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NCM 103 RLE
Prelims
STUDENT NAME (Last Name, First
Name) *
Laracas, Lezel
1. A nurse is following the principles of
medical asepsis when performing
patient care in a hospital setting. Which
nursing action performed by the nurse
follows these recommended
guidelines? *
The nurse moves the patient table away
from the nurse's body when wiping it off after
a meal.
The nurse cleans the most soiled items in
the patient's bathroom first and follows with
the cleaner items.
The nurse places soiled bed linens and
hospital gowns on the floor when making the
bed.
The nurse carries the patients' soiled bed
linens close to the body to prevent spreading
microorganisms into the air.
2. A nurse is preparing a sterile field
using a packaged sterile drape for a
confused patient who is scheduled for a
surgical procedure. When setting up the
field, the patient accidentally touches
an instrument in the sterile field. What
is the appropriate nursing action in this
situation? *
Ask another nurse to hold the hand of the
patient and continue setting up the field.
Remove the instrument that was touched by
the patient and continue setting up the sterile
field.
Discard the supplies and prepare a new
sterile field with another person holding the
patient's hand.
No action is necessary since the patient has
touched his or her own sterile field.
3. A stethoscope has two components
to the chest piece. These are called the
__________ and the __________. *
bell . . . diaphragm
cone . . . disc
cone . . . diaphragm
bell . . . disc
4. A nurse takes a patient's blood
pressure and records it at 146/92
mmHg. This is the patient's first visit to
the clinic and they have no past
medical records available. Would this
patient be diagnosed with
hypertension? *
Yes, this is malignant hypertension
Yes, this is stage I hypertension
No, there is not enough information
No, this is within the normal range
5. Which of the following is not a normal
part of taking a patient's vitals? *
Overall visual appearance
Temperature
All of these are part of taking a patient's
vitals
Pulse
6. The physician on call pages you to
ask if the patient you are taking care of
is afebrile. Which of the following vital
signs would you find in an afebrile
patient? *
Temperature of 39.5 degrees Celsius
Heart rate of 105 beats per minute
Temperature of 36.6 degrees Celsius
Blood pressure of 105 over 89
7. While assessing a patient's blood
pressure, what part of the stethoscope
should be placed against the patient's
antecubital fossa: the bell, or the
diaphragm? *
The diaphragm
The bell
The diaphragm should be used first, then the
bell
The bell should be used first, then the
diaphragm
8. The nurse is measuring blood
pressures as part of a community
health fair. Which blood pressure
reading would cause the nurse to refer
the patient for follow-up regarding
potential hypertension? *
136/90
118/78
126/84
144/94
9. The nurse is admitting a stable
patient for a minor outpatient
procedure. What site would the nurse
most commonly use to assess pulse
rate? *
Apical site
Radial site
Brachial site
Carotid site
10. The unlicensed assistive personnel
reports vital signs for a patient to the
nurse: temperature of 99.2º F (37.3º C)
oral, pulse of 88 beats/min and regular,
respirations of 18 BPM and regular,
blood pressure of 178/112, oxygen
saturation of 96%, and pain score of 3
on a 0-to-10 scale for headache. Which
vital sign should the nurse be most
concerned about? *
Pulse
Respirations
Temperature
Blood pressure
11. Which clinical patient scenario is
associated with the most critical need
for the nurse to obtain vital signs? *
Complaining of hunger while NPO (nothing
by mouth)
Ambulating for the first time after surgery
Completing ambulating 100 feet after a
stroke
Complaining of pressure in the chest
12. The nurse notes that the patient has
an irregular pulse. What is the first
action the nurse should take? *
Assess the pulse at two different sites.
Assess the pulse at the carotid artery.
Assess the pulse with a Doppler ultrasound.
Assess the pulse for a full minute.
13. Which assessment findings would
require the nurse to further assess the
patient? *
A 72-year-old female with a respiratory rate
of 10 breaths per minute
A young adult male with a pulse rate of 136
after running 2 miles
A 50-year-old male with a pulse rate of 88
beats per minute
A 40-year-old female with a blood pressure
of 110/70 when first awakened
14. Vital signs are normally taken when
the person is *
Sitting or lying down
Only when sitting down
Only when lying down
Sitting or standing
15. All of the following may decrease
blood pressure except *
Fasting
Depression
Pain
Shock
16. In a blood pressure measurement
of 132/86, the number 86 is the *
Tachycardia
Systolic
Bradycardia
Diastolic
17. Heart sounds are caused by *
Movement of blood through the heart
chambers
Contraction of the heart muscle
Relaxation of the heart muscle
Closing of the valves in the heart
18. The pulse site used while taking a
blood pressure is *
Femoral
Carotid
Popliteal
Brachial
19. You are checking on a patient at
midnight and notice apnea while
observing their respiration without
waking them. You know that apnea
means *
High pitched whistling sound on inspiration
Difficult breathing
Absence of respiration
Bubbling or noisy counts on inspiration
20. Respiration is defined as *
Taking in CO2 and expelling O2 by the heart
Taking in O2 and expelling CO2 by the lungs
Taking in CO2 and expelling O2 by the lungs
Taking in O2 and expelling CO2 by the heart
21. You are counting Mrs. Millie White's
respiration. Which statement is false *
Each rise and fall of the chest is counted as
one
Both sides of her chest should rise and fall
equally
Respiration are usually counted for 1 minute
You need to tell her what you are doing
22. If you count 9 respirations in 30
seconds, your would report *
9 per minute
27 per minute
18 per minute
20 per minute
23. Cheyne-stokes respiration
describes *
Moist or stertorous breathing
Periods of apnea and dyspnea
Difficult or labored breathing
Rapid breathing
24. Difficult or labored respiration are *
Cheyne-Stokes
Dyspnea
Rales
Apnea
25. What supplies will you need to
measure and record a radial pulse *
Watch with a second hand
Paper
Pen/pencil
All of the choices
26. You come to Laura's room on
morning rounds to take her vital signs.
She is lying in the bed. How would you
check her pulse *
Place in comfortable position, support her
arm and place her palm or hand downward
Place in comfortable position, support her
arm and place palm of hand upward
Place in comfortable position, use
stethoscope and place over apex of heart
Place in comfortable position, place two
fingers on neck beside the trachea
27. When taking a pulse, why should
the thumb NOT be used *
The thumb has a pulse and can be confused
with the patients
There is more dexterity in the fingers then in
the thumb
The sensation of the thumb is not as good as
it is in the middle
The width of the thumb impedes an accurate
feel for the pulse
28. Before taking vital signs on a
patient, what should you do first *
Explain the procedure
Introduce yourself
Place the call bell within reach
Close the privacy curtain
29. Which of the following does not lead
to increased body temperature *
Starvation or fasting
Illness or infection
Excitement
Exercise
30. When assessing a temperature
rectally, the nurse would use extreme
care when inserting the thermometer to
prevent which of the following? *
Decrease in BP
Increase in heart rate
Increase in respirations
Decrease in heart rate
31. A patient is having dyspnea. what
would the nurse do first? *
Remove pillows from under the head
Elevate the head of the bed
Elevate the foot of the bed
Take the BP
32. When using an alcohol-based
handrub, after you've applied the rub,
how long should it take of rubbing your
hands together before your hands feel
dry? *
10 seconds
2 minutes
15 seconds
5 seconds
33. When should you practice hand
hygiene? *
All the time
Only when you think the patient is
contaminated or dirt
Only when you think your hands are dirty
Both before and after having contact with a
patient
34. What is the FIRST priority in
preventing transmission of infections? *
Wearing sterile non-latex gloves
Wearing gowns and goggles
Performing proper hand hygiene
Wiping stethoscopes with alcohol
35. The clinical instructor asks her
students the rationale for handwashing.
The students are correct if they
answered that handwashing is
expected to remove: *
resident flora from the skin.
transient flora from the skin.
all microorganisms from the skin.
media for bacterial growth.
36. Which one of the following is a risk
factor for poor handwashing? *
Not wearing gowns/gloves
Being a nurse (rather than a physician)
Female gender
Being a physician (rather than a nurse)
37. What are we trying to reduce or
eliminate when we are doing
handwashing? *
All of the choices
Viruses
Bacteria
Fungi
38. When performing a surgical scrub
with an antimicrobial agent, how far up
the arm must an individual scrub? *
To the elbow
Up to the armpit
Four inches above the wrist
Two inches above the elbow
39. Wearing artificial or acrylic nails in
the surgical setting is: *
unacceptable because they may harbor
microorganisms
unacceptable for aesthetic reasons
permitted if polish is less than four days old
permitted if they are in good repair
40. All of the following statements apply
when drying the hands and arms
EXCEPT: *
Bend over slightly from the waist
Dry thoroughly to avoid skin irritation
Begin drying with the hand and move up the
arm
Roll the towel before discarding into the
appropriate container
41. The sterile areas of the gown
include the:1. front from two inches
below the neck to waist or table level2.
gloves and gown sleeve to two inches
above the elbow3. sides from axillae to
waist or table level4. back of a
wraparound gown *
1, 2, and 3
1 and 2
1 and 3
All of the choices
42. The closed-glove technique is
used: *
when regloving without assistance during the
procedure
only when the hands have never passed
through the gown cuffs
as a method for correcting glove
contamination
to assist a surgeon in donning sterile attire
43. Sterile gloves must be worn for
each of these procedures except: *
Central line dressing change
Urinary Catheterization
Tracheostomy dressing change
Postpartum perineal care
44. To doff (remove) used sterile gloves
the nurse should: *
Pull both off from the inside edge, the nurse
will wash their hands afterwards, so touching
the gloves is not a concern.
Wash the gloved hands with soap and water
before removing the gloves to remove blood
or body fluids
Pull off the first glove by grasping slightly
back from the wrist, turning it inside out, and
wading the dirty glove into the still gloved
hand.
Use clean tongs from the procedure tray to
take them off so that the hands are not
contaminated
45. The first step in donning sterile
gloves, after choosing the correct size
is: *
Open the wrapper fully, touching only the
outer 1inch edge of the paper
Fold the first flap of the outer wrapper away
from you
Use the folded cuffs in the wrapper to open
the sides fully
Wash hand with soap and water using good
hand-washing technique
46. Where should the scrubbed person
hold onto his or her gown when lifting it
up to don it? *
The sterile exterior of the gown
The inside seams at armpits
The inside front of the gown just below the
neckband
At the waist
47. The nurse has opened the sterile
supplies and put on two sterile gloves
to complete a sterile dressing change, a
procedure that requires surgical
asepsis. The nurse must: *
Use forceps soaked in a disinfectant.
Keep splashes on the sterile field to a
minimum.
Cover the nose and mouth with gloved
hands if a sneeze is imminent.
Consider the outer 1 inch of the sterile field
as contaminated.
48. What is the act of cleaning one’s
hands with the use of any liquid with or
without soap for the purpose of
removing dirt or microorganisms? *
Medical Asepsis
Aseptic Technique
Surgical Asepsis
Handwashing
49. Which handwashing method kills
the most germs? *
Liquid soap and water
Antibacterial soap and water
Bar soap and water
Any form of soap and water
50. Which of the following would require
the nurse put on a new pair of sterile
gloves? *
Picking up unused gauze from the central
line dressing tray and dropping it on the
table
Tucking a drape under the patient's hips
using the inside of the drape cuff
Grasping the patients gown to move it out of
the way
Arranging the sterile supplies on the center
of the sterile field
51. It is not necessary to wear gloves
when you handle soiled laundry or
linens *
True
False
52. Your patient care practices send a
powerful message and show your
patients and co-workers that you are
serious about their health. *
False
True
53. Gloves may not be worn when
hands may be contaminated with body
fluids (blood, urine or non-intact skin). *
True
False
54. Gowns will protect your clothes
from germs the client may have *
False
True
55. Bed linens should be changed once
a month *
False
True
56. Germs are only spread by contact,
not through the air. *
True
False
57. Universal precautions are all of the
practices that help to stop the spread of
infection and diseases *
True
False
58. You will always need to wear gloves
during any personal care for your
client *
False
True
59. Hand hygiene must be performed
before placing gloves on and after
glove removal. *
True
False
60. If you touch a surface area in the
exam room and do not touch the patient
you do not have to practice hand
hygiene. *
True
False

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HEALTH ASSESSMENT PRELIMS.docx

  • 1. NCM 103 RLE Prelims STUDENT NAME (Last Name, First Name) * Laracas, Lezel 1. A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? * The nurse moves the patient table away from the nurse's body when wiping it off after a meal. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items. The nurse places soiled bed linens and hospital gowns on the floor when making the bed. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air. 2. A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? * Ask another nurse to hold the hand of the patient and continue setting up the field. Remove the instrument that was touched by the patient and continue setting up the sterile field. Discard the supplies and prepare a new sterile field with another person holding the patient's hand. No action is necessary since the patient has touched his or her own sterile field. 3. A stethoscope has two components to the chest piece. These are called the __________ and the __________. * bell . . . diaphragm cone . . . disc cone . . . diaphragm bell . . . disc 4. A nurse takes a patient's blood pressure and records it at 146/92 mmHg. This is the patient's first visit to the clinic and they have no past medical records available. Would this patient be diagnosed with hypertension? * Yes, this is malignant hypertension Yes, this is stage I hypertension No, there is not enough information No, this is within the normal range 5. Which of the following is not a normal part of taking a patient's vitals? * Overall visual appearance Temperature All of these are part of taking a patient's vitals Pulse 6. The physician on call pages you to ask if the patient you are taking care of is afebrile. Which of the following vital signs would you find in an afebrile patient? * Temperature of 39.5 degrees Celsius Heart rate of 105 beats per minute
  • 2. Temperature of 36.6 degrees Celsius Blood pressure of 105 over 89 7. While assessing a patient's blood pressure, what part of the stethoscope should be placed against the patient's antecubital fossa: the bell, or the diaphragm? * The diaphragm The bell The diaphragm should be used first, then the bell The bell should be used first, then the diaphragm 8. The nurse is measuring blood pressures as part of a community health fair. Which blood pressure reading would cause the nurse to refer the patient for follow-up regarding potential hypertension? * 136/90 118/78 126/84 144/94 9. The nurse is admitting a stable patient for a minor outpatient procedure. What site would the nurse most commonly use to assess pulse rate? * Apical site Radial site Brachial site Carotid site 10. The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature of 99.2º F (37.3º C) oral, pulse of 88 beats/min and regular, respirations of 18 BPM and regular, blood pressure of 178/112, oxygen saturation of 96%, and pain score of 3 on a 0-to-10 scale for headache. Which vital sign should the nurse be most concerned about? * Pulse Respirations Temperature Blood pressure 11. Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital signs? * Complaining of hunger while NPO (nothing by mouth) Ambulating for the first time after surgery Completing ambulating 100 feet after a stroke Complaining of pressure in the chest 12. The nurse notes that the patient has an irregular pulse. What is the first action the nurse should take? * Assess the pulse at two different sites. Assess the pulse at the carotid artery. Assess the pulse with a Doppler ultrasound. Assess the pulse for a full minute. 13. Which assessment findings would require the nurse to further assess the patient? * A 72-year-old female with a respiratory rate of 10 breaths per minute A young adult male with a pulse rate of 136 after running 2 miles A 50-year-old male with a pulse rate of 88 beats per minute A 40-year-old female with a blood pressure of 110/70 when first awakened 14. Vital signs are normally taken when the person is * Sitting or lying down Only when sitting down Only when lying down
  • 3. Sitting or standing 15. All of the following may decrease blood pressure except * Fasting Depression Pain Shock 16. In a blood pressure measurement of 132/86, the number 86 is the * Tachycardia Systolic Bradycardia Diastolic 17. Heart sounds are caused by * Movement of blood through the heart chambers Contraction of the heart muscle Relaxation of the heart muscle Closing of the valves in the heart 18. The pulse site used while taking a blood pressure is * Femoral Carotid Popliteal Brachial 19. You are checking on a patient at midnight and notice apnea while observing their respiration without waking them. You know that apnea means * High pitched whistling sound on inspiration Difficult breathing Absence of respiration Bubbling or noisy counts on inspiration 20. Respiration is defined as * Taking in CO2 and expelling O2 by the heart Taking in O2 and expelling CO2 by the lungs Taking in CO2 and expelling O2 by the lungs Taking in O2 and expelling CO2 by the heart 21. You are counting Mrs. Millie White's respiration. Which statement is false * Each rise and fall of the chest is counted as one Both sides of her chest should rise and fall equally Respiration are usually counted for 1 minute You need to tell her what you are doing 22. If you count 9 respirations in 30 seconds, your would report * 9 per minute 27 per minute 18 per minute 20 per minute 23. Cheyne-stokes respiration describes * Moist or stertorous breathing Periods of apnea and dyspnea Difficult or labored breathing Rapid breathing 24. Difficult or labored respiration are * Cheyne-Stokes Dyspnea Rales Apnea 25. What supplies will you need to measure and record a radial pulse * Watch with a second hand Paper Pen/pencil All of the choices 26. You come to Laura's room on morning rounds to take her vital signs. She is lying in the bed. How would you check her pulse * Place in comfortable position, support her arm and place her palm or hand downward Place in comfortable position, support her arm and place palm of hand upward
  • 4. Place in comfortable position, use stethoscope and place over apex of heart Place in comfortable position, place two fingers on neck beside the trachea 27. When taking a pulse, why should the thumb NOT be used * The thumb has a pulse and can be confused with the patients There is more dexterity in the fingers then in the thumb The sensation of the thumb is not as good as it is in the middle The width of the thumb impedes an accurate feel for the pulse 28. Before taking vital signs on a patient, what should you do first * Explain the procedure Introduce yourself Place the call bell within reach Close the privacy curtain 29. Which of the following does not lead to increased body temperature * Starvation or fasting Illness or infection Excitement Exercise 30. When assessing a temperature rectally, the nurse would use extreme care when inserting the thermometer to prevent which of the following? * Decrease in BP Increase in heart rate Increase in respirations Decrease in heart rate 31. A patient is having dyspnea. what would the nurse do first? * Remove pillows from under the head Elevate the head of the bed Elevate the foot of the bed Take the BP 32. When using an alcohol-based handrub, after you've applied the rub, how long should it take of rubbing your hands together before your hands feel dry? * 10 seconds 2 minutes 15 seconds 5 seconds 33. When should you practice hand hygiene? * All the time Only when you think the patient is contaminated or dirt Only when you think your hands are dirty Both before and after having contact with a patient 34. What is the FIRST priority in preventing transmission of infections? * Wearing sterile non-latex gloves Wearing gowns and goggles Performing proper hand hygiene Wiping stethoscopes with alcohol 35. The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: * resident flora from the skin. transient flora from the skin. all microorganisms from the skin. media for bacterial growth. 36. Which one of the following is a risk factor for poor handwashing? * Not wearing gowns/gloves Being a nurse (rather than a physician) Female gender Being a physician (rather than a nurse)
  • 5. 37. What are we trying to reduce or eliminate when we are doing handwashing? * All of the choices Viruses Bacteria Fungi 38. When performing a surgical scrub with an antimicrobial agent, how far up the arm must an individual scrub? * To the elbow Up to the armpit Four inches above the wrist Two inches above the elbow 39. Wearing artificial or acrylic nails in the surgical setting is: * unacceptable because they may harbor microorganisms unacceptable for aesthetic reasons permitted if polish is less than four days old permitted if they are in good repair 40. All of the following statements apply when drying the hands and arms EXCEPT: * Bend over slightly from the waist Dry thoroughly to avoid skin irritation Begin drying with the hand and move up the arm Roll the towel before discarding into the appropriate container 41. The sterile areas of the gown include the:1. front from two inches below the neck to waist or table level2. gloves and gown sleeve to two inches above the elbow3. sides from axillae to waist or table level4. back of a wraparound gown * 1, 2, and 3 1 and 2 1 and 3 All of the choices 42. The closed-glove technique is used: * when regloving without assistance during the procedure only when the hands have never passed through the gown cuffs as a method for correcting glove contamination to assist a surgeon in donning sterile attire 43. Sterile gloves must be worn for each of these procedures except: * Central line dressing change Urinary Catheterization Tracheostomy dressing change Postpartum perineal care 44. To doff (remove) used sterile gloves the nurse should: * Pull both off from the inside edge, the nurse will wash their hands afterwards, so touching the gloves is not a concern. Wash the gloved hands with soap and water before removing the gloves to remove blood or body fluids Pull off the first glove by grasping slightly back from the wrist, turning it inside out, and wading the dirty glove into the still gloved hand. Use clean tongs from the procedure tray to take them off so that the hands are not contaminated 45. The first step in donning sterile gloves, after choosing the correct size is: * Open the wrapper fully, touching only the outer 1inch edge of the paper Fold the first flap of the outer wrapper away from you Use the folded cuffs in the wrapper to open the sides fully
  • 6. Wash hand with soap and water using good hand-washing technique 46. Where should the scrubbed person hold onto his or her gown when lifting it up to don it? * The sterile exterior of the gown The inside seams at armpits The inside front of the gown just below the neckband At the waist 47. The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: * Use forceps soaked in a disinfectant. Keep splashes on the sterile field to a minimum. Cover the nose and mouth with gloved hands if a sneeze is imminent. Consider the outer 1 inch of the sterile field as contaminated. 48. What is the act of cleaning one’s hands with the use of any liquid with or without soap for the purpose of removing dirt or microorganisms? * Medical Asepsis Aseptic Technique Surgical Asepsis Handwashing 49. Which handwashing method kills the most germs? * Liquid soap and water Antibacterial soap and water Bar soap and water Any form of soap and water 50. Which of the following would require the nurse put on a new pair of sterile gloves? * Picking up unused gauze from the central line dressing tray and dropping it on the table Tucking a drape under the patient's hips using the inside of the drape cuff Grasping the patients gown to move it out of the way Arranging the sterile supplies on the center of the sterile field 51. It is not necessary to wear gloves when you handle soiled laundry or linens * True False 52. Your patient care practices send a powerful message and show your patients and co-workers that you are serious about their health. * False True 53. Gloves may not be worn when hands may be contaminated with body fluids (blood, urine or non-intact skin). * True False 54. Gowns will protect your clothes from germs the client may have * False True 55. Bed linens should be changed once a month * False True 56. Germs are only spread by contact, not through the air. * True False
  • 7. 57. Universal precautions are all of the practices that help to stop the spread of infection and diseases * True False 58. You will always need to wear gloves during any personal care for your client * False True 59. Hand hygiene must be performed before placing gloves on and after glove removal. * True False 60. If you touch a surface area in the exam room and do not touch the patient you do not have to practice hand hygiene. * True False