Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
A. Hold hands folded below the waist after donning sterile gloves
This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
B. Pick up and pour solutions with the palm of the hand covering bottle labels
This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape
This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
D. Maintain sterile objects within the line of vision
This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
Maintain sterile objects within the line of vision.
- A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
- B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
- C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
- D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.
Similar Questions
A nurse is providing teaching for a client who has a fracture of the right fibula with a shortleg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
A. Adjust the crutches for comfort as needed.
This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidanc
B. Use a three-point gait.
This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
C. Wear leather-soled shoes.
This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
D. Advance the affected leg first when walking upstairs.
This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
Full Explanation
- A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
- B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
- C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
- D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
A. Initiate contact precautions for the client upon admission
This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
B. Restrict visitors from entering the client's room during hospitalization
This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
C. Wear a surgical mask while providing care for the client
This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
D. Have the client wear a surgical mask while being transported outside the room
This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.
Full Explanation
Have the client wear a surgical mask while being transported outside the room.
- A. Initiate contact precautions for the client upon admission. This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
- B. Restrict visitors from entering the client's room during hospitalization. This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
- C. Wear a surgical mask while providing care for the client. This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
- D. Have the client wear a surgical mask while being transported outside the room. This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.
A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?
A. A 6-month-old infant who has croup and an O2 saturation of 92% on room air
While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.
B. A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication
A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.
C. A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr
A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.
D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.
E. None
None
F. None
None
Full Explanation
The correct answer is D
Choice A Reason: While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.
Choice B Reason: A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.
Choice C Reason: A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.
Choice D Reason: This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.