NURS 230 Chapter 27 Exam Questions With
Answers
Which part of the body does the nurse examine if assessing a patient's peripheral vascular system?
1
Lips
2
Chest
3
Oral cavity
4
Fingernails
D
To assess the function of the peripheral vascular system, the nurse should check the condition of the
toenails and fingernails. Capillary refill in less than 3 seconds indicates good blood supply to the
peripheral vasculature. The lips, chest, and oral cavity are supplied by the central arterial supply.
Therefore examining these parts does not help the nurse obtain data about the peripheral blood
supply.
The nurse is caring for a patient who wears corrective contact lenses. Which advice would the nurse
provide the client to prevent eye infections? Select all that apply.
1
Clean the contact lenses once a month.
2
Use appropriate solutions for disinfection.
3
Clean, rinse, and disinfect a dropped lens before using it.
4
Prevent contamination of the lens storage case.
5
Use homemade saline for cleaning the lenses.
2, 3 & 4
Contact lenses should be disinfected with appropriate solution to prevent infection. If a lens is
dropped, clean, rinse, and disinfect the lens to avoid a potential eye infection from any
microorganisms that might have adhered to the lens. If the lens storage case is contaminated, the
lens would also get contaminated and cause an eye infection. The contact lenses should be cleaned
frequently to prevent contamination and infection. Homemade saline solution should not be used for
cleaning, as it can cause an eye infection.
The nurse collaborates with the occupational therapist to prepare a hygiene care plan for a patient
who has suffered a stroke. How will this collaboration be helpful to the nurse?
1
The nurse can ensure that the patient is cooperative during hygiene interventions.
2
The nurse can understand the extent to which the patient can be independent in care.
3
The nurse can determine if the patient is comfortable with the nurse providing hygiene.
4
The nurse can make the patient's caregivers provide adequate hygiene care after discharge.
B
, The nurse asks the unlicensed assistive personnel (UAP) to clean a patient who has been incontinent
of urine. Several minutes later the nurse passes the open door of the room and sees the UAP
changing the patient's gown and linen. Which concern requires the nurse's immediate attention?
1
Room temperature is overly warm.
2
Room door is open to the hallway.
3
Television volume is too loud.
4
Strong odor of urine is detected.
B
The door being open to the hallway violates the patient's privacy. Although attention to the room
temperature, noise level, and odor is required, the immediate concern is with privacy.
Before providing oral hygiene, the nurse turns the patient to a side-lying position. Why does the nurse
perform this intervention?
1
To reduce the risk of aspiration
2
To promote patient comfort during care
3
To prevent the spread of microorganisms
4
To reduce the fluid draining from the mouth
A
When providing oral hygiene, the nurse turns the patient to the side to allow the fluid to drain from
the side of the mouth and reduce the risk of aspiration. The nurse can ensure the patient's comfort by
properly positioning the patient in bed; simply turning the patient to the side is not sufficient. The
nurse uses personal protective equipment such as gloves and masks to prevent the spread of
pathogens; turning does not prevent the spread of microorganisms. Turning the patient to the side
does not reduce the amount of fluid drained.
A patient presents with itching and a reddened scalp from head lice. Which precautions does the
nurse take to prevent the spread of lice?
1
Droplet
2
Contact
3
Airborne
4
Protective isolation
B
Contact precautions should be instituted for a patient with pediculosis. Symptoms such as itching and
a reddened scalp are observed in a patient who has the contagious scalp infection pediculosis, caused
by head lice. This infection is spread either by direct contact or by indirect contact through the sharing
of combs, hats, or linens. Pediculosis is not a droplet infection. Droplet precautions would be given to
patients who have tuberculosis, for example, as the patient can spread the infection when coughing.
Airborne precautions are established to prevent the transmission of infections that can be spread
through the air, including polio and smallpox, not pediculosis. Protective isolation precautions are
useful for immunocompromised patients.
Answers
Which part of the body does the nurse examine if assessing a patient's peripheral vascular system?
1
Lips
2
Chest
3
Oral cavity
4
Fingernails
D
To assess the function of the peripheral vascular system, the nurse should check the condition of the
toenails and fingernails. Capillary refill in less than 3 seconds indicates good blood supply to the
peripheral vasculature. The lips, chest, and oral cavity are supplied by the central arterial supply.
Therefore examining these parts does not help the nurse obtain data about the peripheral blood
supply.
The nurse is caring for a patient who wears corrective contact lenses. Which advice would the nurse
provide the client to prevent eye infections? Select all that apply.
1
Clean the contact lenses once a month.
2
Use appropriate solutions for disinfection.
3
Clean, rinse, and disinfect a dropped lens before using it.
4
Prevent contamination of the lens storage case.
5
Use homemade saline for cleaning the lenses.
2, 3 & 4
Contact lenses should be disinfected with appropriate solution to prevent infection. If a lens is
dropped, clean, rinse, and disinfect the lens to avoid a potential eye infection from any
microorganisms that might have adhered to the lens. If the lens storage case is contaminated, the
lens would also get contaminated and cause an eye infection. The contact lenses should be cleaned
frequently to prevent contamination and infection. Homemade saline solution should not be used for
cleaning, as it can cause an eye infection.
The nurse collaborates with the occupational therapist to prepare a hygiene care plan for a patient
who has suffered a stroke. How will this collaboration be helpful to the nurse?
1
The nurse can ensure that the patient is cooperative during hygiene interventions.
2
The nurse can understand the extent to which the patient can be independent in care.
3
The nurse can determine if the patient is comfortable with the nurse providing hygiene.
4
The nurse can make the patient's caregivers provide adequate hygiene care after discharge.
B
, The nurse asks the unlicensed assistive personnel (UAP) to clean a patient who has been incontinent
of urine. Several minutes later the nurse passes the open door of the room and sees the UAP
changing the patient's gown and linen. Which concern requires the nurse's immediate attention?
1
Room temperature is overly warm.
2
Room door is open to the hallway.
3
Television volume is too loud.
4
Strong odor of urine is detected.
B
The door being open to the hallway violates the patient's privacy. Although attention to the room
temperature, noise level, and odor is required, the immediate concern is with privacy.
Before providing oral hygiene, the nurse turns the patient to a side-lying position. Why does the nurse
perform this intervention?
1
To reduce the risk of aspiration
2
To promote patient comfort during care
3
To prevent the spread of microorganisms
4
To reduce the fluid draining from the mouth
A
When providing oral hygiene, the nurse turns the patient to the side to allow the fluid to drain from
the side of the mouth and reduce the risk of aspiration. The nurse can ensure the patient's comfort by
properly positioning the patient in bed; simply turning the patient to the side is not sufficient. The
nurse uses personal protective equipment such as gloves and masks to prevent the spread of
pathogens; turning does not prevent the spread of microorganisms. Turning the patient to the side
does not reduce the amount of fluid drained.
A patient presents with itching and a reddened scalp from head lice. Which precautions does the
nurse take to prevent the spread of lice?
1
Droplet
2
Contact
3
Airborne
4
Protective isolation
B
Contact precautions should be instituted for a patient with pediculosis. Symptoms such as itching and
a reddened scalp are observed in a patient who has the contagious scalp infection pediculosis, caused
by head lice. This infection is spread either by direct contact or by indirect contact through the sharing
of combs, hats, or linens. Pediculosis is not a droplet infection. Droplet precautions would be given to
patients who have tuberculosis, for example, as the patient can spread the infection when coughing.
Airborne precautions are established to prevent the transmission of infections that can be spread
through the air, including polio and smallpox, not pediculosis. Protective isolation precautions are
useful for immunocompromised patients.
