Online Practice Test 31

Your Results for: "NCLEX® Review"

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 31 > NCLEX® Review Date/Time Submitted: July 18, 2012 at 7:09 AM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		A client has a yeast infection. What category of microorganism is yeast? Your Answer: Fungi
		Objective: Identify factors influencing a microorganism's capability to produce an infectious process. Rationale: Fungi include yeasts and molds. Bacteria include organisms like staphylococcus and streptococcus. Parasites live on other living organisms and include protozoa, worms, and fleas. Viruses include rhinovirus, hepatitis, herpes and HIV. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		What are the major categories of microorganisms that cause infections in humans? (Select all that apply.) Your Answer: Bacteria Viruses Parasites
		Objective: Identify anatomic and physiologic barriers that defend the body against microorganisms. Rationale: An infection becomes a disease when the signs and symptoms of the infection are unique and can be differentiated from other conditions. Colonization is not a type of microorganism. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		What are the most common infecting microorganisms in nosocomial infections? (Select all that apply.)  Your Answer: Escherichia coli Enterococci Staphylcoccus aureus
		Objective: Identify anatomic and physiologic barriers that defend the body against microorganisms. Rationale: Nosocomial infections are associated with the delivery of health services in a health care facility. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make selections.
4.		The nurse notes hyperemia when evaluating the incision of a client. The nurse knows that this indicates what stage in the inflammatory response? Your Answer: Vascular and cellular response
		Objective: Identify signs of localized and systemic infections. Rationale: Hyperemia indicates a marked increase in blood supply, and is the first stage of the inflammatory response. The vascular and cellular response is the first stage. Exudate production is the second stage. Reparative phase is the third stage. Margination is part of the first stage. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		What type of immunity is lost when a client develops human immunodeficiency virus (HIV)? Your Answer: Humoral immunity Correct Answer: Cellular immunity
		Objective: Identify anatomic and physiologic barriers that defend the body against microorganisms. Rationale: Cellular immunity, which occurs through the T-cell system, is lost with HIV. Active immunity occurs in response to an infection or vaccines. Passive immunity occurs through an injection of immune serum, or, for an infant, from breastfeeding. Antibodies produced by B cells mediate humoral immunity. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		A mother is planning on weaning her 5-month-old infant from breastfeeding. She says that the infant may get my infections, since the baby will not be getting immunity through her breast milk. What response by the nurse would be most appropriate? Your Answer: "You baby will be fine; the natural immunity will continue until the baby produces its own antibodies." Correct Answer: "Infants begin to make their own immunity between 1 and 3 months of age."
		Objective: Differentiate active from passive immunity. Rationale: The newborn does begin to synthesize its own immunoglobulins between 1 and 3 months of age. Infections are a major cause of death in newborns, but that is not the reason to consider continuation of breastfeeding. The other answers are inaccurate and not reassuring. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
7.		A hospitalized client is in a private room. When outside the room, the client must wear a surgical mask. What type of isolation precaution is in use? Your Answer: Airborne Correct Answer: Droplet
		Objective: Correctly implement aseptic practices, including hand washing; donning and removing a facemask, gown, and disposable gloves, managing equipment used for isolation clients, and maintaining a sterile field. Rationale: Droplet precautions involve use of mask to prevent passing to others. Airborne precautions require an isolation room, and the client is not allowed outside the room. Contact precautions involve gown and glove for direct client contact. This client would not be out of the room. Standard precaution is the global term for all types of precautions. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		A home health nurse has just changed a soiled dressing from an infected wound of a client's. After placing the soiled dressing in a paper bag provided by the client, how should the nurse dispose of it? Your Answer: Place the paper bag inside a plastic bag for disposal.
		Objective: Correctly implement aseptic practices, including hand washing; donning and removing a facemask, gown, and disposable gloves, managing equipment used for isolation clients, and maintaining a sterile field. Rationale: Placing the paper bag inside a plastic bag for disposal is sufficient for protection. The other answers are inappropriate. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		A client with tuberculosis is expecting visitors, and asks if they need to wear masks if they are healthy. What response by the nurse would be most accurate? Your Answer: "Everyone who enters your room must wear a mask to protect themselves from tuberculosis."
		Objective: Compare and contrast category-specific, disease-specific, universal, body substance, standard, and transmission-based isolation precaution systems. Rationale: All people entering the client's room must wear a protective mask to prevent transmission to them. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		A client has been diagnosed with a urinary tract infection. What is the most likely cause of this infection? Your Answer: Escherichia coli enterococci
		Objective: Identify factors influencing a microorganism's capability to produce an infectious process. Rationale: Escherichia coli enterococci are the most common infectious organism. Staphylococcus is common in the respiratory tract and blood. Neisseria gonorrhoeae is common in the reproductive tract. Streptococcus A or B is common in tissues. Nursing Process: Diagnosis Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.