Evoke-ATII Nurse Review Center 6.
When removing an isolation gown, steps the nurse should take
CGFNS Boot Camp
Nursing Leadership & Management/CHN
1. A nurse is just exiting an isolation room. Considering
infection control protocol, which action would the nurse
take first?
a. Bag equipment and double-bag it out at the door.
b. Remove protective gear.
c. Dispose of equipment appropriately inside the
room.
d. Wash hands.
2. The nurse is assigned care for two clients. One client has
just returned from surgery for an abdominal resection.
The second client is hospitalized with an acute case of
tuberculosis. What special precautions should the nurse
take when providing care for these two clients?
a. Proper handwashing between clients and use of
specific isolation garb.
b. Provide care to the client with tuberculosis
before the client with abdominal surgery.
c. Strictly adhere to barrier nursing principles.
d. Thorough handwashing and gloving is sufficient
in this situation.
3. CDC guidelines are specific for clients with tuberculosis.
The major differences in providing care for the client with
TB versus other clients requiring barrier nursing are
a. The staff must wear gowns, mask, and gloves.
b. The client should be in a private room with a
special ventilation system.
c. The client may be place in a room with other
clients requiring barrier-nursing protocol.
d. The protocol of donning and removing isolation
garb before entering or leaving the client’s room
is different.
4. A nurse is assigned to take two client’s vital signs, complete
a focus assessment and provide hygienic care, administer
meds, and complete a dressing change for a client with an
abdominal wound. Which task will have priority with this
assignment?
a. Take vital signs and provide hygienic care on the
first client.
b. Administer medications to the clients.
c. Complete the dressing change.
d. Take vital signs on the two clients.
5. All staff must wear disposable particulate respirators (HEPA
filter) when
a. Working with a client in isolation.
b. There is inadequate room ventilation
c. Working with a client with tuberculosis
d. There are suspected colonized microorganisms.
would be to
a. Untie the neck strings, remove gloves, and untie
waist strings
b. Untie front waist strings, remove gloves, and untie
neck ties.
c. Remove gloves, untie waist strings, and wash hands.
d. Remove gloves, untie neck strings, and wash hands.
7. A nurse is assigned to provide care for an AIDS client. Infection
control guidelines specify that a gown should be worn when
the nurse
a. Enters the room to provide clients care.
b. Administers IV medications.
c. Completes a dressing change
d. Administers an IM injection
8. Gloves are an important component of infection control
protocol. Which of the following situations would not require
that gloves be worn
a. When the nurse is in contact with the urine.
b. Suctioning a client who does not have an infectious
disease
c. Changing an ostomy pouch
d. Delivering a food tray to a client with AIDS.
9. Protective eyewear should be worn at all times when the nurse is
a. Giving personal care to an AIDS client.
b. Bathing a neonate for the first time
c. Drawing cord blood.
d. Taking a specimen to the laboratory
10. The RN team leader will assign a health care worker to care for
a client in isolation. Which team member would be
appropriate for this assignment?
a. LVN/LPN only
b. LVN/LPN, CAN
c. LVN/LPN, UAP
d. LVN/LPN, CAN, UAP
11. The nurse is assigned to draw blood from a suspected AIDS
client. Standard Precautions dictate that she should use
a. gown, clean gloves, and mask
b. gown, sterile gloves
c. handwashing, gown, clean gloves
d. handwashing, sterile gloves
12. The rationale for isolating a newborn who was born to a
mother who had rubella is that
a. The newborn may be actively shedding the virus
b. The newborn is more susceptible to infections.
c. The child may develop encephalitis, a complication
of rubella.
d. A newborn’s autoimmune system is depressed.
13. The nurse is responsible to check that the nursing assistant
(UAP) is aware of Standard Precaution/isolation
techniques. If the nursing assistant understands these
techniques, she will say that she must wear
a. Gloves at all times when in contact with any
clients, regardless of the diagnosis.
b. Gloves and gown when in contact with blood or
body fluids.
c. Sterile gloves, gown and mask at all times when
caring for identified AIDS clients
d. Mask and gloves at all times when caring for
diagnosed AIDS clients
14. Which of the following is a type of transmission-based
precaution?
a. droplet
b. respiratory
c. blood
d. body fluids
15. Two major factors that influence whether an infection
occur in an individual are
a. age and general health status
b. underlying disease status and exposure to
infectious agent
c. inherent health and immunologic status
d. type of organism and age
16. When an area becomes inflamed, the substance that is
released around the injured site is labeled
a. plasmin
b. histamine
c. kinin
d. leukocytes
17. Which of the following statements is true when evaluating
infection control practices?
a. Gloves should be worn for contact with blood
and body fluids of all clients.
b. Gloves should be changed after contact with
blood or body fluid; otherwise, it is not
necessary to change them between client care.
c. Gowns should be worn at all times when caring
for clients with drainage.
d. Health care workers with open lesions should
wear special gloves when providing client care.
18. The census on the unit is 90 percent and there are no
private rooms available. An elderly client with influenza
is admitted. Which of the following rooms would it be
appropriate to assign this client?
a. A double room with another client with the same
diagnosis
b. A four-bed room with three clients who have had
orthopedic surgery
c. A double room with an elderly client with a
diagnosis of chickenpox.
d. A double room with a client admitted for impetigo.
19. For an infection to occur, six links or steps must be present.
Which of the following is not considered a link?
a. Infectious agent.
b. Reservoir
c. Portal of entry
d. Droplet transmission
20. The nurse has instituted contact precautions on a client with
herpes infection. These precautions would not include
a. special particulate (HEPA) filter mask
b. private room or double room with a client with the
same illness
c. gloves when providing client care and changing
gloves following contact procedures.
d. Gown if clothing will come in contact with the client,
environmental surfaces, or items in the room.
21. The single major risk a client faces when entering a hospital in
the United States for any reason is
a. Resistant strain of Staphylococcus.
b. Vancomycin-resistant enterococcus
c. Nosocomial infection
d. Death
22. Considering the most basic infection control measures, which
of the following statement is correct?
a. Wearing gloves eliminates the need to wash hands
between clients.
b. Donning gloves, even with unclean hands, will
protect the client.
c. It is important to wash hands between clients and
before and after using gloves.
d. OSHA stipulates that gloves must be worn for all
client contact.
23. The most common nosocomial infection is
a. urinary tract infection
b. infectious diarrhea (C. difficile)
c. pneumonia (gram negative bacteria)
d. bloodstream infection
24. A client returns to the unit following neurosurgery for removal
of a meningioma. The client has been in intensive care for 2
days and now is assigned to a step-down unit. When
completing an assessment the nurse notes that the client has a
fever of 102 0F and is complaining of cramps and pain in the
stomach. The appropriate intervention is to
a. repeat the assessment in 12 hours
b. notify the physician
c. do nothing—these symptoms are expected with this
condition.
d. Suggest a stool assay for toxin A or B.
25. A nurse accidentally has had a needle stick in her hand as she
pulled an IM needle from the muscle. The first action is to
a. Report the accident to the charge nurse.
 b. Scrub the area vigorously with soap and water
for 5 minutes.
c. Cleanse area with povidone-iodine (Betadine)
d. Irrigate the wound with sterile water.
26. The nursing team consists of an RN, an LPN/LVN, and
three nursing assistants. The RN should care for the
following patients?
a. A patient with a chest tube ambulating in the
hall.
b. A patient with a colostomy who requires
assistance with colostomy irrigation.
c. A patient with a right-sided cerebral vascular
accident (CVA) who requires assistance with
bathing.
d. A patient who is refusing medication to treat
cancer of the colon.
27. Which of the following nursing actions would be least
helpful for a battered client?
a. Helping the client displace her feelings
b. Giving her information about a safe home and a
crisis help line telephone number.
c. Teaching the client about the cycle of violence
d. Discussing the client’s legal and personal rights
28. The nurse caring for a child with leukemia should place
priority on
a. preventing injury
b. monitoring the child’s temperature
c. monitoring the child’s platelet count
d. encouraging increased fluid intake
29. A parent calls the clinic saying her 3 year old has
chickenpox. The parent asks how to care for the lesions.
The nurse would advise that the child
a. soak in a hot tub for 30 minutes three times a day
b. take an antihistamine and use calamine lotion on
lesions
c. can return to preschool in 3 days
d. will not appear very ill
30. Two adolescents come to the school nurse’s office to talk
about their friend. They are concerned because he seems
to be using several different drugs. One of the
adolescents asks how he would be able to tell if his friend
was using cocaine? The nurse replies that his
a. eyes would be red and bloodshot
b. pupils would be constricted to pinpoints
c. pupils would be large
d. eyes would look tired
31. A nurse working in a community center counsels a
husband and wife referred to the center because of
suspected abuse of their 3-year-old daughter. The couple
also has 3 older daughters at home. During counseling,
the nurse should recognize that the parents give a typical
description of an abused child when they say that their
daughter
a. tends to lie and cheat frequently
b. always keeps running away from home
c. does not show respect for authority
d. has always been different form her sisters
32. The nurse is planning an educational program about the
prevention of osteoporosis for a group of women at the local
community center. Which of the following preventive
measures would be appropriate for the nurse to include in the
teaching plan?
a. encouraging weight bearing exercise on a regular
basis
b. increasing daily intake of protein
c. ingesting 2000 mg of calcium supplements daily
d. sunbathing for 1 hour a day during the summer
months
33. While visiting a client with multiple sclerosis, the community
health nurse observes that the client looks unkempt and sad.
The client suddenly says, “I can’t even find the strength to
comb my hair,” and burst into tears. Which of the following
responses by the nurse would be best?
a. It must be frustrating not to be able to care for
yourself.
b. How many days have you been unable to comb your
hair?
c. Why hasn’t your husband been helping you?
d. Tell me more about how you’re feeling?
34. The nurse makes a home visit to a primigravida on the fourth
postpartum day after delivery of a viable neonate. When the
nurse enters the house, the nurse finds the client sitting in a
chair, crying inconsolably, while the neonate is crying in
another room. The client tells the nurse that she hasn’t been
sleeping well, and she has been hearing voices. The nurse
determines that the client is most likely experiencing
a. normal reactions to being a new mother
b. the “baby blues”
c. postpartum depression
d. postpartum psychosis
35. Two days after a client’s wife and child were found dead in a
flood, the client returns to the crisis center and says he thinks
it would be better to “end it all right now and join my wife and
kid, wherever they are.” The nurse has already determined
that the client has no history of psychiatric problems. In terms
of the seriousness of the client’s suicide threat, his risk should
be considered as
a. very low; as long as the client speaks of suicide, he is
unlikely to carry out the act
b. low; a person who has not had psychiatric problems
in the past rarely carries out a first suicide threat
c. moderate; the client appears to be making an effort to
gain attention and extra support
 d. high; the client’s suicide threat can be considered
a call for help and should be taken seriously.
36. When caring for a patient who has jaundice, hepatomegaly
and with history of STD, which of these precautions
should the nurse take?
a. wearing a mask when entering the room
b. wearing gloves when performing a venipuncture
c. wearing goggles when giving oral medication
d. wearing a gown when assisting with hygiene
37. If a 3 ½ year old child began receiving immunizations on
schedule, the nurse would expect the child to have had the
following immunizations:
a. 3 DPT , measles, mumps, rubella
b. 2 DPT , 2 OPV , rubella, measles
c. 3 DPT , 3 OPV, measles, mumps
d. 4 DPT, 3 OPV, measles, mumps, rubella
38. A patient with AIDS suddenly spills his secretions on floor.
What chemical solution could be used in cleaning
secretions?
a. bleach
b. alcohol
c. ammonia
d. iodine
39. When entering a room to assess a new client, the nurse
identifies that the client has brought with him a copy of
the Torah. To further assess his spirituality, an appropriate
statement would be:
a. “Would you like me to call a rabbi to see you?”
b. “Would you like me to read the Torah to you
during your stay?”
c. “Are there any particular religious practices that
are important to you?”
d. “Would you like to call the hospital chaplain to
see you?”
40. The culturally sensitive nurse should question which of the
following menu selections served to her Islamic client?
a. poached salmon, rice, green salad and tea
b. beef stew, potatoes, carrots and milk
c. ham steak, potato salad, and apple pie
d. broiled lamb chops, buttered noodles and coffee
41. A large number of family members are gathered at the
bedside of a terminally ill Hispanic client in a semi
private room. Recognizing the family’s cultural response
to death and dying, the nurse should:
a. restrict visitors 2 at a time in the client’s room
b. move the client to a private room to allow family
to be with the client
c. have security limit the members of the family
who can visit at one time
d. ask the family members to show greater
emotional control around the client
42. For dietary planning, the nurse would expect the client of
Asian-American heritage to choose primarily form which of
the following food groups?
a. milk and dairy products
b. breads, starches, and cereals
c. meats and poultry
d. vegetables and fruits
43. The nurse should instruct a Chinese client who is pregnant
about alternatives for which of the following food groups?
a. cereals and breads
b. fruits and vegetables
c. meats and fish
d. milk and cheese
44. An orthodox Jewish man in the intensive care unit is dying.
Which of these statements by the nurse would indicate
sensitivity to his cultural/religious beliefs?
a. “I’m sorry but visiting hours are over now and your
visitors will have to leave.”
b. “Shall I call the rabbi to perform last rites for you?”
c. “Would you like an autopsy performed after your
death?”
d. “Do you want us to call the rest of your family to be
here with you?”
45. The nurse is giving discharge instructions to an Asian-
American client who smiles and nods her head as she listens.
The nurse should interpret this behavior to mean that the client
a. agrees to follow the instruction
b. Is happy to be going home to her extended behavior
c. understands the instructions
d. has a mannerism
46. Which of the following statements by the nurse would be most
appropriate when the nurse is asked to obtain consent from an
18-year-old undergoing major surgery?
a. “I will have to speak with the parents for consent to
operate.”
b. “I will have to ask the client to read and sign the
informed consent.”
c. “The client’s physician should obtain the consent for
surgery.”
d. “There is no need for consent since the client is 18
years of age.”
47. The nurse should be aware that a client is susceptible to
spontaneous bleeding if taking which of the following herbs
with an anticoagulant?
a. black cohosh
b. gingko biloba
c. chamomile tea
d. valerian root
48. The physician prescribes Fluoxetine (Prozac). Before
starting this medication, it is most important for the nurse
to ask the client if he takes which of the following herb?
a. St. John’s wort
b. Valerian root
c. Black cohosh
d. Chamomile tea
The following patients are in your charge. Delegate the
following patient’s general care to a registered nurse (RN),
licensed practical nurse (LPN), and unlicensed personnel
(ULP).
49. A 60 year old patient with congestive heart failure (CHF)
second day after admission to the hospital.
50. A 40 year old patient with MI new admission to the
hospital
51. A 70 year old patient with chronic renal failure new
admission
52. A 30 year old patient with secondary polycythemia second
day after admission
A 50-year-old patient has been admitted to the hospital with
severe renal failure. Delegate the following tasks to an RN,
LPN, and ULP.
53. Assessment of the patient at the time of admission
54. Administration of medications
55. Urinary Foley care and measuring output
56. Working with a patient to develop short term goals
57-58: Select all that applies. Incomplete or excess tagging
will not be considered correct.(1 point each number)
57. The nurse is planning care for a client with human
immunodeficiency virus (HIV). She’s being assisted by
licensed practical nurse (LPN). Which statements by the
LPN indicate her understanding of HIV transmission?
A. “I’ll wear a gown, mask and gloves for all client
contact.”
B. “I don’t need to wear any personal protective
equipment because nurses have a low risk of
occupational exposure.”
C. “I’ll wear a mask if the client has a cough caused by
an upper respiratory infection.”
D. “I’ll wear a mask, gown and gloves when splashing
of body fluids is likely.”
E. “I will wash my hands after client care.”
58. The nurse is monitoring a client who is receiving oxytocin
(Pitocin) to induce labor. The nurse should be prepared
for which of the following maternal adverse reactions.
A. hypertension
B. jaundice
C. dehydration
D. fluid overload
E. uterine tetany
F. bradycardia
59. An end-stage AIDS client requires suctioning. When
performing this task, the nurse is correct to wear
a. mask and eye protection
b. sterile gloves and eye protection
c. mask and sterile gloves
d. mask, eye protection, and sterile gloves
60. When counseling a parent about the side effects of varicella
vaccine (Varivax), the nurse is correct to include which of the
following in the teaching plan?
a. The child may cry inconsolably for 24 hours after the
vaccination.
b. A lump may appear at the site of injection and persist
for weeks to months (local pain and tenderness may
occur)
c. Vaccine-induced paralysis may occur
d. A mild maculopapular rash may appear
A 52-year-old male patient has been admitted to the hospital
diagnosed with CHF. Delegate the following tasks to an RN,
LPN, and ULP.
61. Irrigate central line
62. Change abdominal dressing
63. IV push 20 mg of Lasix
64. Report slow decubitus ulcer healing to RN
The following patients are in your charge. Delegate their
general care to an RN, LPN and ULP. A patient with
65. Asthma on the day of admission to the hospital
66. Viral hepatitis on the second day after admission
67. Liver abscess on the second day of admission
68. Chronic glomerulonephritis on the third day after admission
You are caring for a 90 year old female on the second day in the
hospital after a colon resection surgery. Delegate the following
interventions to an RN, LPN, and ULP.
69. Administer potassium 20 mg IV push
70. Aspirin PO
71. Use restraints as prescribed
72. Insertion of a nasogastric tube
A 28-year-old female has been admitted to the hospital with
a diagnosis of appendicitis. Which of the following skills
would you delegate to an RN, LPN, and ULP?
73. Vital signs and I and O on the day of admission
74. Evaluating the patient’s vital signs
75. Assessing abdominal pain
76. Administering intravenous fluids
You are caring for a 90 year old female the second day in the
hospital after hip replacement. Which of the following tasks
would you delegate to an RN, LPN, and ULP?
77. Bathing and turning client
78. Listening and answering family and patient’s basic
concerns.
79. Removing Buck’s traction per physician’s orders
80. Administering blood
A 52 year old male is admitted to the hospital with severe
herpes zoster and you have on your team a female RN, 28
years of age; a female LPN, 52 years of age; and a 30 year
old male ULP. Delegate the following skills to them.
81. Bathing the client
82. Administering medications
83. Apply calamine lotion as prescribed
84. Observe the patient for hearing loss
Patients with the following diagnosis have been assigned to
you. Delegate their general care to an RN, LPN and ULP. A
client with
85. scarlet fever
86. meningitis
87. encephalitis
88. diverticulitis
The following patients have been assigned to your care.
Delegate their general care to an RN, LPN, and ULP. A
client with
89. intussusception 2 days after admission to the hospital
90. diabetes insipidus and blood sugar level of 52 mg/dL
91. diabetes insipidus and specific gravity of 1.010.
92. Downs syndrome, 20 years of age, with a WBC count of
10,000 ml
93. The nurse is teaching a group of unlicensed personnel new to
psychiatry about balance in a therapeutic milieu. Which of the
following statements by a member of the group indicates the
need for further teaching?
a. “Balance includes safe and effective treatment for all
clients.”
b. “Controlling clients helps them feel more
comfortable.”
c. “We don’t fix clients but help them solve their
problems.”
d. “We need to think of “patients’ rights” when working
with clients.”
94. Two nursing assistants are arguing about which person is
responsible for taking the dirty linen bags into the utility room.
One nursing assistant approaches the charge nurse and
complains about the other. Which of the following actions
would the nurse employ?
a. Advise the nursing assistant to be more tolerant of his
coworker.
b. Tell the nursing assistant to take care of the linen
bags himself.
c. Urge the nursing assistant to discuss the problem with
his coworker.
d. Take care of the linen bags to avoid further conflict.
95. Which of the following interventions can be delegated to an
unlicensed assistive personnel?
a. assessment of the blood pressure of a patient with
pre-eclampsia
b. providing discharge teaching to a diabetic patient
c. observing a patient in the demonstration of crutch
walking
d. obtaining a specimen form an indwelling urinary
catheter
96. Which attitude would most likely be seen in a Mexican
American client with pain
a. “Enduring pain is a part of God’s will.”
b. “This pain is killing me.”
c. “I’ve got to see a doctor right away.”
d. “I can’t go on in pain like this any longer.”
97. A nurse working in a community health center is interviewing a
family. The nurse suspects that the 20 month old is being
abused. Which of the following behaviors would make the
nurse think abuse?
a. Does not cry while being examined
b. Clings to the parent during the examination
c. Plays with the toys on the floor in the examination
room
d. talks easily to the nurse
98. A community health nurse is creating a program to
decrease the primary cause of disability and death in
children. The nurse would
a. encourage the state legislator to draft legislation
to promote prenatal care
b. encourage the health department to make
immunizations available at no cost to all children
c. teach health and safety practices to children and
parents
d. use blood tests to screen for cancer in school aged
children

99. When teaching a sexuality class at a community center, the

nurse should instruct class participants that human
immunodeficiency virus (HIV) transmission could be
greatly reduced by which of the following behaviors?
a. avoiding inhalant
b. avoiding prolonged sex
c. using latex condoms during sexual intercourse
d. douching after sexual intercourse

100. A nurse is making a home health visit and finds the client
experiencing right lower quadrant abdominal pain, which
has decreased in intensity over the last day. The client
also has a rigid abdomen and a temperature of 103. 6 F.
The nurse should intervene by
a. administering Tylenol for the elevated
temperature
b. advising the client to increase oral fluids
c. asking the client when she last had a bowel
d. notifying the physician