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.NUR 164 EXAM 2 (Textbook Questions) Latest
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A charge nurse working on a medical-surgical unit stops the AP from taking rectal
temperatures on patients with which problems? Select all that apply.
A. Hypothermia
B. Pneumonia
C. Bradycardia
D. Leukemia
E. Thrombocytopenia
F. Pancreatitis - CORRECT ANSWER: c, d, e. The rectal site should not be used in
newborns, children with diarrhea, and in patients who have undergone rectal or vaginal
surgery. Inserting a rectal thermometer can stimulate the vagus nerve causing or
worsening bradycardia; this route may be contraindicated in certain cardiac patients.
The rectal route is also contraindicated in patients who have neutropenia (low white
blood cell counts, such as in leukemia or those receiving chemotherapy),
thrombocytopenia (low platelet counts), and certain neurologic disorders.
A home health nurse teaches a patient to a change the dressing for a chronic venous
stasis ulcer using clean technique. Which principle of asepsis will the nurse consider
when preparing the teaching plan?
A. The nurse chooses clean or sterile technique based on personal preference.
B. The use of clean technique is considered safe in the home setting.
C. Surgical asepsis is the safest method to use in a home setting.
D.The patient can use clean technique; their partner must wear sterile gloves. -
CORRECT ANSWER: b. Medical asepsis, or clean technique, involves procedures and
practices that reduce the number and transfer of pathogens. This is usually
recommended in the home setting, where the patient's environment is more controlled.
Injections require surgical asepsis. The patient and partner share the same home;
medical asepsis is appropriate.
A new graduate nurse tells the preceptor they want to obtain recognition in wound care,
a specialty area of nursing. What credential will this nurse need to seek?
A. Accreditation
B. Licensure
C. Certification
D. Board approval - CORRECT ANSWER: C. Certification is the process by which a
person who has met certain criteria established by a nongovernmental association is
granted recognition in a specified practice area. Nursing is one of the groups operating
under state laws that promote the general welfare by determining minimum standards of
education through accreditation of schools of nursing. Licensure is a legal document
that permits a person to offer to the public skills and knowledge in a particular
jurisdiction, where such practice would otherwise be unlawful without a license. State
board of approval ensures that nurses have received the proper training to practice
nursing.
A nurse administering an injection to a patient who tested positive for HIV sustains a
needlestick. What action should the nurse take first?
A. Report the incident to the nurse manager and file an injury report
B. Wash the exposed area with warm water and soap
C. Consent to postexposure prophylaxis (PEP) at the appropriate time
D. Set up counseling sessions regarding safe practice to protect self - CORRECT
ANSWER: b. When a needlestick injury occurs, the nurse should wash the affected
area immediately with warm water and soap, report the incident to the nurse manager
or appropriate person and complete an injury report, consent to and await the results of
blood tests, consent to PEP, and attend counseling sessions regarding safe practice to
protect self and others.
A nurse and health care provider are preparing for insertion of a central venous catheter
when the patient accidentally touches the sterile field. What action will the nurse take
next?
A. Ask another nurse to hold the patient's hand and continue setting up the field
B. Remove any objects the patient touched and resume setting up the sterile field
C. Have someone hold the patient's hand, discard the supplies, and prepare a new
sterile field
D. No action since the patient has touched their own sterile field - CORRECT ANSWER:
c. If a patient touches a sterile field, the nurse should discard all supplies and prepare a
new sterile field. If the patient is restless or confused, the nurse obtains an assistant to
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