NUR 3028 exam 1 Questions With
Complete Solutions
"speak up campaign" Correct Answers encourages pt/family to
take an active role in preventing errors in healthcare
2 point gait Correct Answers crutch and opposite foot move
together at same time
3 nursing diagnosis Correct Answers 1. actual: thing happening
right now: wound/cut (PES)
2. risk: condition that may dvlp later: infection from that wound,
or fall risk
3. health promotion: based off of educational deficit; enhance
the public's knowledge
3 point gait Correct Answers bear all weight on one foot
-move both crutches at same time, move uninjured leg (used
with people who have a cast)
3 steps for concept mapping Correct Answers 1. list GM in
center, subj/obj data under GM, 4 nursing diagnoses
2. data and goals for each nursing diagnoses
under subj data → cult/personal considerations
under obj data → diagnostic data
3. interventions for each nursing diagnoses
4 point gait Correct Answers bear weight on both feet
-right crutch, left foot, left crutch, right foot
,7 principles of surgical asepsis Correct Answers 1. sterile only
touches sterile
2. only sterile objects can be in the field
3. non-sterile: object falling below the waist, unattended objects
- turning your back, don't cross over field
4. prolonged exposure to air can contaminate field
5. moisture can contaminate field
6. fluid flow the direction of gravity
7. 1" border is not sterile
A nurse enters the hospital room of a patient who had a total
knee replacement the day before. Which of the following pose
potential safety risks? (Select all that apply.)
1. A current safety inspection sticker is on the IV fluids pump.
2. A walker is positioned near the patient's bedside.
3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
5. The over bed table with the patient's glasses is positioned
against the wall opposite the end of the bed. Correct Answers
3, 4, 5
1. All electrical equipment should be inspected routinely and
have current safety inspection stickers.
2. walker near the pt bedside does not impose risk
A nurse is assigned to a new patient admitted to the medical
unit. The nurse collects a nursing history and interviews the
patient. Place the following steps for making a nursing diagnosis
in the correct order Correct Answers 1. Review assessment
data, noting objective and subjective clinical information
2. cluster
3. nursing diagnosis
,4. Consider the context of patient's health problem and select a
related factor
5. Identify appropriate assessment findings for diagnosis
A nurse working the night shift is assigned a patient who has a
history of having fallen in the hospital during a previous
admission. The nurse wants to review the admission assessment
completed by the nurse on the day shift. Which of the following
sections in the assessment are most likely to provide information
about the patient's current fall risks? (Select all that apply.)
1. Allergy history
2. Medication history
3. Patient age
4. Patient's occupation
5. Physical exam of neuromuscular function Correct Answers
2, 3, 5
A patient is being given a bed bath. The nurse realizes that
another washcloth is needed to complete the bath. What is one
way in which the nurse can ensure the patient's safety?
A. Raise the bed to its highest position
B. Make sure the call light is within the patient's reach
C. Raise all four side rails on the patient's bed
D. Use the call light to ask someone else to bring a washcloth
Correct Answers B - having call light in reach decreases
likelihood of the pt getting up while you are gone
raising all 4 bed rails is considered a restraint; asking someone
else to bring a washcloth is unrealistic
, A patient is diagnosed with a multidrug-resistant organism
(MDRO) in his surgical wound and asks the nurse what this
means. What is the nurse's best response? (Select all that apply.)
1. There is more than one organism in the wound that is causing
the infection.
2. The antibiotics the patient has received are not strong enough
to kill the organism.
3. The patient will need more than one type of antibiotic to kill
the organism.
4. The organism has developed a resistance to one or more
broad-spectrum antibiotics, indicating that the organism will be
hard to treat effectively.
5. There are no longer any antibiotic options available to treat
the patient's infection. Correct Answers 2, 4
An MDRO is a single organism that is resistant to one or more
classes of antibiotics, which makes it harder to treat, but there is
treatment available
adding items to sterile field Correct Answers hold outer
wrapper in non-dominant hand, open top of wrapper away from
you
-throw at an angle
alterations of oral cavity: xerostomia, gingivitis, Dental caries
Correct Answers xerostomia: dry mouth
gingivitis: inflammation of gums
dental caries: tooth decay and tooth loss
oral cavity is very vascular: trauma and ulcerations can cause
increased bleeding
-anticoagulant therapy: use oral swabs (prevent gum bleeding)
-do inspections and brush teeth 2x per day
Complete Solutions
"speak up campaign" Correct Answers encourages pt/family to
take an active role in preventing errors in healthcare
2 point gait Correct Answers crutch and opposite foot move
together at same time
3 nursing diagnosis Correct Answers 1. actual: thing happening
right now: wound/cut (PES)
2. risk: condition that may dvlp later: infection from that wound,
or fall risk
3. health promotion: based off of educational deficit; enhance
the public's knowledge
3 point gait Correct Answers bear all weight on one foot
-move both crutches at same time, move uninjured leg (used
with people who have a cast)
3 steps for concept mapping Correct Answers 1. list GM in
center, subj/obj data under GM, 4 nursing diagnoses
2. data and goals for each nursing diagnoses
under subj data → cult/personal considerations
under obj data → diagnostic data
3. interventions for each nursing diagnoses
4 point gait Correct Answers bear weight on both feet
-right crutch, left foot, left crutch, right foot
,7 principles of surgical asepsis Correct Answers 1. sterile only
touches sterile
2. only sterile objects can be in the field
3. non-sterile: object falling below the waist, unattended objects
- turning your back, don't cross over field
4. prolonged exposure to air can contaminate field
5. moisture can contaminate field
6. fluid flow the direction of gravity
7. 1" border is not sterile
A nurse enters the hospital room of a patient who had a total
knee replacement the day before. Which of the following pose
potential safety risks? (Select all that apply.)
1. A current safety inspection sticker is on the IV fluids pump.
2. A walker is positioned near the patient's bedside.
3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
5. The over bed table with the patient's glasses is positioned
against the wall opposite the end of the bed. Correct Answers
3, 4, 5
1. All electrical equipment should be inspected routinely and
have current safety inspection stickers.
2. walker near the pt bedside does not impose risk
A nurse is assigned to a new patient admitted to the medical
unit. The nurse collects a nursing history and interviews the
patient. Place the following steps for making a nursing diagnosis
in the correct order Correct Answers 1. Review assessment
data, noting objective and subjective clinical information
2. cluster
3. nursing diagnosis
,4. Consider the context of patient's health problem and select a
related factor
5. Identify appropriate assessment findings for diagnosis
A nurse working the night shift is assigned a patient who has a
history of having fallen in the hospital during a previous
admission. The nurse wants to review the admission assessment
completed by the nurse on the day shift. Which of the following
sections in the assessment are most likely to provide information
about the patient's current fall risks? (Select all that apply.)
1. Allergy history
2. Medication history
3. Patient age
4. Patient's occupation
5. Physical exam of neuromuscular function Correct Answers
2, 3, 5
A patient is being given a bed bath. The nurse realizes that
another washcloth is needed to complete the bath. What is one
way in which the nurse can ensure the patient's safety?
A. Raise the bed to its highest position
B. Make sure the call light is within the patient's reach
C. Raise all four side rails on the patient's bed
D. Use the call light to ask someone else to bring a washcloth
Correct Answers B - having call light in reach decreases
likelihood of the pt getting up while you are gone
raising all 4 bed rails is considered a restraint; asking someone
else to bring a washcloth is unrealistic
, A patient is diagnosed with a multidrug-resistant organism
(MDRO) in his surgical wound and asks the nurse what this
means. What is the nurse's best response? (Select all that apply.)
1. There is more than one organism in the wound that is causing
the infection.
2. The antibiotics the patient has received are not strong enough
to kill the organism.
3. The patient will need more than one type of antibiotic to kill
the organism.
4. The organism has developed a resistance to one or more
broad-spectrum antibiotics, indicating that the organism will be
hard to treat effectively.
5. There are no longer any antibiotic options available to treat
the patient's infection. Correct Answers 2, 4
An MDRO is a single organism that is resistant to one or more
classes of antibiotics, which makes it harder to treat, but there is
treatment available
adding items to sterile field Correct Answers hold outer
wrapper in non-dominant hand, open top of wrapper away from
you
-throw at an angle
alterations of oral cavity: xerostomia, gingivitis, Dental caries
Correct Answers xerostomia: dry mouth
gingivitis: inflammation of gums
dental caries: tooth decay and tooth loss
oral cavity is very vascular: trauma and ulcerations can cause
increased bleeding
-anticoagulant therapy: use oral swabs (prevent gum bleeding)
-do inspections and brush teeth 2x per day
