A patient becomes infected with oral candidiasis (thrush) while receiving intravenous
antibiotics to treat a systemic infection. Which type of infection has the patient
developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
3) Latent
4) Primary
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ANS: 1
Thrush in this patient is an example of an endogenous nosocomial
infection. This type of infection arises from suppression of the patients
normal floras as a result of some form of treatment, such as antibiotics.
Normal floras usually keep yeast from growing in the mouth. In exogenous
nosocomial infection, the pathogen arises from the healthcare
environment. A latent infection causes no symptoms for long periods. An
example of a latent infection is human immunodeficiency virus infection. A
primary infection is the first infection that occurs in a patient.
,Which of the following behaviors indicates the highest potential for spreading
infections among clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only when leaving each room.
4) uses cold water for medical asepsis.
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ANS: 3
Patients acquire infection by contact with other patients, family members,
and healthcare equipment. But most infection among patients is spread
through the hands of healthcare workers. Hand washing interrupts the
transmission and should be done before and after all contact with patients,
regardless of the diagnosis. When the hands are soiled, healthcare staff
should use antibacterial soap with warm water to remove dirt and debris
from the skin surface. When no visible dirt is present, an alcohol-based rub
should be applied and allowed to dry for 10 to 15 seconds.
Which of the following is a correct step in removing and cleaning a hearing aid?
1) Clean only the external surfaces, not the canal portion.
2) Clean the top part of the canal portion of the device.
3) Insert a wax loop or toothpick into the hearing aid.
4) Remove the battery before taking the hearing aid from the ear.
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, ANS: 2
The nurse should clean the top part of the canal portion of the hearing aid
using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner,
or toothpick. Nothing should be inserted into the hearing aid. The external
surfaces are cleaned with a damp cloth. The hearing aid should be turned
off before removing it from the ear, but the battery is not removed at that
step of the procedure. It would not likely be possible to remove the battery
while the device was still in the ear.
For which of the following adult clients should the nurse make follow-up observations
and monitor the vital signs closely? A client whose
1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg
2) Oral temperature is 97.9F in the morning and 99.8F in the evening
3) Heart rate was 76 beats/min before eating and 88 beats/min after eating
4) Respiratory rate is 16 breaths/min when standing and 18 when lying down
Give this one a try later!
ANS: 1
Both the blood pressures would be classified as prehypertension
according to the JNC 7 Express guidelines. Body temperature normally
increases during the course of a day. Heart rate increases for several hours
after eating. Respiratory depth decreases when lying down, so it would be
normal for the rate would increase; both rates are within normal limits.
While bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The
nurse should document this finding as:
1) Pallor.
2) Erythema.
3) Jaundice.
4) Cyanosis.
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, ANS: 3
A yellow skin tone, known as jaundice, commonly occurs in patients with
impaired liver function. Pallor is pale skin without underlying pink tones in
the light-skinned person. Pallor occurs with anemia. Erythema, or redness
of the skin, commonly occurs with inflammation or vasodilation. Cyanosis, a
bluish coloring of the skin, is caused by poor peripheral circulation or
decreased oxygen in the blood.
To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution
over all surfaces of the hands?
1) When fingers feel sticky
2) After 5 to 10 seconds
3) When leaving the clients room
4) Once fingers and hands feel dry
Give this one a try later!
ANS: 4
The nurse should rub the antiseptic hand solution over all surfaces of the
hands until the solution dries, usually 10 to 15 seconds, to ensure
effectiveness.
Which of the following nursing activities is of highest priority for maintaining medical
asepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
Give this one a try later!
antibiotics to treat a systemic infection. Which type of infection has the patient
developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
3) Latent
4) Primary
Give this one a try later!
ANS: 1
Thrush in this patient is an example of an endogenous nosocomial
infection. This type of infection arises from suppression of the patients
normal floras as a result of some form of treatment, such as antibiotics.
Normal floras usually keep yeast from growing in the mouth. In exogenous
nosocomial infection, the pathogen arises from the healthcare
environment. A latent infection causes no symptoms for long periods. An
example of a latent infection is human immunodeficiency virus infection. A
primary infection is the first infection that occurs in a patient.
,Which of the following behaviors indicates the highest potential for spreading
infections among clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only when leaving each room.
4) uses cold water for medical asepsis.
Give this one a try later!
ANS: 3
Patients acquire infection by contact with other patients, family members,
and healthcare equipment. But most infection among patients is spread
through the hands of healthcare workers. Hand washing interrupts the
transmission and should be done before and after all contact with patients,
regardless of the diagnosis. When the hands are soiled, healthcare staff
should use antibacterial soap with warm water to remove dirt and debris
from the skin surface. When no visible dirt is present, an alcohol-based rub
should be applied and allowed to dry for 10 to 15 seconds.
Which of the following is a correct step in removing and cleaning a hearing aid?
1) Clean only the external surfaces, not the canal portion.
2) Clean the top part of the canal portion of the device.
3) Insert a wax loop or toothpick into the hearing aid.
4) Remove the battery before taking the hearing aid from the ear.
Give this one a try later!
, ANS: 2
The nurse should clean the top part of the canal portion of the hearing aid
using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner,
or toothpick. Nothing should be inserted into the hearing aid. The external
surfaces are cleaned with a damp cloth. The hearing aid should be turned
off before removing it from the ear, but the battery is not removed at that
step of the procedure. It would not likely be possible to remove the battery
while the device was still in the ear.
For which of the following adult clients should the nurse make follow-up observations
and monitor the vital signs closely? A client whose
1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg
2) Oral temperature is 97.9F in the morning and 99.8F in the evening
3) Heart rate was 76 beats/min before eating and 88 beats/min after eating
4) Respiratory rate is 16 breaths/min when standing and 18 when lying down
Give this one a try later!
ANS: 1
Both the blood pressures would be classified as prehypertension
according to the JNC 7 Express guidelines. Body temperature normally
increases during the course of a day. Heart rate increases for several hours
after eating. Respiratory depth decreases when lying down, so it would be
normal for the rate would increase; both rates are within normal limits.
While bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The
nurse should document this finding as:
1) Pallor.
2) Erythema.
3) Jaundice.
4) Cyanosis.
Give this one a try later!
, ANS: 3
A yellow skin tone, known as jaundice, commonly occurs in patients with
impaired liver function. Pallor is pale skin without underlying pink tones in
the light-skinned person. Pallor occurs with anemia. Erythema, or redness
of the skin, commonly occurs with inflammation or vasodilation. Cyanosis, a
bluish coloring of the skin, is caused by poor peripheral circulation or
decreased oxygen in the blood.
To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution
over all surfaces of the hands?
1) When fingers feel sticky
2) After 5 to 10 seconds
3) When leaving the clients room
4) Once fingers and hands feel dry
Give this one a try later!
ANS: 4
The nurse should rub the antiseptic hand solution over all surfaces of the
hands until the solution dries, usually 10 to 15 seconds, to ensure
effectiveness.
Which of the following nursing activities is of highest priority for maintaining medical
asepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
Give this one a try later!
