Republic of the Philippines

GOLDEN GATE COLLEGES

P.Prieto St. Batangas City
COLLEGE OF NURSING, CAREGIVING AND MIDWIFERY
____________________________________________________________________________

Name: Tubice, Eanah Reachie Date: June 20, 2021

Course & Section: BSN-1 RLE Group: Group 1

BOARD EXAM QUESTIONS

(FUNDAMENTALS)

I. MEDICAL HANDWASHING

Question 1:
What is the act of cleaning one’s hands with the use of any liquid with or without soap for the
purpose of removing dirt or microorganisms?
a. Aseptic Technique
b. Handwashing
c. Medical Asepsis
d. Surgical Asepsis

Rationale:
Handwashing is the act of cleaning one’s hands with the use of any liquid with or without soap
for the purpose of removing dirt or microorganisms. It is the most effective measure in reducing the
risk of transmitting infectious diseases.

Question 2:
The clinical instructor asks her students the rationale for handwashing. The students are correct if
they answered that handwashing is expected to remove:
a. Transient flora from the skin.
b. Resident flora from the skin.
c. All microorganisms from the skin.
d. Media for bacterial growth.

Rationale:
There are two types of normal flora: transient and resident. Transient flora are normal flora that
a person picks up by coming in contact with objects or another person (e.g., when you touch a
soiled dressing). You can remove these with hand washing. Resident flora, live deep in skin layers
where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot
usually be removed with routine hand washing. Removing all microorganisms from the skin
(sterilization) is not possible without damaging the skin tissues. To live and thrive in humans,
microbes must be able to use the body’s precise balance of food, moisture, nutrients, electrolytes,
pH, temperature, and light. Food, water, and soil that provide these conditions may serve as
nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms,
except perhaps briefly when an antiseptic agent is used for cleansing.

II. OPEN GLOVING TECHNIQUE

Question 1:
The nurse in charge is evaluating the infection control procedures on the unit. Which finding
indicates a break in technique and the need for education of staff?
a. The nurse aide is not wearing gloves when feeding an elderly client.
b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to
another department for testing.
c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct
client care.
d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict
isolation.

Rationale:
There is no need to wear gloves when feeding a client. However, universal precautions (treating
all blood and body fluids as if they are infectious) should be observed in all situations. A client with
active tuberculosis should be on respiratory precautions.  Having the client wear a mask when
leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis
should not give direct client care or handle client-care equipment until the condition resolves. Strict
isolation requires the use of mask, gown, and gloves.

Question 2:
The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound.
After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After
removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in
preparation for cleaning and redressing the wound. The most appropriate action for the charge
nurse is to:
a. Interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove
the old dressing.
b. Congratulate the nurse on the use of good technique.
c. Discuss dressing change technique with the nurse at a later date.
d. Interrupt the procedure to inform the nurse of the need to wash her hands after
removal of the dirty dressing and gloves.

Rationale:
Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves
does not put the client in danger so discussion of this can wait until later. The staff nurse is doing
two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse
should wash her hands after removing the soiled dressing and before donning sterile gloves to
clean and dress the wound. The nurse should wash her hands after removing the soiled dressing
and before donning the sterile gloves to clean and dress the wound. Not doing this compromises
client safety and should be brought to the immediate attention of the nurse. The staff nurse is doing
two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the
use of sterile gloves does not put the client in danger so discussion of this can wait until later.
However, the nurse should wash her hands after removing the soiled dressing and before donning
sterile gloves to clean and dress the wound. Not doing this compromises client safety and should
be brought to the immediate attention of the nurse.

III. VITAL SIGN

Question 1:
When performing a newborn assessment. The nurse should measure the vital signs in the following
sequence:
a. Pulse. Respirations. Temperature
b. Temperature. Pulse. Respirations
c. Respirations. Temperature. Pulse
d. Respirations. Pulse. Temperature

Rationale:
This sequence is least disturbing. Touching with the stethoscope and inserting the
thermometer increase anxiety and elevate vital signs.

Question 2:
Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30
breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea
means:
a. Pulse rate greater than 100 beats per minute
b. Blood pressure of 140/90
c. Respiratory rate greater than 20 breaths per minute
d. Frequent bowel sounds

Rationale:
A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of
140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia.
Frequent bowel sounds refer to hyper-active bowel sound

Prepared by:

EANAH REACHIE TUBICE

SIGNATURE over PRINTED NAME