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