decreased breath
sounds. This assessment is important for detecting respiratory conditions, such as asthma,
pneumonia, or pulmonary embolism.

55.During the respiratory system assessment, the nurse assesses VR's oxygen saturation level.
What is the normal range for oxygen saturation level?
A. 70-80% C. 90-95%
B. 80-90% D. 95-100%
Answer: d. 95-100%
Rationale: The normal range for oxygen saturation level is 95-100%. This assessment is important
to identify any alterations in oxygen saturation level, which may indicate respiratory distress or
hypoxia.

56.During the respiratory system assessment, the nurse assesses VR's respiratory pattern. What
is the normal respiratory pattern for adults?
A. Apnea C. Cheyne-Stokes breathing
B. Kussmaul breathing D. Eupnea
Answer: d. Eupnea
Rationale: The normal respiratory pattern for adults is eupnea, which is characterized by regular
and even breathing. This assessment is important to identify any alterations in respiratory pattern,
which may indicate respiratory distress or dysfunction

57.During the respiratory system assessment, the nurse assesses VR's cough. What is the purpose
of this assessment?

A. To assess for chest wall abnormalities

B. To evaluate the client's cognitive function
C. To identify potential respiratory problems and abnormalities
D. To measure the client's fluid and electrolyte balance
Answer: c. To identify potential respiratory problems and abnormalities
Rationale: The respiratory system assessment includes assessment of the cough to identify
potential respiratory problems and abnormalities, such as coughing up blood or sputum. This
assessment is important for detecting respiratory conditions, such as bronchitis or tuberculosis.

Assessment of the Cardiovascular and Peripheral Vascular System

Case Scenario:
Mr. RJ is a 65-year-old male with a history of hypertension, hyperlipidemia, and smoking. He
presents to the clinic complaining of chest pain that radiates to his left arm. The nurse suspects
a cardiac issue and performs a cardiovascular and peripheral vascular assessment.

58.When assessing Mr. RJ's pulse, the nurse notes a regular rhythm with a rate of 70 beats per
minute. What is the normal range for an adult pulse rate?
A. 40-60 beats per minute C. 100-140 beats per minute
B. 60-100 beats per minute D. 140-180 beats per minute
Answer: B. The normal range for an adult pulse rate is 60-100 beats per minute.
Rationale: The normal pulse rate for an adult is 60-100 beats per minute.

59.During the assessment, the nurse auscultates a blowing sound over the carotid artery. What is
this sound called?
A. Murmur C. Thrill
B. Bruit D. Rub
Answer: B. The blowing sound heard over the carotid artery is called a bruit.
Rationale: A bruit is a blowing sound heard over an artery due to turbulence caused by narrowed
or irregular vessel walls.

60.The nurse palpates Mr. RJ’'s radial pulse and notes a weak, thready pulse. What might cause
this finding?
A. Hypertension C. Tachycardia
B. Hypotension D. Bradycardia
Answer: B. A weak, thready pulse may be caused by hypotension.
Rationale: A weak, thready pulse is often seen in hypotension, which is defined as a blood pressure
reading less than 90/60 mmHg.

61.During the cardiovascular assessment, the nurse assesses Mr. RJ's jugular venous pressure
(JVP). Where is the JVP measured?
A. At the carotid artery C. At the femoral artery
B. At the brachial artery D. At the jugular vein
Answer: D. The jugular venous pressure is measured at the jugular vein.
Rationale: The jugular venous pressure is measured at the jugular vein to assess for fluid overload
or right-sided heart failure.

62.While palpating Mr. RJ's apical pulse, the nurse notes an irregular rhythm. What might cause
this finding?
A. Atrial fibrillation C. Sinus tachycardia
B. Ventricular fibrillation D. Sinus bradycardia
Answer: A. An irregular apical pulse rhythm may indicate atrial fibrillation.
Rationale: An irregular apical pulse rhythm may indicate atrial fibrillation, which is a common
cardiac arrhythmia.

63.During the peripheral vascular assessment, the nurse observes Mr. RJ's legs for signs of
peripheral artery disease (PAD). What is a classic symptom of PAD?
A. Pallor of the legs C. Warmth of the legs
B. Redness of the legs D. Swelling of the legs
Answer: A. Pallor of the legs is a classic symptom of PAD.
Rationale: Pallor of the legs is a classic symptom of PAD, which is caused by narrowing or blockage
of the arteries in the legs.

64.The nurse assesses Mr. RJ's pedal pulses and notes that they are absent bilaterally. What might
this finding indicate?
A. Peripheral artery disease C. Deep vein thrombosis
B. Peripheral venous disease D. Pulmonary embolism
Answer: A. Absent pedal pulses may indicate peripheral artery disease.
Rationale: Absent pedal pulses may indicate peripheral artery disease, which is a condition
characterized by narrowing or blockage of the arteries in the legs.

65.During the cardiovascular assessment, the nurse performs a point of maximal impulse (PMI)
assessment. Where is the PMI located?
A. At the apex of the heart C. At the left sternal border
B. At the base of the heart D. At the right sternal border
Answer: A. The point of maximal impulse is located at the apex of the heart.
Rationale : The point of maximal impulse is located at the apex of the heart, which is the point
where the heartbeat is felt most strongly.

66.While auscultating Mr. RJ's heart, the nurse notes a high-pitched, blowing sound during systole.
What might cause this sound?
A. Aortic stenosis C. Pulmonary stenosis
B. Mitral regurgitation D. Tricuspid regurgitation
Answer: B. A high-pitched, blowing sound heard during systole is a classic sign of mitral
regurgitation.
Rationale: A high-pitched, blowing sound heard during systole is a classic sign of mitral
regurgitation, which is caused by a leaky mitral valve.

67.During the cardiovascular assessment, the nurse assesses Mr. RJ's blood pressure and notes a
reading of 160/100 mmHg. What is the term for this blood pressure reading?
A. Normal blood pressure C. Stage 1 hypertension
B. Prehypertension D. Stage 2 hypertension
Answer: C. A blood pressure reading of 160/100 mmHg is classified as stage 1 hypertension.
Rationale: A blood pressure reading of 160/100 mmHg is classified as stage 1 hypertension, which
requires medical intervention to prevent further complications.

Assessment of the Lymphatic System

Case Scenario:
Mr. Jonas, a 55-year-old male, presents to the clinic complaining of swelling in his left leg. Upon
examination, the nurse notes the presence of pitting edema and tenderness on palpation of the
left leg. The nurse suspects lymphedema and performs an assessment of the lymphatic system.

68.Which of the following is a characteristic finding of lymphedema?

A. Brawny edema C. Non-pitting edema
B. Dependent edema D. Peripheral edema
Answer: A. Brawny edema
Rationale: Lymphedema is a condition characterized by the accumulation of lymphatic fluid,
leading to swelling in the affected area. Brawny edema is a type of edema that is hard, non-pitting,
and may have a brownish appearance, which is a characteristic finding in lymphedema.

69.Which of the following techniques is used to assess the lymphatic system?

A. Blood pressure measurement C. Percussion
B. Palpation D. Auscultation
Answer: B. Palpation
Rationale: Palpation is the technique used to assess the lymphatic system. The nurse may use
their fingers to feel for lymph nodes and check for swelling, tenderness, or hardness.

70.Which lymph nodes are commonly palpated during an assessment of the lower extremities?
A. Axillary lymph nodes C. Popliteal lymph nodes
B. Supraclavicular lymph nodes D. Submandibular lymph nodes
Answer: C. Popliteal lymph nodes
Rationale: Popliteal lymph nodes are commonly palpated during an assessment of the lower
extremities. They are located in the popliteal fossa, behind the knee.

71.Which of the following is a potential complication of lymphedema?

A. Cellulitis C. Hypertension
B. Anemia D. Hyperthyroidism
Answer: A. Cellulitis
Rationale: Cellulitis is a potential complication of lymphedema. The accumulation of lymphatic fluid
can increase the risk of infection, and cellulitis is a bacterial skin infection that can occur in areas
of lymphedema.

72.Which of the following is an appropriate nursing intervention for lymphedema?

A. Elevating the affected limb
B. Applying heat to the affected limb
C. Encouraging the patient to cross their legs
D. Applying tight clothing to the affected limb
Answer: A. Elevating the affected limb
Rationale: Elevating the affected limb is an appropriate nursing intervention for lymphedema. It
can help reduce swelling by promoting lymphatic drainage. Applying heat or tight clothing can
worsen lymphedema, and crossing the legs can impede lymphatic flow.

73.Which of the following is a sign of lymphangitis?

A. Tender, red streaks along the skin C. Cyanosis of the affected limb
B. Pitting edema in the affected area D. Cool skin temperature
Answer: A. Tender, red streaks along the skin
Rationale: Lymphangitis is an inflammation of the lymphatic vessels, and it can present with
tender, red streaks along the skin that may be warm to the touch.

74.Which of the following lymph nodes are commonly palpated during an assessment of the head
and neck?
A. Inguinal lymph nodes C. Epitrochlear lymph nodes
B. Cervical lymph nodes D. Supratrochlear lymph nodes
Answer: B. Cervical lymph nodes
Rationale: Cervical lymph nodes are commonly palpated during an assessment of the head and
neck. They are located in the neck, along the jugular vein

75.Which of the following is a diagnostic test used to evaluate lymphatic function?

A. Magnetic resonance imaging (MRI) C. Lymphoscintigraphy
B. Computed tomography (CT) scan D. Electrocardiogram (ECG)
Answer: C. Lymphoscintigraphy
Rationale: Lymphoscintigraphy is a diagnostic test used to evaluate lymphatic function. It involves
injecting a radioactive tracer into the lymphatic system and using a special camera to monitor the
movement of the tracer.

76.Which of the following is a potential cause of lymphedema?

A. Hypertension C. Cancer treatment
B. Diabetes mellitus D. Osteoarthritis
Answer: C. Cancer treatment
Rationale: Cancer treatment, such as radiation therapy or lymph node removal, is a potential cause of
lymphedema. Other potential causes include infection or injury to the lymphatic system.

77.Which of the following is an appropriate nursing intervention for a patient with lymphedema?
A. Encouraging the patient to avoid physical activity
B. Applying compression bandages to the affected limb
C. Massaging the affected limb vigorously
D. Keeping the affected limb in a dependent position
Answer: B. Applying compression bandages to the affected limb
Rationale: Applying compression bandages to the affected limb is an appropriate nursing
intervention for a patient with lymphedema. Compression can help reduce swelling and promote
lymphatic drainage. Avoiding physical activity, massaging the limb vigorously, or keeping it in a
dependent position can worsen lymphedema.

Assessment of Breast and Axilla

Case Scenario: Ms. Jonabel is a 45-year-old woman who presents to the clinic for her annual
physical exam. During the exam, the nurse performs a breast and axilla assessment.

78.Which of the following techniques should the nurse use to assess Ms. Jonabel’s' breasts?
A. Inspection C. Auscultation
B. Palpation D. Percussion
Answer: b. Palpation
Rationale: Breast assessment involves inspection and palpation. Inspection involves visual
examination of the breasts for size, shape, symmetry, and any abnormalities. Palpation involves
using the fingers to feel for any lumps or masses in the breasts.

79.During the breast assessment, the nurse palpates a 2cm firm, non-mobile, painless lump in
Ms. Jonabel's right breast. What is the nurse's next step?
A. Document the finding and continue with the exam
B. Refer Ms. Jonabels for a mammogram
C. Tell Ms. Jonabels not to worry about it
D. Ignore the finding and continue with the exam
Answer: b. Refer Ms. Jonabels’s for a mammogram
Rationale: A lump in the breast requires further evaluation to rule out the possibility of breast
cancer. The nurse should refer Ms. Jonabel’s for a mammogram or breast ultrasound.

80.During the axilla assessment, the nurse notes that Ms. Jonabel has enlarged lymph nodes in
her left axilla. What is the nurse's next step?
A. Document the finding and continue with the exam
B. Palpate the lymph nodes to determine if they are tender
C. Notify the healthcare provider
D. Tell Ms. Jones not to worry about it
Answer: c. Notify the healthcare provider
Rationale: Enlarged lymph nodes in the axilla can be a sign of breast cancer or other conditions
The nurse should notify the healthcare provider and document the finding.

81.Which of the following is not a risk factor for breast cancer?

A. Family history of breast cancer C. Smoking
B. Age over 50 D. Female gender
Answer: c. Smoking
Rationale: Smoking is not a risk factor for breast cancer. However, family history of breast cancer,
age over 50, and female gender are all risk factors for breast cancer.

82.Which of the following is not a symptom of breast cancer?

A. A painless lump in the breast
B. Nipple discharge
C. Breast pain
D. Dimpling or puckering of the skin on the breast
Answer: c. Breast pain
Rationale: Breast pain is not typically a symptom of breast cancer. However, a painless lump in
the breast, nipple discharge, and dimpling or puckering of the skin on the breast can be signs of
breast cancer.

83.During the breast assessment, the nurse observes asymmetry between Ms. Jonabel’s' breasts.
What is the nurse's next step?
A. Document the finding and continue with the exam
B. Palpate the breasts to determine if there are any lumps or masses
C. Notify the healthcare provider
D. Tell Ms. Jonabel not to worry about it
Answer: b. Palpate the breasts to determine if there are any lumps or masses
Rationale: Asymmetry between the breasts can be a normal variation, but it can also be a sign of
breast cancer or other conditions. The nurse should palpate both breasts to determine if there are
any lumps or masses present.

84.Which of the following statements about breast self-exams (BSE) is true?

A. BSE should be done only once a year
B. BSE is not recommended for women under 50 years of age
C. BSE should be done at the same time every month
D. BSE should only be done by healthcare providers
Answer: c. BSE should be done at the same time every month
Rationale: Breast self-exams should be done once a month, at the same time every month. BSE
is recommended for women starting in their 20s and should continue throughout their lifetime.

85.During the breast assessment, the nurse palpates a soft, movable lump in Ms. Jonabel’s' left
breast. What is the nurse's next step?

A. Document the finding and continue with the exam

B. Refer Ms. Jonable for a mammogram
C. Tell Ms. Jonabel not to worry about it
D. Palpate the lump again to confirm its characteristics
Answer: a. Document the finding and continue with the exam
Rationale: A soft, movable lump in the breast is likely a benign cyst or fibroadenoma. The nurse
should document the finding and continue with the exam.

86.Which of the following is not a potential complication of breast cancer surgery?

A. Lymphedema C. Hemorrhage
B. Infection D. Blindness
Answer: d. Blindness
Rationale: Blindness is not a potential complication of breast cancer surgery. However,
lymphedema (swelling of the arm), infection, and hemorrhage are all potential complications

87.A client asks the nurse to explain how to perform a proper handwashing procedure. Which of
these responses would be the most appropriate for the nurse to make?
A. "Running water helps to wash away the dirt on your hands."
B. "Be sure to wet your hands thoroughly before using soap."
C. "It is okay to use your washed hands to turn off the faucet."
D. "You should wash your hands for at least 30 seconds before rinsing them."
88.Which of these client statements is the most reliable indicator that a client has an
understanding of infection prevention?
A. "I will use alcohol to wash my hands."
B. "Soiled dressings can be placed in a paper bag."
C. "My fingernails are short and well-trimmed."
D. "The family dog can sleep with me on the bed."
89.The nurse instructs a client in infection prevention. Which of the following statements, if made
by the client, indicates that the teaching was effective?
A. "I should wash my hands before changing my wound dressing."
B. "The organisms on my skin will not infect my leg wound."
C. "The dressings from my wound can be removed without wearing gloves."
D. "The drainage from my wound can be rinsed down the kitchen sink."
90.If an infectious disease can be transmitted directly from one person to another, it is a:
A. Susceptible host.
B. Communicable disease.
C. Port of entry to a host.
D. Port of exit from the reservoir.
91.Which of the following is the most effective way to break the chain of infection?
A. Hand hygiene
B. Wearing gloves
C. Placing patients in isolation
D. Providing private rooms for patients
92.A family member is providing care to a loved one who has an infected leg wound. What would
you instruct the family member to do after providing care and handling contaminated
equipment or organic material?
A. Wear gloves before eating or handling food.
B. Place any soiled materials into a bag and double bag it.
C. Have the family member check with the doctor about need for immunization.
D. Perform hand hygiene after care and/or handling contaminated equipment or material.
93.A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be
angry, but he knows that this is a normal response to isolation. Which is the best intervention?
A. Provide a dark, quiet room to calm the patient.
B. Reduce the level of precautions to keep the patient from becoming angry.
C. Explain the reasons for isolation procedures and provide meaningful stimulation.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection.
94.The nurse has redressed a patient's wound and now plans to administer a medication to the
patient. Which is the correct infection control procedure?
A. Leave the gloves on to administer the medication.
B. Remove gloves and administer the medication.
C. Remove gloves and perform hand hygiene before administering the medication.
D. Leave the medication on the bedside table to avoid having to remove gloves before leaving
the patient's room.