Question: What should the nurse do to maintain standard precautions?
Answer Options: A. Rinse gloves that become visibly soiled during use.
B. Use an antimicrobial soap for routine handwashing.
C. Disinfect hands immediately after removing gloves.
D. Keep gloves on when touching environmental surfaces.
Answer: C. Disinfect hands immediately after removing gloves.
Question: To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry?
Answer Options: A. Drying provides the full antiseptic effect.
B. Residual alcohol can easily stain clothing.
C. Excess gel could transfer to the client.
D. Slippery gel can make the nurse drop supplies.
Answer: A. Drying provides the full antiseptic effect.
Question: A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take?
Answer Options: A. Warm the enema solution prior to instillation.
B. Prepare 1,500 mL of enema fluid.
C. Use tap water as the enema fluid.
D. Hang the enema container 24 inches above the anus.
Answer: A. Warm the enema solution prior to instillation.
Question: A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas?
Answer Options: A. Cleansing
B. Return-flow
C. Medicated
D. Oil-retention
Answer: B. Return-flow
Question: A nurse is caring for a client who has a health care–associated infection (HAI). Which of the following describes an exogenous HAI?
Answer Options: A. A Salmonella infection that occurs after eating contaminated food from the cafeteria
B. An infection that occurs during a therapeutic procedure
C. A yeast infection that occurs while receiving broad-spectrum antibiotics
D. A urinary tract infection that occurs after a sterile catheter insertion
Answer: A. A Salmonella infection that occurs after eating contaminated food from the cafeteria
Question: After completing a procedure that required donning PPE consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately?
Answer Options: A. The gloves
B. The gown
C. The face shield
D. The N95 respirator
Answer: A. The gloves
Question: While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?
Answer Options: A. Measure the client’s vital signs.
B. Notify the primary care provider.
C. Lower the enema fluid container.
D. Stop the enema instillation.
Answer: C. Lower the enema fluid container.
Question: A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube?
Answer Options: A. 2.5 cm to 3.75 cm (1 to 1.5 in)
B. 5 cm to 7.5 cm (2 to 3 in)
C. 7.5 cm to 10 cm (3 to 4 in)
D. 10 cm to 12.5 cm (4 to 5 in)
Answer: C. 7.5 cm to 10 cm (3 to 4 in)
Question: After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take?
Answer Options: A. Cleanse their hands with an alcohol-based gel.
B. Wash their hands with soap and water.
C. Brush off the soil against a cloth surface.
D. Use a wet paper towel to remove the soil.
Answer: B. Wash their hands with soap and water.
Question: A nurse is about to irrigate a client’s open wound. Besides gloves, which of the following personal protective equipment should the nurse wear?
Answer Options: A. A sterile gown
B. Goggles
C. A face shield
D. An N95 respirator
Answer: C. A face shield
Question: Which of the following products can affect the permeability of latex gloves?
Answer Options: A. Antimicrobial soap and water
B. Alcohol-based antiseptic gel
C. Petroleum-based hand lotion
D. Water-based hand lotion
Answer: C. Petroleum-based hand lotion
Question: A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take which of the following actions?
Answer Options: A. Make sure that the water is hot.
B. Wash for at least 20 seconds.
C. Use a liquid soap preparation.
D. Remove rings and watches first.
Answer: B. Wash for at least 20 seconds.
Question: A nurse is administering a return-flow (Harris flush) enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take?
Answer Options: A. Instruct the client to retain the fluid.
B. Lower the container to allow the solution to flow back out.
C. Help the client to the toilet or bedside commode.
D. Wait 5 min and instill another 100 mL of fluid.
Answer: B. Lower the container to allow the solution to flow back out.
Question: Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?
Answer Options: A. Hepatitis B
B. Measles
C. Meningitis
D. Infectious diarrhea
Answer: D. Infectious diarrhea
Question: A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations?
Answer Options: A. The duration of the procedure
B. 10 to 15 min
C. Until the client feels the urge to defecate
D. At least 30 min
Answer: D. At least 30 min
Question: A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client?
Answer Options: A. Wear a respirator.
B. Protect their eyes.
C. Put on clean gloves.
D. Wear shoe covers.
Answer: B. Protect their eyes.
Question: A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take?
Answer Options: A. Place the client in the dorsal recumbent position on a bedpan.
B. Administer the enema while the client sits on the toilet.
C. Administer an antidiarrheal medication 3 hr prior to the enema.
D. Instill 200 mL of fluid over an hour at 15-min intervals.
Answer: A. Place the client in the dorsal recumbent position on a bedpan.
Question: Which of the following is an advantage of using alcohol-based gel?
Answer Options: A. It takes less time to use than washing with soap and water.
B. It removes gross contamination better than soap and water does.
C. Its protective nature reduces the need for frequent handwashing.
D. It provides adequate protection before surgical applications.
Answer: A. It takes less time to use than washing with soap and water.
Question: A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions?
Answer Options: A. Prone
B. Dorsal recumbent
C. Right lateral with both knees at chest
D. Left lateral with the right leg flexed
Answer: D. Left lateral with the right leg flexed