NUR 164 EXAM 2 (Textbook Questions) QUESTIONS
WITH COMPLETE SOLUTIONS
A charge nurse working on a medical-surgical unit stops the AP
from taking rectal temperatures on patients with which
problems? Select all that apply.
A. Hypothermia
B. Pneumonia
C. Bradycardia
D. Leukemia
E. Thrombocytopenia
F. Pancreatitis Correct Answers c, d, e. The rectal site should
not be used in newborns, children with diarrhea, and in patients
who have undergone rectal or vaginal surgery. Inserting a rectal
thermometer can stimulate the vagus nerve causing or worsening
bradycardia; this route may be contraindicated in certain cardiac
patients. The rectal route is also contraindicated in patients who
have neutropenia (low white blood cell counts, such as in
leukemia or those receiving chemotherapy), thrombocytopenia
(low platelet counts), and certain neurologic disorders.
A home health nurse teaches a patient to a change the dressing
for a chronic venous stasis ulcer using clean technique. Which
principle of asepsis will the nurse consider when preparing the
teaching plan?
A. The nurse chooses clean or sterile technique based on
personal preference.
B. The use of clean technique is considered safe in the home
setting.
,C. Surgical asepsis is the safest method to use in a home setting.
D.The patient can use clean technique; their partner must wear
sterile gloves. Correct Answers b. Medical asepsis, or clean
technique, involves procedures and practices that reduce the
number and transfer of pathogens. This is usually recommended
in the home setting, where the patient's environment is more
controlled. Injections require surgical asepsis. The patient and
partner share the same home; medical asepsis is appropriate.
A new graduate nurse tells the preceptor they want to obtain
recognition in wound care, a specialty area of nursing. What
credential will this nurse need to seek?
A. Accreditation
B. Licensure
C. Certification
D. Board approval Correct Answers C. Certification is the
process by which a person who has met certain criteria
established by a nongovernmental association is granted
recognition in a specified practice area. Nursing is one of the
groups operating under state laws that promote the general
welfare by determining minimum standards of education
through accreditation of schools of nursing. Licensure is a legal
document that permits a person to offer to the public skills and
knowledge in a particular jurisdiction, where such practice
would otherwise be unlawful without a license. State board of
approval ensures that nurses have received the proper training to
practice nursing.
, A nurse administering an injection to a patient who tested
positive for HIV sustains a needlestick. What action should the
nurse take first?
A. Report the incident to the nurse manager and file an injury
report
B. Wash the exposed area with warm water and soap
C. Consent to postexposure prophylaxis (PEP) at the appropriate
time
D. Set up counseling sessions regarding safe practice to protect
self Correct Answers b. When a needlestick injury occurs, the
nurse should wash the affected area immediately with warm
water and soap, report the incident to the nurse manager or
appropriate person and complete an injury report, consent to and
await the results of blood tests, consent to PEP, and attend
counseling sessions regarding safe practice to protect self and
others.
A nurse and health care provider are preparing for insertion of a
central venous catheter when the patient accidentally touches the
sterile field. What action will the nurse take next?
A. Ask another nurse to hold the patient's hand and continue
setting up the field
B. Remove any objects the patient touched and resume setting
up the sterile field
C. Have someone hold the patient's hand, discard the supplies,
and prepare a new sterile field
D. No action since the patient has touched their own sterile field
Correct Answers c. If a patient touches a sterile field, the nurse
should discard all supplies and prepare a new sterile field. If the
WITH COMPLETE SOLUTIONS
A charge nurse working on a medical-surgical unit stops the AP
from taking rectal temperatures on patients with which
problems? Select all that apply.
A. Hypothermia
B. Pneumonia
C. Bradycardia
D. Leukemia
E. Thrombocytopenia
F. Pancreatitis Correct Answers c, d, e. The rectal site should
not be used in newborns, children with diarrhea, and in patients
who have undergone rectal or vaginal surgery. Inserting a rectal
thermometer can stimulate the vagus nerve causing or worsening
bradycardia; this route may be contraindicated in certain cardiac
patients. The rectal route is also contraindicated in patients who
have neutropenia (low white blood cell counts, such as in
leukemia or those receiving chemotherapy), thrombocytopenia
(low platelet counts), and certain neurologic disorders.
A home health nurse teaches a patient to a change the dressing
for a chronic venous stasis ulcer using clean technique. Which
principle of asepsis will the nurse consider when preparing the
teaching plan?
A. The nurse chooses clean or sterile technique based on
personal preference.
B. The use of clean technique is considered safe in the home
setting.
,C. Surgical asepsis is the safest method to use in a home setting.
D.The patient can use clean technique; their partner must wear
sterile gloves. Correct Answers b. Medical asepsis, or clean
technique, involves procedures and practices that reduce the
number and transfer of pathogens. This is usually recommended
in the home setting, where the patient's environment is more
controlled. Injections require surgical asepsis. The patient and
partner share the same home; medical asepsis is appropriate.
A new graduate nurse tells the preceptor they want to obtain
recognition in wound care, a specialty area of nursing. What
credential will this nurse need to seek?
A. Accreditation
B. Licensure
C. Certification
D. Board approval Correct Answers C. Certification is the
process by which a person who has met certain criteria
established by a nongovernmental association is granted
recognition in a specified practice area. Nursing is one of the
groups operating under state laws that promote the general
welfare by determining minimum standards of education
through accreditation of schools of nursing. Licensure is a legal
document that permits a person to offer to the public skills and
knowledge in a particular jurisdiction, where such practice
would otherwise be unlawful without a license. State board of
approval ensures that nurses have received the proper training to
practice nursing.
, A nurse administering an injection to a patient who tested
positive for HIV sustains a needlestick. What action should the
nurse take first?
A. Report the incident to the nurse manager and file an injury
report
B. Wash the exposed area with warm water and soap
C. Consent to postexposure prophylaxis (PEP) at the appropriate
time
D. Set up counseling sessions regarding safe practice to protect
self Correct Answers b. When a needlestick injury occurs, the
nurse should wash the affected area immediately with warm
water and soap, report the incident to the nurse manager or
appropriate person and complete an injury report, consent to and
await the results of blood tests, consent to PEP, and attend
counseling sessions regarding safe practice to protect self and
others.
A nurse and health care provider are preparing for insertion of a
central venous catheter when the patient accidentally touches the
sterile field. What action will the nurse take next?
A. Ask another nurse to hold the patient's hand and continue
setting up the field
B. Remove any objects the patient touched and resume setting
up the sterile field
C. Have someone hold the patient's hand, discard the supplies,
and prepare a new sterile field
D. No action since the patient has touched their own sterile field
Correct Answers c. If a patient touches a sterile field, the nurse
should discard all supplies and prepare a new sterile field. If the
