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NSG 3100 - Exam 2 Galen
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The nurse recognizes which term to identify the second line of defense that leads to local capillary dilation and leukocyte infiltration? A. Normal flora
B. Inflammatory response C. Immune response D. Humoral immunity - Answer: B. Inflammatory response The nurse knows that the antigen-antibody reaction is an example of what type of immunity? A. Humoral B. Cellular C. Innate D. Passive - Answer: A. Humoral The nurse uses what term to identify a disease-causing organism? A. Pathogen B. Normal flora C. Vector D. Microorganism - Answer: A. Pathogen
B. Portal of exit C. Portal of entry D. Mode of transmission - Answer: D. Mode of transmission The nurse is teaching a group of patients about diseases that are transmitted by ticks. Which term would the nurse use when identifying the function of a tick in spreading disease? A. Vectors B. Bacteria C. Viruses D. Fungi - Answer: A. Vectors What response would the nurse provide to correctly identify the most effective method to prevent hospital- acquired infections? A. Use of sterile technique B. Isolation protocols C. Antibiotic use
D. Handwashing - Answer: D. Handwashing The nurse correctly identifies which patient as having the greatest risk for infection? A. An 80-year-old male with an enlarged prostate B. A 24-year-old female long-distance runner C. A 50-year-old obese male D. A 40-year-old sexually active female - Answer: A. An 80-year-old male with an enlarged prostate The nurse understands that which set of vital signs most likely indicates infection? A. T: 98.6 °F (37.0 °C), P: 75 beats/min, R: 18 breaths/min, BP 120/80 mm Hg B. T: 99 °F (37.2 °C), P: 80 beats/min, R: 18 breaths/min, BP: 110/70 mm Hg C. T: 100.5 °F (38 °C), P: 96 beats/min, R: 22 breaths/min, BP: 150/100 mm Hg D. T: 98.9 °F (37.1 °C), P: 66 beats/min, R: 18 breaths/min, BP: 98/62 mm Hg - Answer: C. T: 100.5 °F
D. Daily - Answer: C. Every 4 hours The nurse knows which skill does not require the use of sterile technique? A. NG tube insertion B. Foley catheterization C. Tracheostomy care D. PICC line insertion - Answer: A. NG tube insertion The nurse recognizes which situation to be inappropriate to use alcohol-based hand sanitizer? A. Patient with pneumonia B. Patient with Clostridium difficile C. Status post-appendectomy D. Patient with HIV - Answer: B. Patient with Clostridium difficile The nurse is preparing to perform suctioning on a new tracheostomy with the potential for forceful expulsion of
secretions and identifies what PPE (personal protective equipment) should be worn? A. Gloves and eyewear B. Gloves, gown, and mask C. Eyewear and gown D. Eyewear, mask, gown, and gloves - Answer: D. Eyewear, mask, gown, and gloves Which isolation precaution should the nurse implement for the patient who has been diagnosed with hepatitis A? A. Airborne B. Contact C. Droplet D. Protective - Answer: B. Contact When the patient is diagnosed with pertussis, which isolation precaution should the nurse implement? A. Droplet B. Airborne C. Contact
The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply.) A. Decreased cough reflex B. Decreased lung elasticity C. Increased activity of the cilia D. Abnormal swallowing reflex E. Increased sputum production - Answer: A. Decreased cough reflex B. Decreased lung elasticity D. Abnormal swallowing reflex The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which statement(s) by the patient indicates further education is needed? (Select all that apply.) A. "I should take antibiotics every time I am sick." B. "I should take all antibiotics as prescribed." C. "I should save all unused antibiotics." D. "I should stop taking antibiotics when I feel better."
E. "If I develop a rash while taking these I will call the provider." - Answer: A. "I should take antibiotics every time I am sick." C. "I should save all unused antibiotics." D. "I should stop taking antibiotics when I feel better." The nurse recognizes which statements by the student nurse regarding handwashing indicate a need for further education? (Select all that apply.) A. Wash hands first, then wrists. B. Rinse from fingertips to wrists. C. Dry using a scrubbing motion. D. Turn off faucet with clean, dry paper towel. E. Dry the hands in the same order as washing them. - Answer: A. Wash hands first, then wrists. B. Rinse from fingertips to wrists. C. Dry using a scrubbing motion. The nurse knows that standard precautions are indicated for which group(s) of patients? (Select all that apply.)
A nurse notes a patient has abnormal vital signs. What action by the nurse is best? A. Document the findings. B. Notify the provider. C. Compare with prior readings. D. Retake the vital signs in 15 minutes. - Answer: C. Compare with prior readings. A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What priority action by the nurse is most appropriate? A. Take the vital signs again in another hour. B. Document the findings in the patient's chart. C. Have another nurse recheck the vital signs. D. Plan to take the vital signs more often. - Answer: D. Plan to take the vital signs more often.
A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement? A. Blood pressure 152/98 mm Hg B. Oral temperature 98.4 °F (36.8 °C) C. Apical pulse 82 beats/min D. Oral temperature 100.8 °F (38.2 °C) - Answer: B. Oral temperature 98.4 °F (36.8 °C) A nurse is caring for a patient who has an elevated temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use? A. Placing a cooling fan in the patient's room B. Putting ice packs in the patient's axillae C. Spraying the patient with a fine mist of water D. Turning the temperature down in the room - Answer: B. Putting ice packs in the patient's axillae
A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best? A. Assess the patient for causes of tachycardia. B. Take an apical heart rate and compare the two. C. Document the findings in the patient's chart. D. Notify the patient's health care provider - Answer: A. Assess the patient for causes of tachycardia. The student nurse is assessing a patient's pulses. What action by the student requires the nurse to intervene? A. Assessing apical pulse between the fifth and sixth intercostal spaces B. Assessing the dorsalis pedis pulse by palpating behind the patient's knee C. Assessing the radial pulse on the patient's wrist D. Assessing the brachial pulse on the patient's inner elbow - Answer: B. Assessing the dorsalis pedis pulse by palpating behind the patient's knee
The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is the most appropriate? A. Assess the patient for fluid volume overload. B. Assess the patient for fluid volume deficit. C. Assess the patient's apical heart rate. D. Assess the patient's pulse deficit. - Answer: A. Assess the patient for fluid volume overload. The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member? A. Counts pulse for 30 seconds and multiplies by two. B. Performs hand hygiene prior to patient contact. C. Compares pulses in both carotid arteries at the same time. D. Assesses pulse on one side then assesses the other side - Answer: C. Compares pulses in both carotid arteries at the same time.
A. Instruct the patient not to get up without help. B. Document the findings and continue to monitor. C. Reassure the patient that these findings are normal. D. Reassess the blood pressures in 1 hour. - Answer: A. Instruct the patient not to get up without help. The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate? A. Place a sign above the bed: "No blood pressures on the right arm." B. Place a sign above the bed: "No continuous blood pressures on the right arm." C. Place a sign above the bed: "Blood pressures in legs only." D. No specific action is needed for this situation. - Answer: A. Place a sign above the bed: "No blood pressures on the right arm." Which patient assessment result would require the nurse to assess that patient further?
A. A 40-year-old woman with a radial pulse of 68. B. A 65-year-old man with a respiratory rate of 10. C. A 12-year-old with a pulse of 92 after ambulating in the hallway. D. A 50-year-old man with a BP of 112/60 upon awakening in the morning. - Answer: B. A 65-year-old man with a respiratory rate of 10. The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first? A. Pulse oximetry 96% B. Blood pressure 102/62 mm Hg C. Pulse 42 beats/min D. Respiratory rate 18 breaths/min - Answer: C. Pulse 42 beats/min A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why he is experiencing tachypnea. What response by the nurse is best?
