A patient comes into the ambulatory clinic and is diagnosed as having pneumococcal pneumonia. The patient asks the nurse what kind of pneumonia this is, and the nurse explains to the patient that it is a(n)
bacterial infection that should respond to treatment with antibiotics.
A mother and her 2-week-old infant, who is breast-fed, are exposed to chickenpox. The mother had chickenpox as a child. It is most likely that
neither is likely to get chickenpox, because the mother should have naturally acquired immunity, and she passes antibodies to the baby through the breast milk (and earlier through the placenta).
A nurse washes his hands for 3 minutes with soap and running water at the beginning of the shift and for 20 to 30 seconds before and after each patient contact during the shift, as well as whenever they are soiled, after toileting, and before eating. This
should wash for 3 minutes every time he washes his hands
The use of surgical asepsis is required for
administration of intravenous medication
A nurse is teaching family members about hand hygiene in the home so that they can care for their newborn. It is important to emphasize
keeping fingernails short and avoiding wearing rings (except a wedding band) or bracelets that can harbor organisms and can scratch the infant.
When removing a used face mask, the nurse correctly
unties the bottom ties first, then the top, and disposes of the mask without touching it.
Standard Precautions, as outlined by the Centers for Disease Control and Prevention (CDC), are
used in the care of all patients.
When the nurse is using a syringe and needle to give a patient an injection, he should
never recap the needle after use nor manipulate it with both hands, to avoid risk of needle stick.
To properly use protective nonsterile gloves in the provision of patient care, the nurse
washes his hands immediately after removing the gloves.
Because an elderly person is more at risk for infection, which of the following nursing interventions is appropriate to reduce that risk?
Encourage deep-breathing and increased intake of fluids to keep respiratory secretions thin and keep them from accumulating in the lower lungs
A patient is sent home with an open wound that is still infected and being treated with wet-to-dry dressing changes four times a day. Before discharge, the nurse would teach the patient which of the following to prevent the spread of infection to other fa
Proper hand hygiene to maintain medical asepsis and the proper handling and disposal of the contaminated dressings are most important.
When the nurse uses a disinfectant, he
thoroughly cleans and rinses all soap off the equipment before disinfecting it, because soap decreases the effectiveness of disinfectants.
The best method of sterilizing equipment is the use of
moist heat under pressure.
An elderly patient who had abdominal surgery 2 days ago has developed a fever and has a productive cough. The most likely explanation of these symptoms is that the patient
has impaired cough mechanism and cilia action as a result of aging, which predisposed her to a lower respiratory infection after surgery
If blood or body fluids have contaminated the patient's bed sheet, the nurse should
don nonsterile gloves and gown, remove the soiled sheet, replace it with a clean one, then dispose of the sheet in a plastic bag to prevent skin or clothing contact.
A nursing instructor is teaching a group of nursing students about how to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA). The nursing instructor identifies that further teaching is warranted when a nursing student states
It is important to keep cuts and abrasions open to air until healing has occurred.
A patient has been diagnosed with Rocky Mountain spotted fever. The nurse recognizes this disease is caused by
Rickettsia.
A patient has been diagnosed with tinea pedis. The nurse recognizes that this is caused by
fungi.
A patient has been diagnosed with tuberculosis. The nurse recognizes that the portal of entry for this illness is the
respiratory tract
A patient is diagnosed with acquired immunodeficiency syndrome. The nurse recognizes that the portal of entry for this disease is
the blood stream
A patient who has active primary tuberculosis is placed on Airborne Precautions. In addition to observing Standard Precautions for this patient, the nurse expects that
a special mask (respirator) will be worn by anyone entering the room.
In which of the following patient situations are barrier gloves required by Standard Precautions?
Emptying the urinary catheter drainage bag for a patient with Alzheimer's disease
The correct way to handle soiled linens in the room of a patient who is on Contact Precautions is for the nurse to
wear a gown to protect her uniform and barrier gloves to roll the soiled sheets together and place in the designated container
A patient on Airborne Precautions says to the nurse, "I feel like I'm going crazy cooped up in here. I feel like just sneaking out and not coming back." The best response by the nurse is
You must be feeling lonely being cooped up in here. How about if I come back after lunch and we play a board game?
A family member has been instructed in the administration of subcutaneous medication at home but has forgotten what to do with the used needles and syringes. The nurse instructs her to
place the used syringe and needle, without recapping it, in a large plastic bottle with a secure lid.
Which of the following nursing interventions is most likely to decrease the chance of health care-associated (HAI) infections for a postoperative patient?
Help the patient turn and change his position in bed, as well as cough and deep-breathe, every 2 hours
When caring for a patient on Droplet Precautions, it is most important for the nurse to
wear a mask if working within 3 feet of the patient.
An expected nursing outcome for a patient who is admitted for surgery and is identified as having Infection, risk for, is that
a health care-associated (HAI) infections will not be evident
A physician is performing a sterile procedure at the patient's bedside. Near the end of the procedure, the nurse suspects the physician has contaminated her sterile glove and the sterile field. The nurse should
point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field.
A nurse is instructing one of the facility's unlicensed assistive personnel (UAPs) in ways to prevent health care-associated infections. The nurse recognizes that further instruction is warranted when the UAP states, "I will
cleanse patients from the rectum to the urinary meatus.
A patient is hospitalized with suspected varicella. The nurse should place the patient on what type of precautions
Airborne Precautions
A patient is hospitalized with pertussis. The nurse should place the patient on what type of precautions?
Droplet Precautions
A patient is hospitalized with respiratory syncytial virus (RSV). The nurse should place the patient on what type of precautions?
Contact Precautions
A patient is hospitalized with tuberculosis. The nurse should expect which of the following precautions to be initiated?
All personnel entering the patient's room must wear an N95 mask.
A nurse is caring for a patient who is diagnosed with tuberculosis and is on Airborne Precautions. The nurse should
wear an N95 mask when entering the patient's room.
An elderly patient is scheduled for surgery this morning. For the anesthesiologist to accurately calculate the amount of anesthesia needed, the nurse should have data available on the chart, such as
height and weight.
The nurse is asked to obtain an informed consent for a child who will undergo surgery. To do this appropriately, it is important to
obtain a parent's signature on the consent form
A patient who needs emergency surgery is not competent to make decisions about care, and family members live an hour away from the hospital. The nurse anticipates that
telephone consent will be obtained from family with two witnesses listening on telephone extension lines.
During preoperative teaching, the nurse explains to a patient that it is important to turn, cough, and deep-breathe at least every 2 hours. The best reason for these exercises is to
maintain lung expansion
To prevent injury to a patient before administering preoperative medication, the best action for the nurse is to
have the patient void in the bathroom.
A patient just left by stretcher to go to the operating room and will return this afternoon. When preparing the patient's room, the nurse should
have the suction and oxygen equipment connected and ready.
A patient undergoing preadmission testing before same-day surgery asks how long he will remain in the recovery area before being allowed to go home. The best response is to say that the recovery time in this area is usually
1 to 3 hours
You have requested and received permission to observe a surgical procedure of interest to you in the hospital in which you are employed. While the patient is being draped, you notice that a break in sterile technique occurs. Which action on your part is m
Point out the observation immediately to the personnel involved.
A nurse is admitting a patient to the surgical unit from the postanesthesia care unit. The nurse should plan her workload to enable monitoring of vital signs and level of consciousness for this patient as frequently as every
15 minutes
A patient who has returned to the surgical nursing unit from the postanesthesia care unit is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is
side-lying.
A nurse is instructing a patient who had surgical removal of a brain tumor on how to prevent respiratory complications from surgery. The best action to include in the teaching plan is
using deep breathing and an incentive spirometer
A patient who had surgery earlier in the day using general anesthesia asks whether he can have something to drink. The diet order indicates clear liquids can be taken. Before giving a drink to the patient, the nurse should check for the presence of
bowel sounds in all quadrants.
A patient is ready for discharge following same-day surgery. The teaching plan for this patient includes
not driving or making important decisions for 24 hours
Which of the following patients is at risk for impaired healing and tissue repair? (Select all that apply.)
A 79 year old who weighs 98 pounds and has a poor appetite
A 56 year old with poorly controlled diabetes
A 33 year old with complications from AIDS
A 69 year old alcoholic with dehydration
A nurse is caring for a patient in protective isolation. Before entering the room, which of the following actions should the nurse take? (Select all that apply.)
Don a gown Don a mask.Put on gloves. Apply a head covering. Apply shoe coverings