Instructions Read each question carefully. Answer each question by bubbling your answer on the Scantron answer sheet. After you have finished answering all questions, select TRUE. Click Finish Attempt at the bottom of the page. On the next page, click Submit All and Finish. If a confirmation message appears, click Submit All and Finish again to complete your submission. Once your assessment has been submitted successfully, notify your proctor that you are finished. Please wait for the proctor’s instructions before proceeding to the next step. Chapters 28-30 Key/Variation A____ 1. What principle distinguishes surgical asepsis from medical asepsis? a. Surgical asepsis requires hand hygiene only, whereas medical asepsis requires sterile gloves. c. Surgical asepsis is used only in home care, whereas medical asepsis is used only in hospitals. b. Surgical asepsis eliminates all microorganisms, including spores, whereas medical asepsis reduces the number and spread of microorganisms. d. Surgical asepsis prevents all infections without additional infection control measures. ____ 2. What best guides a nurse’s clinical judgment when determining whether additional vital sign measurements are needed? a. Patient assessment findings and changes in clinical condition c. Routine unit schedule alone b. Time remaining until the end of the shift d. Number of patients assigned to the nurse ____ 3. What instruction is most appropriate for obtaining an accurate self-measured blood pressure reading at home? a. Place the cuff over thick clothing to improve comfort. c. Measure blood pressure immediately after vigorous exercise. b. Cross the legs while sitting to stabilize body position. d. Support the arm at heart level while seated comfortably during the measurement. ____ 4. What event occurs first during the normal inflammatory response following tissue injury? a. Vasodilation with increased blood flow to the affected area c. Migration of white blood cells to the injured tissue b. Tissue repair and scar formation d. Formation of antibodies against microorganisms ____ 5. What is the primary purpose of Standard Precautions in health care? a. Eliminate the need for personal protective equipment during patient care c. Prevent transmission of microorganisms from both recognized and unrecognized sources of infection b. Replace Transmission-Based Precautions for all patients d. Protect only patients with confirmed infectious diseases ____ 6. When is it most appropriate for the nurse to obtain a complete set of vital signs? a. Only after receiving a provider’s prescription c. Only at the beginning of each hospitalization b. Before, during, and after procedures or interventions that may affect physiological status d. Only when the patient reports pain ____ 7. Which pulse site is most appropriate for accurately determining heart rate when an irregular cardiac rhythm is suspected? a. Apical pulse c. Femoral pulse b. Radial pulse d. Brachial pulse ____ 8. What nursing intervention primarily promotes heat loss in a patient with hyperthermia? a. Increasing room temperature above the patient’s comfort level c. Applying lightweight clothing and encouraging adequate fluid intake b. Limiting fluid intake to reduce perspiration d. Covering the patient with multiple warm blankets ____ 9. Which adult oral temperature is classified as febrile? a. 35.8°C (96.4°F) c. 37.2°C (99.0°F) b. 38.5°C (101.3°F) d. 36.8°C (98.2°F) ____ 10. What is the nurse’s priority action immediately after occupational exposure to blood that may contain the hepatitis B virus? a. Report the exposure promptly and follow the agency’s postexposure protocol. c. Return to patient care after washing the exposed area without further action. b. Begin prescribed antibiotic therapy immediately. d. Wait for symptoms of infection before reporting the exposure. ____ 11. Which characteristic is included in a complete respiratory assessment? a. Heart sounds, pulse deficit, and peripheral edema c. Oxygen saturation, temperature, and capillary refill b. Pulse strength, rhythm, and blood pressure d. Rate, rhythm, depth, and effort of respirations ____ 12. What type of Transmission-Based Precaution requires placement of the patient in an airborne infection isolation room (AIIR) with negative air pressure? a. Contact Precautions c. Droplet Precautions b. Standard Precautions d. Airborne Precautions ____ 13. Which information is an essential component of the nursing history obtained before performing a physical examination? a. Patient’s health history, current medications, allergies, and chief concern c. Date of the facility’s most recent accreditation survey b. Manufacturer of the examination table d. Number of staff members assigned to the examination area ____ 14. What is a common outcome associated with health care–associated infections (HAIs)? a. Increased morbidity, mortality, and health care costs c. Improved patient recovery and rehabilitation b. Reduced need for antimicrobial therapy d. Shortened length of hospitalization ____ 15. What does a pulse deficit indicate when comparing the apical and radial pulse rates?What does a pulse deficit indicate when comparing the apical and radial pulse rates? a. The radial pulse rate is higher than the apical pulse rate. c. The patient’s pulse strength is stronger in the lower extremities. b. The heart is contracting effectively with each heartbeat. d. Some cardiac contractions fail to produce a palpable peripheral pulse. ____ 16. What is the correct sequence for donning personal protective equipment (PPE)? a. Gown – Mask or respirator – Eye protection – Gloves c. Gloves – Gown -Mask or respirator – Eye protection b. Eye protection – Gloves – Gown – Mask or respirator d. Mask or respirator – Gloves – Eye protection – Gown ____ 17. What infection control practice is unique to the hospital setting when compared with routine home care? a. Covering the mouth and nose during coughing or sneezing c. Using Standard Precautions for every patient regardless of diagnosis b. Performing hand hygiene before and after contact with body fluids d. Cleaning frequently touched household surfaces on a regular schedule ____ 18. Which finding is considered a normal age-related change in an older adult? a. Fixed and unequal pupils c. Persistent irregular respiratory rhythm b. Complete loss of peripheral pulses d. Gradual decrease in skin elasticity ____ 19. Which factor can produce a falsely low pulse oximetry (SpO?22) reading despite adequate oxygenation? a. Warm extremities with good peripheral perfusion c. Proper probe placement on a well-perfused finger b. Dark-colored nail polish covering the fingernail d. Adequate circulation to the monitoring site ____ 20. When is it appropriate for the registered nurse to delegate routine vital sign measurement to assistive personnel? a. When immediate nursing assessment is required following surgery c. When the patient is clinically stable and the nurse will interpret the findings b. When the patient has newly developed chest pain d. When the patient is experiencing rapid physiological deterioration ____ 21. What body defense serves as the first physical barrier against the entry of microorganisms? a. Lymph nodes c. Intact skin b. Bone marrow d. Red blood cells ____ 22. What nursing action best demonstrates culturally competent care during a health assessment? a. Omitting questions regarding cultural practices to avoid discomfort c. Performing the same assessment approach for every patient regardless of cultural background b. Asking family members to answer all assessment questions regardless of the patient’s preference d. Modifying communication and assessment techniques based on the patient’s cultural beliefs and preferences ____ 23. What is the primary purpose of breaking a link in the chain of infection? a. To promote faster tissue repair after infection c. To interrupt the transmission of infectious microorganisms b. To increase the body’s inflammatory response d. To eliminate all microorganisms from the environment ____ 24. What environmental preparation best promotes an effective physical examination? a. Keeping examination equipment outside the room until needed c. Lowering the room lighting to increase patient relaxation b. Maintaining a private, well-lit, quiet room with a comfortable temperature d. Performing the examination in a busy hallway to improve efficiency ____ 25. What finding best indicates that nursing interventions to improve oxygenation have been effective? a. Oxygen saturation increases to the patient’s expected target range with improved respiratory status. c. Heart rate increases while body temperature remains unchanged. b. Respiratory rate remains elevated while the patient reports fatigue. d. Blood pressure decreases below the patient’s baseline after intervention. ____ 26. Which patient characteristic places an individual at the greatest risk for developing an infection? a. Chronic disease associated with impaired immune response c. Regular physical activity and balanced nutrition b. Normal skin integrity without invasive devices d. Intact immune function with adequate nutritional status ____ 27. What nursing intervention best prepares a patient psychologically before a physical examination? a. Explaining the examination procedures and encouraging the patient to ask questions c. Beginning the examination immediately to reduce delays b. Performing all invasive procedures before providing explanations d. Limiting communication until the examination is completed ____ 28. What nursing action best incorporates health promotion during a routine physical examination? a. Postponing all health education until hospital discharge c. Limiting the examination to data collection without patient education b. Providing individualized health teaching based on identified risk factors and assessment findings d. Teaching identical preventive measures to every patient regardless of health status ____ 29. \What finding is most characteristic of a systemic infection rather than a localized infection? a. Fever accompanied by generalized malaise c. Redness confined to a single wound b. Swelling limited to one affected area d. Purulent drainage from one incision ____ 30. What physiological response commonly occurs during the chill phase of a fever?What physiological response commonly occurs during the chill phase of a fever? a. Decreased metabolic rate and reduced oxygen consumption c. Peripheral vasoconstriction accompanied by shivering b. Peripheral vasodilation with profuse sweating d. Increased heat loss through evaporation ____ 31. What action is essential when performing hand hygiene with alcohol-based hand rub? a. Apply the solution and wipe the hands dry immediately with a paper towel. c. Rub all hand surfaces together until the hands are completely dry. b. Rinse the hands with water before applying the alcohol-based hand rub. d. Apply the alcohol-based hand rub only after removing visible soil with soap and water. ____ 32. Which blood pressure reading is classified as Stage 2 hypertension in an adult? a. 148/94 mm Hg c. 124/78 mm Hg b. 116/74 mm Hg d. 134/86 mm Hg ____ 33. What nursing intervention most directly interrupts the mode of transmission in the chain of infection? a. Performing hand hygiene before and after patient contact c. Administering prescribed antimicrobial therapy b. Encouraging adequate nutritional intake d. Assessing body temperature every shift ____ 34. Which factor commonly affects all vital sign measurements and should be considered during assessment? a. Eye colorEye color c. Hand dominance b. Physical activity d. Hair color ____ 35. What SpO2 value generally indicates adequate oxygenation in a healthy adult? a. 92% c. 88% b. 82% d. 97% ____ 36. Which physical assessment technique is performed by listening to sounds produced within the body using a stethoscope? a. Palpation c. Inspection b. Auscultation d. Percussion ____ 37. What documentation practice best reflects accurate recording and reporting of vital sign measurements? a. Documenting vital signs promptly with the measured values and reporting significant abnormalities according to agency policy. c. Recording estimated values when equipment is temporarily unavailable. b. Recording only abnormal vital signs at the end of the shift. d. Delaying documentation until all nursing interventions have been completed. ____ 38. What communication technique best promotes accurate data collection during a nursing history interview? a. Asking primarily closed-ended questions throughout the interview c. Interrupting the patient to maintain the interview schedule b. Completing the patient’s responses based on previous medical records d. Using open-ended questions followed by focused clarification when needed ____ 39. What factor is most important when selecting an appropriate site for temperature assessment? a. Patient’s age, clinical condition, and accuracy requirements c. Time required to complete the assessment b. Availability of disposable thermometer covers only d. Nurse’s personal preference ____ 40. What is the primary purpose of performing a comprehensive physical assessment? a. To determine the patient’s financial eligibility for health services c. To replace the need for laboratory and diagnostic testing b. To confirm only previously diagnosed medical conditions d. To establish baseline data for identifying health status and planning individualized nursing care
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