which of the following microorganisms are considered normal body flora

NCLEX-PN

NCLEX PN Test Bank

1. Which of the following microorganisms are considered normal body flora?

A. staphylococcus on the skin
B. streptococcus in the nares
C. candida albicans in the vagina
D. pseudomonas in the blood

Correct answer: A

Rationale: Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.

2. The LPN has been given assignments by the RN. Which assignment should the LPN question as being beyond the scope of the LPN?

A. The LPN is assigned to care for a client with diabetes mellitus who needs instructions reinforced on how to self-administer insulin.
B. The LPN is assigned to reinforce discharge teaching about dressing changes and medications to a 35-year-old man.
C. The LPN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications.
D. The LPN is assigned to care for a woman with newly diagnosed leukemia who will be receiving her initial dose of chemotherapy.

Correct answer: D

Rationale: The LPN should be able to recognize when an assignment is beyond their scope of practice. Administering chemotherapy for leukemia is not within the scope of practice for the LPN, and this assignment should be questioned. Choices A, B, and C are within the scope of practice for an LPN. Reinforcing teaching on self-administration of insulin, assisting with discharge instructions on dressing changes, and caring for a client being discharged with no medications are all appropriate tasks for an LPN.

3. What does carrying a donor card for organ donation mean?

A. medical care is altered to obtain organs for donation in the event of serious injuries
B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
C. a client is allowed to revoke their decision for organ donation at any time
D. a client is considered an organ donor for multiple organs or tissues

Correct answer: C

Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.

4. An LPN is caring for a primarily bedridden client. Which finding should be of least concern?

A. swollen feet
B. brown discoloration above the ankles
C. leg pain
D. capillary refill time of 3 seconds on the big toe

Correct answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.

5. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?

A. The history and presentation might indicate chickenpox, a highly contagious disease.
B. The lesions might indicate a noncontagious infection that does not require isolation.
C. The history and presentation might indicate an infectious illness called impetigo.
D. The lesions are not contagious unless others have open wounds or lesions themselves.

Correct answer: C

Rationale: The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy. Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever. Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection. Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.