NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 491:

  What is the single most important thing that nurses do in order to prevent the spread of infection?

  A. Applying standard precautions.

  B. Using personal protective equipment.

  C. Adhering to the principles of asepsis.

  D. Handwashing.

  Correct Answer: D

  Handwashing is the single, most important thing that nurses, and other healthcare professionals, can do in order to prevent the spread of infection. Applying standard precautions, using personal protective equipment, as indicated, and adhering to the principles of asepsis also prevent the spread of infections; however, handwashing is the single most important thing to prevent the spread of infection.

• Question 492:

  Which of these patients is affected with a healthcare acquired infection?

  A. A 18-year-old male patient who developed an intravenous line infection two days after insertion.

  B. A 72-year-old male patient who is at risk for infection secondary to AIDS/HIV.

  C. A 67-year-old female patient who was admitted with a urinary tract infection.

  D. A 5-year-old pediatric patient who develops the measles rash 3 days after admission.

  Correct Answer: A

  The 18-year-old male patient who developed an intravenous line infection two days after insertion is affected with a healthcare related, or nosocomial, infection. These infections include all infections that occur while the patient is receiving healthcare services.

  The patient who was admitted with a urinary tract infection and the pediatric patient who develops the measles rash 3 days after admission acquired these infections prior to receiving healthcare services so they are not considered healthcare related, or nosocomial, infections. Lastly, the 72-year-old male patient who is at risk for infection secondary to AIDS/HIV has not yet been infected; he is simply at risk for infection.

• Question 493:

  Select the method of special precautions that is accurately paired with the personal protective equipment that is minimally required in order to prevent the spread of infection.

  A. Contact precautions: Gowns, gloves and mask.

  B. Droplet precautions: Face mask.

  C. Airborne transmission precautions: Negative pressure room.

  D. Contact precautions: Gloves.

  Correct Answer: B

  The minimal personal protective equipment that is required for droplet precautions is a face mask.

  Contact precautions minimally require the use of gloves and gowns; and airborne transmission precautions

  minimally require the use of a negative pressure room, a HEPA mask, gowns and gloves.

• Question 494:

  States throughout our nation vary somewhat in terms of things that nursing assistants can and cannot legally do.

  Which statements about these state to state differences are accurate? (Choose all that apply.)

  A. Nursing assistants can change catheter tubings but not catheters

  B. Nursing assistants can change sterile dressings

  C. Nursing assistants have an expanding role in many states.

  D. Nursing assistants cannot assess the physical status of the patients.

  E. Nursing assistants can apply topical medication lotions to intact skin.

  F. The trend is moving toward nurses only staffing patterns.

  Correct Answer: CD

  Nursing assistants have an expanding role in many states. For example, some states permit nursing

  assistants to take ECGs, or EKGs, and to perform phlebotomy when they are given the necessary training

  and have been deemed competent to do so.

  Only nurses assess; nursing assistants cannot assess the physical status of the patients.

• Question 495:

  Which of the following is a vector of infection?

  A. A contaminated ball

  B. A contaminated thermometer

  C. An infected person

  D. An infectious fly

  Correct Answer: D

  An infectious fly is an example of a vector that can transmit infection.

  Other vectors, or nonhuman living beings that can transmit infections to humans, include mice, vermin and

  mosquitoes.

  Inanimate items that can spread infection by contact are referred to as fomites. Examples of fomites

  include a contaminated thermometer, balls and door knobs.

  An infected human being is a host according to the chain of infection and not a vector.

• Question 496:

  You are preparing a sterile field for an operating room surgical procedure.

  When should you stop the preparation of this sterile field?

  A. When you have placed a sterile item only 1 inch and not 2 inches from the edge of the sterile field.

  B. When you have completely finished the field. You cannot stop the set up until it is all done.

  C. When you have accidentally poured a sterile liquid into a container that was on the sterile field.

  D. When you turn your upper body only away from the field because the surgeon calls your name.

  Correct Answer: D

  You must stop the preparation of the sterile field and begin all over again when you have turned your

  upper body away from the field because sterile technique has been violated and the sterility of the field has

  been broken even when on turns away from the sterile field even for a second.

  Sterile items must be placed within one inch, not two inches from the edge of the sterile field.

  Lastly, sterile solutions can be poured into sterile containers on the sterile field without breaking the

  techniques required according to surgical asepsis.

• Question 497:

  Select the following fire emergency interventions in correct sequential order.

  

  A. C, B, A, D

  B. A, C, B, D

  C. C, A, B, D

  D. C, A, D, B

  Correct Answer: C

  The RACE acronym is used to prioritize and sequence the steps that must be followed when a fire occurs.

  R stands for rescue patients;

  A is pulling the fire alarm;

  C is to contain the fire by closing doors, etc.; and

  E is extinguishing the fire with a fire extinguisher when possible.

• Question 498:

  Which of the following are necessary elements of malpractice? (Choose all that apply.)

  A. A breach of duty

  B. An intentional act

  C. A nonintentional act

  D. Foreseeability

  E. Patient harm

  F. Causation

  Correct Answer: ADEF

  The necessary elements of malpractice are a duty to the patient, a breach of duty, foreseeability,

  causation, and patient harm.

  The breach of duty can be intentional or nonintentional.

• Question 499:

  What is a major difference between a problem oriented medical record and a source oriented medical record?

  A. The problem oriented medical system has a centralized part of the chart for interdisciplinary progress notes and the source oriented medical record has separate areas for each profession's progress notes.

  B. The problem oriented medical system consists of narrative progress notes and the source oriented medical record uses SOAP.

  C. The source oriented medical system uses charting by exception and the source oriented medical record system does not.

  D. The source oriented medical system has a centralized part of the chart for interdisciplinary progress notes and the problem oriented medical record has separate areas for each profession's progress notes.

  Correct Answer: A

  The problem oriented medical system has a centralized part of the chart for interdisciplinary SOAP progress notes and the source oriented medical record has separate areas for each profession's progress notes. Although source oriented medical records can use SOAP, this is not a defining characteristic and most of these notes are free formed narrative notes. Charting by exception is a distinctly different medical system than source or problem oriented medical systems.

• Question 500:

  During which phase of the nursing process does data get collected and validated with the patient and/or family members by the nurse?

  A. The implementation phase.

  B. The assessment phase.

  C. The evaluation phase.

  D. The planning phase.

  Correct Answer: B

  Subjective, objective, primary and secondary data is collected and validated with the patient and/or family members by the nurse during the assessment phase of the nursing process. The implementation phase is the actual care of the patient; the evaluation phase includes the comparison of current data to expected outcomes to determine if the patient has achieved the pre-established goals and the planning phase consists of priority setting and care planning.