Conceptual Actual Emended Exam Questions
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1. A medical-surgical nurse is assisting a wound care nurse with the
debridement of a client's coccyx wound. What is the primary goal of this
action?
A. Removing purulent drainage from the wound bed in order to accurately assess
it
B. Stimulating the wound bed to promote the growth of granulation tissue
C. Removing dead or infected tissue to promote wound healing
D. Removing excess drainage and wet tissue to prevent maceration of surrounding
skin - ANSWER C. Removing dead or infected tissue to promote wound healing
2. Which body fluid is a transcellular fluid? Select all that apply
A. Synovial fluid
B. Peritoneal fluid
C. Cerebrospinal fluid
D. Fluid outside the cells
E. Fluid outside the blood vessels
ANSWER A. Synovial fluid
B. Peritoneal fluid
C. Cerebrospinal fluid
3. A patient states “I’m allergic to latex.” What is the nurse’s first action?
A. Place in isolation
B. Document allergy immediately
C. Ask the patient to describe the type of reaction
D. Notify dietary services
ANSWER C. Ask the patient to describe the type of reaction
, 4. Which nursing action demonstrates safe injection practice?
A. use multiple-dose vials when administering medication to multiple clients
B. clean injection equipment when dust becomes visible
C. use sterile single-use disposable syringes for each injection
D. recap needles if necessary - ANSWER Use sterile sing-use disposable
syringes for each injection
5. A nurse administers an antihypertensive medication without checking the
patient’s most recent blood pressure. This is an error in which step of the nursing
process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
- ANSWER A. Assessment
6. What should have been done before medication administration? (Select all that
apply)
A. Check latest vital signs
B. Compare current BP to safe parameters
C. Ask NAP if vitals were stable
D. Review provider’s orders
ANSWER b&c
7. Which action demonstrates safe assessment before giving an antihypertensive?
• A. Holding the medication if systolic < 100
• B. Rechecking the blood pressure
• C. Documenting the drug given without assessing
• D. Asking patient to rate pain
ANSWER A&B
,8. The nurse is completing a sterile dressing change on a confused client. During
the procedure, the client reaches down and touches the contents of the open
dressing kit. What is the nurse's next action?
A. Wash the patient's hands
B. Continue changing the dressing
C. Restrain the patient's hands
D. Open a new sterile dressing kit - ANSWER Open a new sterile dressing
kit
9. When accessing a patient's central line, a drop of the patient's blood falls on
the nurse's gloved hand. What is the appropriate action by the nurse?
A. Perform hand hygiene after removing the glove
B. Follow the agency's policy of exposure to communicable infections
C. Have the patient tested for HIV and hepatitis C
D. Report the incident to the supervisor immediately - ANSWER Perform
hand hygiene after removing glove
10. An older adult woman has been in the hospital for more than 1 week. While
assessing her intravenous catheter port, the nurse finds a staph infection, which
has developed in the past day or so. This infection is an example of which type of
infection?
A. Sexually transmitted infection
B. Droplet infection
C. Respiratory infection
, D. Healthcare-associated infection - ANSWER Healthcare-associated
(Noscomial) infection
11. A nurse prefers to use an alcohol-based hand rub when providing care for
patients. In which case is this practice contraindicated?
A. The nurse finishes patient care and hands are not visibly soiled.
B. The nurse finishes cleaning a patient's table.
C. The nurse performs routine care and is moving to another patient.
D. The nurse is caring for a patient with a C. difficile infection. - ANSWER
The nurse is caring for a patient with C. difficile infection
reasoning:
C diff. is not killed by alcohol, and using alcohol based hand rub will increase risk
of spreading infection
12. The nurse is caring for a patient with shortness of breath who is receiving
oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen
therapy is effective?
A. Oxygen saturation 97%
B. Heart rate 110 beat/minute
C. Respirations 26 breaths/minute
D. Clubbing of fingers - ANSWER Oxygen saturation 97%
13. The nurse is caring for a patient with chronic obstructive pulmonary disease
(COPD) who expresses concerns about the ability to breathe easier. The nurse will
suggest which position to help alleviate the patient's dyspnea?
A. Side-lying with head slightly elevated