Chapter 16 Nursing Assessment: NCLEX Style Questions with Rationales

The nursing process is a critical thinking five-step process (Figure 16-1) page 209

A Critical Thinking Approach to Assessment page 209

Types of Data: There are two primary sources of data: subjective and objective page 213 –
214

Key Points page 221

The Brainshark link that follows helps to explain the nursing process and the nursing scope
of practice (what a RN can legally do). Please watch this video if you are interested.

http://www.brainshark.com/devry/vu?pi=zGrzJTlOEzSXCUz0

1. The nurse palpates a patient’s radial pulse as 56 beats per minute. The patient
appears relaxed and in no distress. Which action by the nurse best demonstrates
proper use of the nursing process?
a. Informs the patient that the pulse rate is very low and this signifies a
problem.
b. Asks the patient to walk up and down the halls to see if the pulse increases.
c. Documents the low pulse, exits the room, and calls the doctor immediately.
d. Questions the patient as to which medications the patient may be taking.

ANSWER D: Remember to use the nursing process “AND PIE”. When an abnormal is
assessed and the patient is stable, continue further assessment to gather all available data.
In the above scenario, answer D was the only answer that demonstrated further
assessment. All of the other answers were part of a plan/implementation and
inappropriate without further assessment.

2. The nurse is gathering assessment data. Which are considered subjective

assessment findings? (Select all that apply)
a. Patient report of abdominal pain and nausea.
b. Lab report of low serum potassium (K+) level with blood draw.
c. 200 milliliters (mL) of green vomit in the basin at the patient's bedside.
d. Family report that the patient has not been feeling well for 3 days.
 ANSWER: A, D: Reports from a patient or family member are considered subjective
assessment finding. Remember “S” for Subjective and “S” for patient Says, family
Says. Objective data are observations or measurements of a patient's health status
made by the healthcare professional.

Chapter 29 Infection Control and Prevention NCLEX Style Questions with Rationales

Six components of the Chain of Infection, page 443 Figure 29-1. Infection occurs only if the
cycle is unbroken and depends on the presence of ALL of the following elements:

1. An infectious agent or pathogen (bacteria, viruses, fungi)

2. A reservoir or source for pathogen growth (pg 443 Table 29-1) (Also reference
page 457, Box 29-10 Infection Prevention and Control to Reduce Reservoirs of
Infection)
3. A port of exit from the reservoir
4. A mode of transmission (pg 445 Box 29-1)
5. A port of entry to a host
6. A susceptible host (pg 449, Table 29-3)

Therefore, as a professional in the health care industry, we have the opportunity to prevent
infection transmission by breaking the chain. For example, covering the nose and mouth
when sneezing or coughing is an intervention that breaks the chain of infection at which of
the following?

a. A portal of exit.
b. A portal of entry.
c. Host susceptibility
d. The reservoir site.

ANSWER A: Covering the nose and mouth when coughing or sneezing helps
reduce the spread of pathogens from the portal of exit. Understand the term
cough etiquette.
Course of infection by stage and commonalities of each stage (pg 445 Box 29-2):

Incubation Stage: Pathogen has entered the host but the host is asymptomatic (no
symptoms present).
Prodromal Stage: Onset of vague nonspecific symptoms (malaise, possible low-
grade fever, fatigue). During this time microorganisms grow and multiply, and patient
may be capable of spreading disease to others. For example, herpes simplex begins
with itching and tingling at the site before the lesion appears.
Illness Stage: Time period when patient manifests specific signs and symptoms to
type of infection. For example, strep throat is manifested by sore throat, pain, and
swelling; mumps is manifested by high fever, parotid and salivary gland swelling.
Convalescence: Interval when acute symptoms of infection disappear. (Length of
recovery depends on severity of infection and patient's host resistance; recovery
may take several days to months.)

Common signs of localized infection are inflammation (redness and warmth),

drainage/exudate, edema, and pain. Systemic infection can result in an elevated white
blood cell (WBC) count [normal range (WBC) count 5000-10,000/mm3], fever, and malaise
(feeling poorly).

Table 29-2, Natural Defense Mechanisms against Infection

1. Health care–associated infections (HAIs) result from the delivery of health

services in a health care facility. The nurse knows that the BEST way to reduce
the incidence of HAIs is which of the following?
a. Through proper sterile technique
b. Through diligent and proper hand washing
c. By always wearing gloves when in contact with the patient
d. By using disinfectant wipes to clean all surfaces in a patient’s room

ANSWER B: Proper hand washing (hand hygiene) is the single most effective
action a nurse can take to reduce and prevent the transmission of infectious
disease.

2. Hand washing with soap and warm water MUST be performed by the nurse in
which of the following situations? (Select all that apply)
a. When hands are visibly dirty, when soiled with blood or other body fluids
b. Before eating
c. After using the toilet
d. Before using the restroom
 ANSWER A, B, C: The CDC (cdc.gov) recommends washing hands with soap and
warm water in the above scenarios a, b, and c. Refer to page 457 of your text.
***Also exposure to spore-forming organisms such as Clostridium difficile
requires strict and diligent hand washing.***

3. The nurse is preparing a sterile field. Which of the following are principles of
sterile asepsis? (Select all that apply)
a. Only sterile objects may be placed on a sterile field
b. A sterile object or field out of the range of vision is considered contaminated
c. An object held below a person's waist is considered contaminated
d. You may never set up a sterile field in a contact isolation room because the
whole room is contaminated.

ANSWER A, B, C: Only sterile objects may be placed on a sterile field. All items are
properly sterilized before use. Sterile objects are kept in clean, dry storage areas.
The package or container holding a sterile object must be intact and dry. A package
that is torn, punctured, wet, or open is considered unsterile. Nurses never turn their
back on a sterile field or a sterile tray or leave it unattended. Contamination can
occur accidentally by a dangling piece of clothing, falling hair, or an unknowing
patient touching a sterile object. Any object held below waist level is considered
contaminated because it cannot be viewed at all times. Keep sterile objects in front
with the hands as close together as possible. Sterile fields may be established in
isolation rooms. An isolation room is contaminated, but so is every room!

The nurse is taking care of patients on transmission-based precautions. Refer

to the following information available on your nursing unit to answer the
questions 4-5. Nurses must know the diseases listed under INFECTION/CONDITION
and the CATEGORY they fall under and which type of PPE (BARRIER PROTECTION) is
necessary.]

Transmission-Based Precautions (Tier Two) for Use with Specific Types of Patients
CATEGORY INFECTION/CONDITION BARRIER PROTECTION
Private room, negative-
Airborne pressure airflow of at
precautions Measles, chickenpox (varicella), least 6 to 12 exchanges per
(droplet nuclei disseminated varicella zoster, pulmonary or hour via high-efficiency
smaller than 5 laryngeal tuberculosis particulate air (HEPA)
microns) filtration; mask or
respiratory protection
 device, N95 respirator

Diphtheria (pharyngeal), influenza, rubella,

Droplet streptococcal pharyngitis, pneumonia or
Private room or cohort
precautions scarlet fever in infants and young children,
patients; mask or
(droplets larger pertussis, mumps, Mycoplasma pneumonia,
respirator required
than 5 microns; meningococcal pneumonia or sepsis,
(depending on condition)
being within 3 feet pneumonic plague
(refer to agency policy)
of the patient)

Colonization or infection with multidrug-

Private room or cohort
Contact resistant organisms such as VRE and MRSA, C.
patients (see agency
precautions (direct difficile, shigella, and other enteric pathogens;
policy), gloves, gowns,
patient or major wound infections; herpes simplex;
wash hands with soap
environmental scabies; varicella zoster (disseminated);
and water when leaving
contact) respiratory syncytial virus in infants, young
room
children or immunocompromised adults

4. A patient has been hospitalized and receiving IV antibiotics for 2 weeks. He

now presents with watery, foul-smelling diarrhea. A fecal sample confirms the
diarrhea is caused by C. difficile. The nurse would expect to perform which of
the following? (Select all that apply)
a. Place the patient in a negative pressure room
b. Wear gloves and gowns upon entering the room
c. Wear a face mask or respirator
d. Wash hands with soap and water when exiting the room

ANSWER B, D: The patient with C.diff does not need to be in a negative pressure
room because C.diff is not an airborne precaution. This patient may be placed in
a private room, but they may also be placed in a room with another patient that
also has C. diff or cohorted. Because C. diff is a contact precaution a face mask or
respirator is unnecessary. Hand sanitizers are not sufficient because they do not
kill the spores. Hands must be washed with warm, soapy water.

5. A 14 y/o male who recently immigrated to the U.S. presents at the hospital
with a red, blistery, itchy rash covering his torso, face, and extremities. The
culture obtained confirms it is varicella (chicken pox). In order to protect
other patients, healthcare workers, and yourself, this patient should
immediately be:
a. Placed on airborne precautions
b. Placed on droplet precautions
 c. Placed on contact precautions only
d. Vaccinated against varicella

ANSWER A: Chicken pox is an airborne AND contact precaution. The patient

should be a negative pressure private room and all individuals entering the
room must wear a specialized mask or respirator device. Vaccination is most
effective BEFORE a disease has be contracted, not at this point.

6. Which are the major sites where health care–associated infections may
develop in a host? (Select all that apply)
a. Urinary tract
b. Respiratory tracts
c. Bloodstream
d. Hair shafts
ANSWER A, B, and C: Page 446, Box 29-3 of your text for specific examples.

7. Which is the most likely means of transmitting infection between patients?

a. Exposure to another patient's cough
b. Sharing equipment among patients
c. Disposing of soiled linen in a shared linen bag
d. Contact with a health care worker's hands

ANSWER: D Once again, the use of proper and diligent hand hygiene is the
number one way healthcare workers can reduce the spread of infection.

8. Which are examples of Personal Protective Equipment (PPE)? (Select all that
apply)
a. I.D. Badge
b. Gowns
c. Masks
d. Eye Shields or goggles

ANSWER: B, C, and D are considered personal protective equipment (PPE),

although not ALL pieces must be worn in ALL situations simultaneously. Which
PPE is appropriate in which situations is on page 458, Table 29-6 (Category,
Barrier protection)

9. A nurse performs sterile technique. Where in the chain of infection does

sterile technique help to prevent the spread of pathogens?
 a. At the reservoir
b. At the portal of exit
c. At the portal of entry
d. Affects the susceptibility of host

ANSWER C: Sterile technique prevents pathogens from entering the host by creating
an environment that is as free of microorganisms as possible. Therefore, sterile technique
or sterile asepsis breaks the chain at the portal of entry.

10. Which statement about standard precautions is correct?

a. Wash hands for 5 seconds after using the restroom.

b. Wear an isolation gown when in direct contact with all patients.
c. Wear gloves when touching non-intact skin and mucous membranes.
d. Wear either a N95 respirator and or a face mask when entering a patient's room.

ANSWER C: Standard precautions are precautions that are USED WITH EVERY
PATEINT in order to protect both you and the patient from the transmission of
infectious pathogens. Hands must be washed for 20 seconds per the new CDC
guidelines (cdc.gov). Isolation gowns are worn with CONTACT PRECAUTIONS, not
standard precautions. A N95 respirator is worn for airborne precautions and a face
mask for droplet precautions.

Please remember there are more practice questions at the end of each chapter in
your textbook.