3040 Exam 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?
A: The nurse carries the patients' soiled bed linens close to the body to prevent
spreading microorganisms into the air
B: The nurse places soiled bed linens and hospital gowns on the floor when making the
bed
C: The nurse moves the patient table away from the nurse's body when wiping it off
after a meal
D: The nurse cleans the most soiled items in the patient's bathroom first and follows
with the cleaner items - answerc. 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.
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?
A. Incubation period
B. Prodromal stage
C. Full stage of illness
D. Convalescent period - answerb. 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.
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.
A. Providing a bed bath for a patient
B. Visibly soiled hands after changing the bedding of a patient
C. Removing gloves when patient care is completed
D Inserting a urinary catheter for a female patient
F. Assisting with a surgical placement of a cardiac stentRemoving old magazines from
a patient's table - answera, 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. Keep in mind that handrubs are
not appropriate for use with C. difficile infection.
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.
A. Removes all jewelry including a platinum wedding band
B. Washes hands to 1 in above the wristsUses approximately one teaspoon of liquid
soap
C. Keeps hands higher than elbows when placing under faucet
D. Uses friction motion when washing for at least 20 seconds
F Rinses thoroughly with water flowing toward fingertips - answerb, c, 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 20 seconds, washing to 1 in
above the wrists with a friction motion for at least 20 seconds, and rinsing thoroughly
with water flowing toward fingertips.
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. Which action by the
nurse is appropriate? A. Keep splashes on the sterile field to a minimum
B Cover the nose and mouth with gloved hands if a sneeze is imminent
C. Use forceps soaked in a disinfectant
D. Consider the outer 1 in of the sterile field as contaminated - answerd . 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.
The nurse caring for patients in a hospital setting institutes CDC standard precaution
recommendations for which category of patients?
A. Only patients with diagnosed infections
B. Only patients with visible blood, body fluids, or sweat
C. Only patients with nonintact skin
D. All patients receiving care in hospitals - answerd. 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.
In addition to standard precautions, the nurse would initiate droplet precautions for
which patients? Select all that apply.
A. A patient diagnosed with rubellaA patient diagnosed with diphtheria
B. A patient diagnosed with varicella
C. A patient diagnosed with tuberculosis
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?
A: The nurse carries the patients' soiled bed linens close to the body to prevent
spreading microorganisms into the air
B: The nurse places soiled bed linens and hospital gowns on the floor when making the
bed
C: The nurse moves the patient table away from the nurse's body when wiping it off
after a meal
D: The nurse cleans the most soiled items in the patient's bathroom first and follows
with the cleaner items - answerc. 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.
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?
A. Incubation period
B. Prodromal stage
C. Full stage of illness
D. Convalescent period - answerb. 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.
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.
A. Providing a bed bath for a patient
B. Visibly soiled hands after changing the bedding of a patient
C. Removing gloves when patient care is completed
D Inserting a urinary catheter for a female patient
F. Assisting with a surgical placement of a cardiac stentRemoving old magazines from
a patient's table - answera, 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. Keep in mind that handrubs are
not appropriate for use with C. difficile infection.
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.
A. Removes all jewelry including a platinum wedding band
B. Washes hands to 1 in above the wristsUses approximately one teaspoon of liquid
soap
C. Keeps hands higher than elbows when placing under faucet
D. Uses friction motion when washing for at least 20 seconds
F Rinses thoroughly with water flowing toward fingertips - answerb, c, 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 20 seconds, washing to 1 in
above the wrists with a friction motion for at least 20 seconds, and rinsing thoroughly
with water flowing toward fingertips.
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. Which action by the
nurse is appropriate? A. Keep splashes on the sterile field to a minimum
B Cover the nose and mouth with gloved hands if a sneeze is imminent
C. Use forceps soaked in a disinfectant
D. Consider the outer 1 in of the sterile field as contaminated - answerd . 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.
The nurse caring for patients in a hospital setting institutes CDC standard precaution
recommendations for which category of patients?
A. Only patients with diagnosed infections
B. Only patients with visible blood, body fluids, or sweat
C. Only patients with nonintact skin
D. All patients receiving care in hospitals - answerd. 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.
In addition to standard precautions, the nurse would initiate droplet precautions for
which patients? Select all that apply.
A. A patient diagnosed with rubellaA patient diagnosed with diphtheria
B. A patient diagnosed with varicella
C. A patient diagnosed with tuberculosis
