Fundamentals of Nursing NCLEX RN Exam Practice Q&A 3

Fundamentals of Nursing NCLEX RN Practice Questions| 75 Questions 1. 1. Question The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? o A. Bathe the patient's entire body using 8 to 10 washcloths. o B. Assist the patient to a chair and provide bathing supplies. o C. Saturate a towel and blanket in a plastic bag, and then bathe the patient. o D. Assist the patient to the bathtub and provide a bath chair. Incorrect Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths. A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. • Option B: A bag bath is not given in a chair or in the tub. The bag bath is one alternative to the traditional bed bath used in some nursing homes. The bath is performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close the door and windows to prevent cold drafts and wash hands with warm water before beginning. • Option C: Moisten the washcloths with water and put in a plastic bag with the cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the temperature of the clothes before touching a resident with them and be careful when you open the bag, as steam can burn. • Option D: Take the bag to the resident’s bedside. When you are not cleaning a body part, keep it covered. Only expose as much of the resident’s body as necessary to adequately clean him or her. Be especially sensitive to exposing genitals, buttocks, and breasts. Bathing can be an extremely stressful experience for residents, so try to make it as easy as possible. 2. 2. Question For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? • A. Cover the mattress with a sheepskin. • B. Keep the linens wrinkle free. • C. Separate the skin folds with towels. • D. Apply petrolatum barrier creams. Incorrect Correct Answer: C. Separate the skin folds with towels. Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and groins may be ignored, leading to an increased risk of skin breakdown in these areas. • Option A: Sheepskins are not recommended for use at all. Skin folds present a challenge in the management of patients who are morbidly obese. The weight from excess adipose tissue in skinfold areas can have an increased risk of skin injury such as friction, maceration, skin tears and pressure ulcer development. • Option B: Skin folds and areas vulnerable to skin injury should be cleaned and dried several times a day. Alcohol-based lotions and harsh soaps, as well as talcum powders, should be avoided in these areas. If necessary, dry cloths to absorb moisture can be left in skin folds in between washing and drying of the skin folds. • Option D: Petrolatum barrier creams are used to minimize moisture caused by incontinence. Patient hydration should also be considered in the nutrition plan for the patients and the health of their skin. 3. 3. Question A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? • A. Fever • B. Intact skin • C. Inflammation • D. Lethargy Incorrect Correct Answer: B. Intact skin Intact skin is considered a primary defense against infection. Usually, the skin prevents invasion by microorganisms unless it is damaged (for example, by an injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are also effective barriers. Typically, mucous membranes are coated with secretions that fight microorganisms. For example, the mucous membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection. • Option A: Body temperature increases as a protective response to infection and injury. An elevated body temperature (fever) enhances the body’s defense mechanisms, although it can cause discomfort. A part of the brain called the hypothalamus controls body temperature. Fever results from an actual resetting of the hypothalamus’s thermostat. The body raises its temperature to a higher level by moving (shunting) blood from the skin surface to the interior of the body, thus reducing heat loss. • Option C: Any injury, including an invasion by microorganisms, causes inflammation in the affected area. Inflammation, a complex reaction, results from many different conditions. During inflammation, the blood supply increases, helping carry immune cells to the affected area. Because of the increased blood flow, an infected area near the surface of the body becomes red and warm. The walls of blood vessels become more porous, allowing fluid and white blood cells to pass into the affected tissue. The increase in fluid causes the inflamed tissue to swell. The white blood cells attack the invading microorganisms and release substances that continue the process of inflammation. • Option D: Lethargy refers to a state of lacking energy. People who are experiencing fatigue or tiredness can also be said to be lethargic because of low energy. The same medical conditions that can lead to tiredness or fatigue can also lead to lethargy. 4. 4. Question A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? • A. A clean gown and gloves must be worn when in contact with the client. • B. Everyone who enters the room must wear a N-95 respirator mask. • C. All linen and trash must be marked as contaminated and send to biohazard waste. • D. Place the client in a room with a client with an upper respiratory infection. Incorrect Correct Answer: A. A clean gown and gloves must be worn when in contact with the client. A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. Visitors might also be asked to wear a gown and gloves. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. • Option B: A respirator mask is required only with airborne precautions, not contact precautions. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. • Option C: All linen must be double-bagged and clearly marked as contaminated. When leaving the room, healthcare providers and visitors remove their gown and gloves and clean their hands. • Option D: The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections. Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. 5. 5. Question A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One: • A. Admitted with unstable diabetes mellitus. • B. Who underwent surgical repair of a perforated bowel. • C. With a stage 3 sacral pressure ulcer. • D. Admitted with a urinary tract infection. Incorrect Correct Answer: A. Admitted with unstable diabetes mellitus. The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Protective Isolation aims to protect an immunocompromised patient who is at high risk of acquiring micro-organisms from either the environment or from other patients, staff, or visitors. • Option B: Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. Patients should remain in isolation whilst they remain symptomatic; a risk assessment should be undertaken to ascertain if and when isolation precautions can be relaxed. • Option C: A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer. Patient’s requiring protective isolation should be nursed in a single room. Where possible this room should have an ante-room, positive pressure ventilation and Hepa filtered air. The room should have an en-suite and hand washing facilities and the doors(s) should be kept closed at all times. • Option D: A client in protective isolation should not be paired with a client who has a urinary tract infection. Many infections acquired by immunocompromised patients are endogenous infections (An infection caused by an infectious agent that is already present in the body but has previously been inapparent or dormant), however, the transmission of infection from other patients, staff, or the environment can be a risk and therefore extra precautions are required. 6. 6. Question A newly hired at Nurseslabs Medical Center is assigned to the OR Department. Which action demonstrates a break in sterile technique? • A. Remaining 1 foot away from non sterile areas. • B. Placing sterile items on the sterile field. • C. Avoiding the border of the sterile drape. • D. Reaching 1 foot over the sterile field. Incorrect Correct Answer: D. Reaching 1 foot over the sterile field. Reaching over the sterile field while wearing sterile garb breaks the sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from non-sterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. The principles of the Sterile Technique are applied in various ways. If the principle itself is understood, the applications of it become obvious. A strict aseptic technique is needed at all times in the Operating Room. • Option A: Sterile persons avoid leaning over an unsterile area; non-sterile persons avoid reaching over a sterile field. Unsterile persons do not get closer than 12 inches from a sterile field. • Option B: Persons who are sterile touch only sterile articles; persons who are not sterile touch only unsterile articles. If in doubt about the sterility of anything consider it not sterile. If a non-sterile person brushes close consider yourself contaminated. • Option C: Sterile persons keep contact with sterile areas to a minimum. Do not lean on the sterile tables or on the draped patient. Do not lean on the nurse’s mayo tray. 7. 7. Question Nurse Berta is facilitating a monthly mothers’ class at a small village. As a knowledgeable nurse, she must know that a mother who breastfeeds her child passes on which antibody through breast milk? • A. IgA • B. IgE • C. IgG • D. IgM Incorrect Correct Answer: A. IgA Antibodies, which are also called immunoglobulins, take five basic forms, indicated as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk, but by far the most abundant type is IgA, particularly the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues. • Option B: IgE is a monomer. It has a molecular weight of 188 Kd and a serum concentration of 0.00005 mg/mL. It protects against parasites and also binds to high-affinity receptors on mast cells and basophils causing allergic reactions. IgE is regarded as the most important host defense against different parasitic infections which include Strongyloides stercoralis, Trichinella spiralis, Ascaris lumbricoides, and the hookworms Necator americanus and Ancylostoma duodenal. • Option C: IgG2 forms an important host defense against bacteria that are encapsulated. IgG is the only immunoglobulin that crosses the placentae as its Fc portion binds to the receptors present on the surface of the placenta, protecting the neonate from infectious diseases. IgG is thus the most abundant antibody present in newborns. • Option D: IgM has a molecular weight of 970 Kd and an average serum concentration of 1.5 mg/ml. It is mainly produced in the primary immune response to infectious agents or antigens. It is a pentamer and activates the classical pathway of the complement system. IgM is regarded as a potent agglutinin (e.g., anti-A and anti-B isoagglutinin present in type B and type A blood respectively) and a monomer of IgM is used as a B cell receptor (BCR). 8. 8. Question The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: • A. Transient flora from the skin • B. Resident flora from the skin • C. All microorganisms from the skin • D. Media for bacterial growth Incorrect Correct Answer: A. Transient flora from the skin There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Hand washing can prevent about 30% of diarrhea-related illnesses and about 20% of respiratory infections (e.g., colds). Antibiotics often are prescribed unnecessarily for these health issues • Option B: Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing.