VNSG 1423 EXAM #1 QUESTIONS WITH
COMPLETE ANSWERS
A nurse is caring for an 82-year-old patient who was admitted to the health care facility
for tachypnea and tachycardia. Which rationale below supports the clients condition? -
ANSWER The heart and lungs work together to provide circulation of nutrients and
oxygen. FA Davis Ch 17, pg. 323
A nurse is instructing a group of nursing students in measuring a client's respiratory
rate. Which guideline should the nurse include? - ANSWER Count each ventilation as
one breathe Ch 17 pg.322-323
A nurse is caring for a client that has a fractured femur, the BP reading 140/49 mm Hg in
the left arm. Which action should the nurse take first? - ANSWER Ask the client if he/she
is in pain Ch 17 pg 329
A nursing student is assisting an 88 yr old client from a supine position to a sitting
position to go to the bathroom. The client faints. The nursing student understands that
the cause of fainting is due to - ANSWER Reduced vasoconstriction of the arteries. Ch
17 pg 329
When measuring the blood pressure after placing the cuff correctly on the arm, the
nurse would assess, which of the following? - ANSWER palpate the artery. Ch 17, pg 328
A nurse is caring for a client that has tuberculosis. According to CDC guidelines for
transmission based precautions. Which personal protective measures should the nurse
implement? Select all that apply (2/4) - ANSWER Enter airborne infection isolation room
Put on a fit-tested N95 respirator
Enter a private room with gown, N95
Put on N95
Ch 14, pg. 235-236
, A nurse is caring for a client that has been placed in contact-based precaution due to
infectious diarrhea. The nurse should follow the CDC's guidelines by performing which
intervention? - ANSWER wash hands, put on gloves and gown before entering the room.
Ch 14, pg 236
A nurse has a sterile package and has placed it on a clean surface in preparation of an
invasive procedure. What is the rationale for unfolding the first flap farthest from the
body? - ANSWER The nurse risks reaching across the sterile package. Ch 22, pg 428
A nurse is wearing sterile gloves to perform a sterile procedure. Which of the following
items listed below are considered sterile and can be touched by the nurse? Select all
that apply (3/5) - ANSWER A bottle containing a sterile solution
The edge of sterile drape
One sterile gloved hand touching the other sterile gloved hand
Irrigation catheter on the sterile field
The inner wrapping of an item on the on the sterile field
Ch 22, pg 427
A nurse is preparing a sterile field for assisting a provider with a sterile procedure. The
nurse recognizes that which of the following has contaminated the field? - ANSWER The
nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
Ch22, pg 427-428
A nursing student identifies that parts of the syringe and needle are considered sterile.
Which part of the syringe and or needle was correctly identified by the nursing student
as being sterile? - ANSWER hub on the needle. Ch 22, pg 429-430
When opening a wrapper containing sterile gloves the nurse opens the outer wrapper
and discards it, positions the inner wrapped so the cuffs of the gloves are towards the
nurse and maintains sterility by touching the 1-inch vertical flaps of the inside wrapper.
What is the nurse's next step? - ANSWER Use non dominant hand to pick up the glove by
the cuff Ch 22, pg 433, step 5
COMPLETE ANSWERS
A nurse is caring for an 82-year-old patient who was admitted to the health care facility
for tachypnea and tachycardia. Which rationale below supports the clients condition? -
ANSWER The heart and lungs work together to provide circulation of nutrients and
oxygen. FA Davis Ch 17, pg. 323
A nurse is instructing a group of nursing students in measuring a client's respiratory
rate. Which guideline should the nurse include? - ANSWER Count each ventilation as
one breathe Ch 17 pg.322-323
A nurse is caring for a client that has a fractured femur, the BP reading 140/49 mm Hg in
the left arm. Which action should the nurse take first? - ANSWER Ask the client if he/she
is in pain Ch 17 pg 329
A nursing student is assisting an 88 yr old client from a supine position to a sitting
position to go to the bathroom. The client faints. The nursing student understands that
the cause of fainting is due to - ANSWER Reduced vasoconstriction of the arteries. Ch
17 pg 329
When measuring the blood pressure after placing the cuff correctly on the arm, the
nurse would assess, which of the following? - ANSWER palpate the artery. Ch 17, pg 328
A nurse is caring for a client that has tuberculosis. According to CDC guidelines for
transmission based precautions. Which personal protective measures should the nurse
implement? Select all that apply (2/4) - ANSWER Enter airborne infection isolation room
Put on a fit-tested N95 respirator
Enter a private room with gown, N95
Put on N95
Ch 14, pg. 235-236
, A nurse is caring for a client that has been placed in contact-based precaution due to
infectious diarrhea. The nurse should follow the CDC's guidelines by performing which
intervention? - ANSWER wash hands, put on gloves and gown before entering the room.
Ch 14, pg 236
A nurse has a sterile package and has placed it on a clean surface in preparation of an
invasive procedure. What is the rationale for unfolding the first flap farthest from the
body? - ANSWER The nurse risks reaching across the sterile package. Ch 22, pg 428
A nurse is wearing sterile gloves to perform a sterile procedure. Which of the following
items listed below are considered sterile and can be touched by the nurse? Select all
that apply (3/5) - ANSWER A bottle containing a sterile solution
The edge of sterile drape
One sterile gloved hand touching the other sterile gloved hand
Irrigation catheter on the sterile field
The inner wrapping of an item on the on the sterile field
Ch 22, pg 427
A nurse is preparing a sterile field for assisting a provider with a sterile procedure. The
nurse recognizes that which of the following has contaminated the field? - ANSWER The
nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
Ch22, pg 427-428
A nursing student identifies that parts of the syringe and needle are considered sterile.
Which part of the syringe and or needle was correctly identified by the nursing student
as being sterile? - ANSWER hub on the needle. Ch 22, pg 429-430
When opening a wrapper containing sterile gloves the nurse opens the outer wrapper
and discards it, positions the inner wrapped so the cuffs of the gloves are towards the
nurse and maintains sterility by touching the 1-inch vertical flaps of the inside wrapper.
What is the nurse's next step? - ANSWER Use non dominant hand to pick up the glove by
the cuff Ch 22, pg 433, step 5
