Nursing 3300 Questions And Rationale Comprehensive
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EXAM PRACTICE QUESTIONS
The nurse is providing care to a client who is hospitalized for uncontrolled
diabetes and performs the following activities. Which activity(ies) would it be
recommended for the nurse to wear clean gloves? Select all that apply.
a.) touching the identification band when verifying the client's name
b.) administering subcutaneous insulin based on the glucose level
c.) assisting the client to the bathroom
d.) performing a fingerstick to check the blood glucose level
e.) taking the client's vital signs
b, d
Explanation:
Nurses wear gloves to prevent direct contact with blood and other body fluids. The
activities in which the nurse could anticipate contact with blood or body fluids are
performing a fingerstick for the blood glucose level and administering insulin.
Touching the identification band, taking vital signs, and assisting the client to the
bathroom does not require clean gloves as long as the client has intact skin.
When an 86-year-old client reports an inability to concentrate, uneasiness,
lightheadedness, weakness, muscle and joint discomfort, and demonstrates
normal temperature, the clinic nurse recalls that:
a.) the client's symptoms are typical of an older adult client.
b.) an older adult can have an infection without a fever.
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c.) an infection was present and has dissipated.
d.) without an elevated temperature, infection is not present.
b.) an older adult can have an infection without a fever.
Explanation:
Older adults may not show a fever or may produce only a low-grade fever when an
infection is present.
The nurse is preparing a sterile field for a dressing change. How would the
nurse add paper-wrapped sterile items to the sterile field?
a.) Separate the sealed flaps and drop contents onto field.
b.) Set up another sterile field for the additional items.
c.) While wearing sterile gloves, unwrap the package and add to the field.
d.) Open the package away from the field.
a.) Separate the sealed flaps and drop contents onto field.
Explanation:
Once a sterile field is set up, only sterile items can be placed on the field. To add
paper-wrapped sterile items, after performing hand hygiene, the nurse would open
the items by separating the sealed flaps and dropping the contents onto the sterile
field. Wearing sterile gloves to open the package would containment the gloves.
Opening the package away from the field would containment the sterile field. It is not
necessary to set up a separate sterile field.
A health care provider performs lumbar puncture and advises the nurse to
send the obtained cerebrospinal fluid for Gram stains. The nurse understands
that this type of testing is beneficial for which reason?
a.) narrows the therapeutic range to avoid prolonged use
b.) helps to determine prescribed antibiotic therapy
c.) permits selection of antibiotic concentration
d.) helps in reducing proliferation of multidrug-resistant organisms
b.) helps to determine prescribed antibiotic therapy
Explanation:
Gram staining helps to order antibiotic therapy while waiting for specific culture
results, whereas minimum inhibitory concentration permits selection of antibiotic
concentration, helps in reducing proliferation of multidrug-resistant organisms,
narrows the therapeutic range, and avoids prolonged use.
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A client is scheduled for an inguinal hernia repair and is concerned about the
possibility of developing a methicillin-resistant Staphylococcus aureus
(MRSA) infection. What is the most important factor to prevent this infection?
a.) Increased vitamin C
b.) Appropriate use of antibiotics
c.) Surgical asepsis
d.) Administration of monoclonal antibodies
c.) Surgical asepsis
Explanation:
Clients are at risk for health care-associated infections when the health care staff
does not follow safety guidelines. Medical and surgical asepsis are the primary
safety interventions for preventing disease in the health care environment. These
measures supersede the importance of reactive treatment, vitamin intake or the use
of targeted therapies like monoclonal antibodies.
A family member with a mild upper respiratory infection comes to visit a client
in a long-term care facility. The nurse takes the opportunity to teach the family
member about preventing the spread of the cold. What response by the family
member indicates that the nurse's teaching was successful?
a.) "I will obtain a mask from the staff and wash my hands before touching my
family member."
b.) "I will use tissue to cover my nose and mouth while I am visiting and will
refrain from touching my family member."
c.) "I will not visit my family member in the first 3 days of my cold."
d.) "If I sneeze or cough, I will make sure to cover my mouth with hand or
tissue."
a.) "I will obtain a mask from the staff and wash my hands before touching my family
member."
Explanation:
Visitors with respiratory infections need to wear a mask until their symptoms have
subsided. Reuse of a disposable mask is a risk for the spread of infection.
Performing hand hygiene prior to family contact is a good practice at all times
especially if the client is an older adult or immune compromised. Coughing and
sneezing into the bend of the elbow is better than contaminating the hands; however,
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a mask is the best protection during an active cold. Preventing or restricting visitation
may adversely affect the client's well-being.
What is the primary purpose for the demonstrated glove application?
a.) Minimize risk of a glove tear
b.) Anchor gown sleeves
c.) Help adjust for glove size
d.) Cover exposed wrist skin
d.) Cover exposed wrist skin
Explanation:
Gloves are intended to protect hands and wrists from exposure to microorganisms.
This is best accomplished by extending the gloves up the arm to cover the cuffs of
the gown. While the proper application of the gloves does anchor the cuffs, the
primary purpose is directed at the risk management of microorganism expose to the
wrists. This application has no value to adjusting for glove size or to prevent tearing
of the glove
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first
glove, but inadvertently inserts the thumb and index finger into the thumb hole
of the second glove. The glove remains intact. Which action is most
appropriate?
a.) Use only the correctly gloved hand to perform the sterile procedure while
making sure the other hand does not contaminate the sterile field.
b.) Leave both the thumb and finger in the thumb hole and perform the
procedure to the best of the nurse's ability.
c.) Don a second pair of sterile gloves over the first pair.
d.) Continue to don the glove, then use the other gloved hand to carefully
insert the finger into the proper hole.
d.) Continue to don the glove, then use the other gloved hand to carefully insert the
finger into the proper hole.
The nurse reminds the visitor of a client with an antibiotic-resistant infection
that gloves are necessary. The visitor states, "I need to directly hold my loved
one's hand without a barrier." What essential information does the nurse need
to explain to the visitor to prevent transmission of the organism?
a.) "Your loved-one understands why you have to wear gloves because he or