1.ATI RN MATERNAL NEWBORN PROCTORED EXAM
2. The nurse is providing an education session to an adult community group about the effects of smoking
on
... [Show More] infection. Which information is most important for the nurse to include in the educational session?
a. Smoke from tobacco products clings to your clothing and hair.
b. Smoking affects the cilia lining the upper airways in the lungs.
c. Smoking can affect the color of the patient’s fingernails.
d. Smoking tobacco products can be very expensive.
ANS: B
A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of
the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and
sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and
increase the patient’s potential for infection. Smoking can be expensive, the smell does cling to hair and
clothing, and the tar within the smoke can alter the color of a patient’s nails. This information can be included
in the education but does not constitute the most important point.
3. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area.
A nurse is taking a health history. Which question is the priority?
“When was the last time you visited your primary health care
a. provider?”
b. “Has this condition affected your eating habits in any way?”
c. “What medications are you currently taking?”
d. “Are you able to sleep at night?”
ANS: C
Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida
albicans in that area. It is important to ask the patient about current medications to obtain information that
may assist with diagnosis. The body contains normal flora (microorganisms) that live on the surface of skin,
saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes
vaginal secretions to achieve a low pH, inhibiting the growth of many microorganisms. Visiting the primary
health care provider is important for the patient’s health maintenance but is not the priority. Learning about
the patient’s eating and sleeping habits will assist in the plan of care but is not the priority.
4. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs
and symptoms will the nurse assess for to determine if the child is experiencing a localized
inflammatory response?
Malaise, anorexia, enlarged lymph nodes, and increased white blood
a. cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
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d. Edema, redness, tenderness, and loss of function
ANS: D
The body’s cellular response to an injury is seen as inflammation. Signs of localized inflammation include
swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of
inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white
blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac
alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.
5. Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory
response?
d. Rest, ice, and elevation
ANS: D
Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the
affected body part. One sign of the inflammatory response, particularly after an injury, is swelling or edema.
Resting the affected injured area, using ice as ordered, wrapping the area to provide support—particularly if
it is an extremity—and elevating the injured area will help to decrease swelling or edema. Turning, coughing,
and deep breathing are utilized for postoperative patients and for immobilized patients to help prevent an
infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with
many different types of patients who may be confused. Vigorous range of motion would irritate the
inflammatory process. Range of motion is utilized for individuals who need to improve movement of their
extremities, including immobilized patients.
6. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing
an infection?
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
c. A patient who is recovering from a right total hip surgery
d. A patient who has been admitted for stabilization of heart problems
ANS: C
The patient who is recovering from a right total hip surgery has a large incision from the surgery. This break in
the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous membranes
allows pathogens to enter and exit the body. The patient has had anesthesia, which depresses the respiratory
system and has the potential to decrease the expansion of alveoli and to increase the chance of infection in
the respiratory system. A patient who is having chest pain, experiencing dehydration, or being admitted with
heart problems does not have open incisions that break the skin; therefore, his or her infection risk is lower.
7. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular
access (IV) device. Which nursing intervention is a priority in this procedure?
Vigorous range-of-motion
breathe
c. Orient to date, time, and place
d. Gather available supplies.
ANS: C
Review the procedure with the patient.
Position the patient
c. Maintain surgical aseptic technique.
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You maintain surgical aseptic technique at the patient’s bedside (e.g., when inserting IV or urinary catheters,
suctioning the tracheobronchial airway, and sterile dressing changes) because patients with disease
processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS,
lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious
organism. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are
all important steps in the procedure but are not the priority in the procedure since the patient already has a
compromised immune response.
8. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding.
The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing
and visualization. What is the primary rationale for the nurse’s actions related to the teaching?
a. Topics taught are standard information taught during health care visits.
The patient requested this information to teach the extended family
b. members.
Stress for long periods of time can lead to exhaustion and decreased
c. resistance to infection.
These techniques will help the patient manage the pain and loss of
d. personal belongings.
ANS: C
The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for
long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no
defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with
pain, but they are not the primary reason. The teachings listed are not all standard interventions taught at
every health care visit. There is no data to indicate the patient requested this information for the family.
9. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include
in an educational session to decrease the risk of infection?
a. Teaching the patient about fall prevention
b. Teaching the patient to take a temperature
c. Teaching the patient to select nutritious foods
d. Teaching the patient about the effects of alcohol
ANS: C
A patient’s nutritional health directly influences susceptibility to infection. A reduction in the intake of protein
and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs
wound healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a
temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual’s
risk for infection. Teaching the patient about fall prevention or about the effects of alcohol does not decrease
the risk of infection.
10. A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot
and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection? a.
Position the patient comfortably on the stretcher.
b. Explain the procedure for dressing change to the patient.
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c. Review the medication list that the patient brought from home.
d. Don gloves and other appropriate personal protective equipment.
ANS: D
Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and
other personal protective equipment as appropriate when examining or providing treatment to localized [Show Less]