DOH Nursing Nursing Fundamentals & Patient Care 2 — Questions and Answers
Question 1: Which type of isolation precaution is required for a patient with active pulmonary tuberculosis?
- Airborne precautions (Correct answer)
- Contact precautions
- Droplet precautions
- Standard precautions only
Correct answer: Airborne precautions
Active pulmonary TB is transmitted via airborne particles (droplet nuclei <5 microns) that remain suspended in air. Airborne precautions require a negative-pressure room and N95 respirators for staff.
Question 2: A nurse notices a patient's IV site is swollen, cool, and pale. What complication has occurred?
- Infiltration (Correct answer)
- Phlebitis
- Thrombosis
- Air embolism
Correct answer: Infiltration
Infiltration occurs when IV fluid leaks into surrounding tissue instead of the vein. Signs include swelling, pallor, coolness, and discomfort at the site. The IV must be discontinued immediately and the area elevated.
Question 3: What is the primary purpose of a nursing care plan?
- To provide individualized, goal-directed care and ensure continuity (Correct answer)
- To document billing information for hospital accounting
- To satisfy accreditation requirements only
- To assign nursing staff to patient care areas
Correct answer: To provide individualized, goal-directed care and ensure continuity
A nursing care plan individualizes care based on each patient's specific diagnoses, goals, and interventions. It promotes continuity across shifts and disciplines, guides decision-making, and provides a legal record of care.
Question 4: When should a nurse perform hand hygiene according to WHO's 5 Moments?
- Before patient contact, before aseptic tasks, after body fluid exposure, after patient contact, after contact with patient surroundings (Correct answer)
- Only before and after direct patient contact
- Before and after every procedure regardless of glove use
- Whenever visibly soiled hands are observed
Correct answer: Before patient contact, before aseptic tasks, after body fluid exposure, after patient contact, after contact with patient surroundings
WHO's 5 Moments for Hand Hygiene defines the exact points: (1) before patient contact, (2) before aseptic/clean procedures, (3) after body fluid exposure risk, (4) after patient contact, and (5) after contact with patient surroundings.
Question 5: A patient rates pain as 8/10. Which nursing action takes priority?
- Administer prescribed analgesic and reassess in 30–60 minutes (Correct answer)
- Document the pain score and continue routine care
- Notify the physician immediately without intervening
- Apply a cold compress and wait for the physician
Correct answer: Administer prescribed analgesic and reassess in 30–60 minutes
A pain score of 8/10 indicates severe pain requiring prompt intervention. The nurse should administer prescribed analgesia, then reassess effectiveness within 30–60 minutes per pain management standards.
Question 6: Which finding during a head-to-toe assessment requires immediate action?
- Unequal pupils (anisocoria) with altered level of consciousness (Correct answer)
- Mild pedal edema in both feet
- A healing surgical incision with no redness
- Blood pressure of 118/76 mmHg
Correct answer: Unequal pupils (anisocoria) with altered level of consciousness
Unequal pupils combined with altered consciousness suggest raised intracranial pressure or brainstem involvement — a neurological emergency requiring immediate escalation. The other findings are either normal or non-urgent.
DOH Nursing Nursing Fundamentals & Patient Care 2
Which type of isolation precaution is required for a patient with active pulmonary tuberculosis?