Fundamentals of Nursing NCLEX
Practice Questions Quiz #3 | 75
Questions
FNDNRS-03-001
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?
A. Bathe the patient’s entire body using 8 to 10 washcloths.
B. Assist the patient to a chair and provide bathing supplies.
C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and provide a bath chair.
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.
FNDNRS-03-002
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.
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.
,FNDNRS-03-003
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
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.
FNDNRS-03-004
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.
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
Practice Questions Quiz #3 | 75
Questions
FNDNRS-03-001
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?
A. Bathe the patient’s entire body using 8 to 10 washcloths.
B. Assist the patient to a chair and provide bathing supplies.
C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and provide a bath chair.
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.
FNDNRS-03-002
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.
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.
,FNDNRS-03-003
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
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.
FNDNRS-03-004
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.
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
