Download NSG 3100 Final Exam Study Guide: Vital Signs, Wound Care, Infection Control and more Exams Nursing in PDF only on Docsity!
NSG 3100 FINAL EXAM/NSG3100 FINAL STUDY GUIDE
LATEST 2025 - 2026 ALL 80 QUESTIONS AND CORRECT
ANSWERS A+ GRADE (100% VERIFIED ANSWERS)
Which of the following is a cause of bradypnea? Increased activity narcotic analgesics Test anxiety Decreased oxygen saturation - CORRECT ANSWER-narcotic analgesics A damp/damp dressing is an example of what type of wound debridement? Autolytic Surgical Mechanical Enzymatic - CORRECT ANSWER-Mechanical What statement describes a stage 2 pressure ulcer? Damage extends to the fascia Skin is intact and does not blanch Presents as open or fluid-filled blister, or shallow crater Base is covered with slough and wound bed cannot be seen - CORRECT ANSWER-Presents as open or fluid-filled blister, or shallow crater Which statement describes a stage 1 pressure ulcer? Intact skin is purple or maroon Skin is pink or red and does not blanch Presents as open or fluid-filled blister, or shallow crater Base is covered with slough and wound bed cannot be seen - CORRECT ANSWER-Skin is pink or red and does not blanch
Age-related findings related to vital signs in older adults: Heart rate increases; blood pressure decreases Heart rate increases; blood pressure increases Heart rate decreases; blood pressure increases Heart rate decreases; blood pressure decreases - CORRECT ANSWER-Heart rate decreases; blood pressure increases What is the correct sequence for donning PPE? Gown, goggles, mask, gloves Gown, gloves, goggles, mask Gown, mask, goggles, gloves Goggles, gown, gloves, mask - CORRECT ANSWER-Gown, mask, goggles, gloves What is the correct sequence for removing (doffing) PPEs? Gloves, gown, goggles, mask Gown, gloves, mask, goggles Goggles, gloves, gown, mask Gloves, goggles, gown, mask - CORRECT ANSWER-Gloves, goggles, gown, mask Medical asepsis refers to all except? Reduces the spread of microorganisms Objects referred to as clean or dirty Eliminates all pathogens Clean technique - CORRECT ANSWER-Eliminates all pathogens Wound exudate that is clear and blood-tinged is called what? Sanguinous Purosanguinous Serosanguinous
The normal range for blood pressure is: systolic 80 - 110/ diastolic 70 - 90 systolic 90-140/diastolic 60- 90 systolic 90 - 120/diastolic 60 - 80 systolic 80 - 130/diastolic 50 - 80 - CORRECT ANSWER-systolic 90 - 120/diastolic 60 - 80 The range for normal temperature is: 96.8 - 98. 97.6 - 99. 96.8 - 99. 98.6 - 99.8 - CORRECT ANSWER-96.8 - 99. 5 A patient with what type of disease should be placed in airborne precautions? Herpes Zoster MRSA Tuberculosis Pneumonia - CORRECT ANSWER-Tuberculosis A pulse oximeter can be placed on all of the following body parts except? Fingers Ear Toes Chest - CORRECT ANSWER-Chest The nurse is aware that which of the following is an accurate statement about the respiratory rate? A- The respiratory rate increases with age. B- Narcotics slow the respiratory rate. C- Acute pain decreases the respiratory rate.
D- The respiratory rate is increased with alkalosis. - CORRECT ANSWER-B- Narcotics slow the respiratory rate. The nurse instructs the UAP that which of the following methods will obtain a falsely low blood pressure reading? A- Using a BP cuff that is too narrow B- Releasing the pressure value too slowly C- Assessing the BP after the patient exercises D- Place the arm above the level of the heart - CORRECT ANSWER-D- Place the arm above the level of the heart The adult patient is seen in the 24 - hour medical center for heat exhaustion. The nurse anticipates that treatment will include which of the following? A- Fluid replacement B- Antibiotic therapy C- Hypothermia wraps D- Tepid water baths - CORRECT ANSWER-A- Fluid Replacement Upon entering the room, the nurse observes that the patient appears to be tachypneic. The nurse should: A- Ask if there have been visitors B- Have the patient lie flat C- Take the radial pulse D- Measure the respiratory rate - CORRECT ANSWER-D- Measure the respiratory rate The patient is experiencing pain and asks for medication, which has been ordered by the provider. The nurse first assesses the vital signs and finds the blood pressure to be 144/82 mmHg, Pulse 88/min., and respirations 24/min. The nurse should: A- Give the medication as ordered B- Check again that the patient has pain C- Withhold the medication
The visiting nurse completes an assessment of the ambulatory patient in the home and determines the nursing diagnosis Risk for injury associated with decreased vision. On the basis of this assessment, the patient will benefit the most from: A- Installing fluorescent lighting throughout the home B- Becoming oriented to the position of the furniture and stairways C- Maintaining complete bed rest in a hospital bed w/ side rails D- Applying physical restraints - CORRECT ANSWER-B- Becoming oriented to the position of the furniture and stairways When applying a wrist restraint, the nurse knows that: A- The padded side is away from the skin B- It should be removed at least once every shift C- The straps should be secured w/ a knot D- Two fingers' width should fit between the skin and the restraint - CORRECT ANSWER-D- Two fingers' width should fit between the skin and the restraint A patient has a 6 - inch laceration on his right forearm. An infection develops at the site. Which of the following is a sign of a local inflammatory response observed by the nurse? A- Blanching of the skin B- Edema at the site C- Decrease in temperature D- Bruising at the site - CORRECT ANSWER-B- Edema at the site The nurse employs surgical aseptic technique when: A- Disposing syringes in a puncture-proof container B- Placing soiled linens in a moisture-resistant bag C- Washing hands before changing a dressing D- Inserting an intravenous catheter - CORRECT ANSWER-D- Inserting an intravenous catheter
A patient with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this patient to the unit will require the implementation by the staff of: A- Droplet precautions B- Airborne precautions C- Contact precautions D- Protective precautions - CORRECT ANSWER-B- Airborne precautions A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: A- Put sterile gloves on before opening sterile packages B- Place the cap of the sterile solution well within the sterile field C- Place sterile items on the edge of the sterile drape D- Discard packages that may have been in contact w/ the area below waist level - CORRECT ANSWER- D- Discard packages that may have been in contact w/ the area below waist level The unit manager observes the new staff nurse perform the following actions for a patient with isolation precautions. Which of the following actions should the unit manager address and correct with the new nurse? A- Keeping a thermometer, stethoscope and BP cuff in the patient's room. B- Documenting the precautions required in the patient's record C- Using a particulate respirator mask for the patient who has tuberculosis D- Coming out of the room in the PPE to quickly get another dressing - CORRECT ANSWER-D- Coming out of the room in the PPE to quickly get another dressing Pressure injuries form primarily as a result of: A- Nitrogen buildup in the underlying tissues B- Prolonged illness or disease C- Tissue ischemia D- Poor hygiene - CORRECT ANSWER-C- Tissue ischemia The nurse prepares to irrigate the patient's wound. The primary reason for this procedure is to:
B- Remove any fingernail polish present on the fingernail C- Assess the fingers for good circulation D- Document that the reading cannot be obtained - CORRECT ANSWER-C- Assess the fingers for good circulation A nurse performs orthostatic blood pressure readings on a patient w/ the following results: lying 148/ mmHg, standing 110/60 mmHg. Which action by the nurse is best? A- Reassesses the blood pressures in 1 hour B- Reassure the patient that these findings are normal C- Document the findings and continue to monitor D- Instruct the patient not to get up w/o help - CORRECT ANSWER-D- Instruct the patient not to get up w/o help A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene? A- Student pulls the pinna of the patient's ear down and back B- Student washes hands prior to patient contact C- Student explains the procedure to the patient D- Student pulls the pinna of the patient's ear up and back - CORRECT ANSWER-A- Student pulls the pinna of the patient's ear down and back The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first? A- Pulse oximetry 96% B- Pulse 42 BPM C- Blood pressure 102/62 mmHg D- Respiratory rate 18 breaths/min - CORRECT ANSWER-B- Pulse 42 BPM Which patient assessment result would require the nurse to assess that patient further? A- A 65 y/o man w/ a respiratory rate of 10 B- A 50 y/o man w/ a BP of 112/60 upon awakening in the morning
C- A 40 y/o woman w/ a radial pulse of 68 D- a 12 y/o w/ a pulse of 92 after ambulating in the hallway - CORRECT ANSWER-A- A 65 y/o man w/ a respiratory rate of 10 The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate? A- Place a sign above the bed: "no BP on the right arm" B- Place a sign above the bed "BP in legs only" C- No specific action is needed for this situation D- Place a sign above the bed: "no continuous BP on the right arm" - CORRECT ANSWER-A- Place a sign above the bed: "no BP on the right arm" A nurse is caring for a patient who has orthopnea. (Discomfort when breathing while lying down flat; common in people with some types of heart or lung conditions.) What action by the nurse is most appropriate? A- Medicate the patient for pain as needed B- Monitor the length of time the patient doesn't breathe C- Keep the head of the bed elevated D- Encourage deep breathing and coughing - CORRECT ANSWER-C- Keep the head of the bed elevated The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty? A- Counts pulse for 30 seconds and multiplies by two. B- Compares pulses in both carotid arteries at the same time. C- Assesses pulse on one side and then assesses the other side. D- Performs hand hygiene prior to patient contact. - CORRECT ANSWER-B- Compares pulses in both carotid arteries at the same time. A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best? A- Assess the patient for causes of tachycardia B- Take an apical heart rate and compare the two
B- Chest pain, shortness of breath, and nausea and vomiting C- Dizziness and disorientation to time, date, and place D- Edema, redness, tenderness, and loss of function - CORRECT ANSWER-D- Edema, redness, tenderness, and loss of function The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A contaminated needle is noted in the linens. For which condition is the nurse most at risk? A- Diphtheria B- Hepatitis B C- Clostridium Difficile D- Methicillin-resistant Staphylococcus aureus - CORRECT ANSWER-B- Hepatitis B The surgical mask the nurse is wearing becomes moist. Which action will the nurse take? A- Apply a new mask B- Reapply the mask after it air-dries C- Change the mask when relieved by the next shift D- Do not change the mask if the nurse is comfortable - CORRECT ANSWER-A- Apply a new mask The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process? A- "Do you have a spouse?" B- "Do you have a chronic disease?" C- "Do you have any children living in the home?" D- "Do you have any religious beliefs that will influence your care?" - CORRECT ANSWER-B- "Do you have a chronic disease?" The nurse is caring for a group of patients. Which patient will the nurse see first? A- A patient w/ Clostridium Difficile in droplet precautions B- A patient w/ tuberculosis in airborne precautions C- A patient w/ MRSA infection in contact precautions
D- A patient w/ pneumonia in droplet precautions - CORRECT ANSWER-A- A patient w/ Clostridium Difficile in droplet precautions The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment (PPE), beginning with the first step? 1) Remove eyewear/face shield and goggles. 2) Perform hand hygiene, leave room, and close door. 3) Remove gloves. 4) Untie gown, allow gown to fall from shoulders, and do not touch outside of gown. 5) Remove mask by strings, do not touch outside of mask.
- Dispose of all contaminated supplies and equipment in designated receptacles. A- 3,1,4,5,6, B- 1,4,5,3,6, C- 1,4,5,3,2, D- 3,1,4,5,2,6 - CORRECT ANSWER-D- 3,1,4,5,2, The nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? A- Protrusion of visceral organs through a wound opening B- Chronic drainage of fluid through the incision site C- Report by patient that something has given way D- Drainage that is odorous and purulent - CORRECT ANSWER-C- Report by patient that something has given way The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? A- Partial-thickness repair B- Secondary intention C- Tertiary intention D- Primary intention - CORRECT ANSWER-D- Primary intention A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? A- Muscular strength
C- Don sterile gloves D- Gather supplies - CORRECT ANSWER-A- Provide analgesic medications as ordered Blood pressure cuff (bladder cuff) too narrow - CORRECT ANSWER-falsely high Blood pressure cuff (bladder cuff) too wide - CORRECT ANSWER-falsely low Arm unsupported during BP reading - CORRECT ANSWER-falsely high Insufficient rest before the BP assessment - CORRECT ANSWER-falsely high Repeating BP assessment too quickly - CORRECT ANSWER-Erroneously high systolic or low diastolic readings Cuff wrapped too loosely or unevenly - CORRECT ANSWER-false high reading Deflating cuff too quickly - CORRECT ANSWER-falsely low systolic and high diastolic readings Deflating cuff too slowly - CORRECT ANSWER-false high diastolic reading Failure to use the same arm consistently - CORRECT ANSWER-inconsistent measurements Arm above level of the heart - CORRECT ANSWER-false low Assessing immediately after a meal or while client smokes or has pain - CORRECT ANSWER-Falsely high Failure to identify auscultatory gap - CORRECT ANSWER-falsely low systolic pressure and erroneously low diastolic pressure
