NCLEX Safety and Infection Control Questions
Safety and Infection Control NCLEX Practice Questions
Question 1.
The nurse is talking with a client about primary and secondary prevention of cancer. Which statements are examples of primary prevention? Select all that apply.
(a) removing colon polyps to prevent colon cancer
(b) limiting alcohol to no more than 1 ounce per day
(c) colonoscopy at age 50 years and then every 10 years
(d) yearly mammogram for all women older than 40 years
(e) getting vaccinated against human papilloma virus (HPV)
(f) eating a low-fat diet high in fiber, including fruits and vegetables
Answer:
(a) removing colon polyps to prevent colon cancer
(b) limiting alcohol to no more than 1 ounce per day
(e) getting vaccinated against human papilloma virus (HPV)
(f) eating a low-fat diet high in fiber, including fruits and vegetables
Rationale:
Primary prevention is focused on using strategies to prevent the actual occurrence of cancer. Secondary prevention uses screening to detect cancer in the early stages when it is most curable.
Question 2.
The nurse is reviewing the facility's emergency preparedness plan. Which statement is true regarding emergency preparedness?
(a) Nurses play supporting roles during and after a disaster or emergency.
(b) The critical incident stress debriefing team analyzes what went wrong and what went right with the plan.
(c) The administrative review meets with team members shortly after the event to promote effective coping strategies to staff.
(d) Without stress management and intervention during and after an event, staff members are at risk of developing post-traumatic stress disorder (PTSD).
Answer:
(d) Without stress management and intervention during and after an event, staff members are at risk of developing post-traumatic stress disorder (PTSD).
Rationale:
Effective stress management techniques and debriefing can help team members use counseling and other resources to help prevent PTSD. Nurses play key roles before, during, and after a disaster. The critical incident stress debriefing team meets with team members to provide coping strategies. The administrative review analyzes what went wrong and what went right with the plan.
Question 3.
The nurse is educating a client on meningitis. Which statements would the nurse include in the teaching? Select all that apply.
(a) The CDC recommends an initial vaccine at age 6 or upon entering first grade.
(b) Immunocompromised clients and older adults are at increased risk of meningitis.
(c) Viral meningitis is the most common type; typically, no organisms are isolated from CSF cultures.
(d) Young preschool-age children have the highest rates of infection from life-threatening meningococcal infection.
(e) A booster vaccine is given at age 11 or 12 to children living in crowded spaces, such as group homes or summer camps.
Answer:
(b) Immunocompromised clients and older adults are at increased risk of meningitis.
(c) Viral meningitis is the most common type; typically, no organisms are isolated from CSF cultures.
Rationale:
In addition to immunocompromised clients and older adults, clients with infection in the head or neck are also at increased risk. Tooth abscess, otitis media, and sinusitis have been linked to meningitis. CDC recommendations include an initial vaccine between ages 11 and 12 years with a booster at 16 years. Booster shots are recommended for adults living in cramped quarters (dorms, military barracks, group homes) or traveling to areas where outbreaks are common.
Question 4.
A nurse is preparing a sterile field for a client who is having a central venous catheter placed for IV therapy. Which action reflects a break in the sterile field?
(a) The nurse uses sterile gloves to place objects on the sterile field.
(b) The nurse stays near the sterile field at all times without turning away from it.
(c) The nurse removes a sterile syringe from the sterile field using clean gloves but does not touch the sterile field itself.
(d) The nurse opens a syringe, carefully peeling the wrapper away from the syringe without touching it so that it can be removed by a clinician wearing sterile gloves.
Answer:
(c) The nurse removes a sterile syringe from the sterile field using clean gloves but does not touch the sterile field itself.
Rationale:
Although the nurse does not touch the sterile field with the clean gloves, there is still contamination because clean gloves were used to remove a sterile object. The syringe is now contaminated, and the close proximity of the clean gloves to the sterile field poses a transmission risk. Any time there is even a suspicion of contamination, the sterile field must be reestablished. Options (a), (b), and (d) reflect safe practice for sterile technique.
Question 5.
The nurse is caring for a client with limited mobility and right-sided paralysis. The nurse needs to pull the client up in the bed. Which statement reflects correct performance of this action?
(a) The nurse stands behind the head of the bed, places her hands under the client's axillae, and pulls him up.
(b) The nurse rolls the client to his left side, stands behind the head of the bed, and pulls the client up with the draw sheet.
(c) The nurse places the bed in the Trendelenburg position and alternates pulling on each side of the draw sheet, maneuvering the client up in the bed.
(d) The nurse calls for another nurse, places the client supine with arms folded across his chest, and each nurse pulls client up using both sides of the draw sheet at the same time.
Answer:
(d) The nurse calls for another nurse, places the client supine with arms folded across his chest, and each nurse pulls client up using both sides of the draw sheet at the same time.
Rationale:
Pulling the client up in bed is always a two-person task, or more if client is obese. The bed position may be flat or Trendelenburg as the client tolerates. Each person grasps the draw sheet and on the count of three, pulls the client up smoothly while taking care not to hit his head on the bed. Options (a), (b), and (c) are incorrect techniques and may harm the client or the nurse.
Question 7.
The nurse sees a small fire in a trash can at the nurses' station. She retrieves the fire extinguisher. Which is the correct method to put out the fire?
(a) pull the pin, squeeze the handles, aim at the top of the fire, and sweep downward to contain the flames
(b) squeeze the handles firmly, aim hose at the top of the fire, and then spray downward in a sweeping motion until flames are extinguished
(c) pull the pin, aim hose at the outside of the trash can, and coat it thoroughly to contain the fire before spraying flames inside trash can
(d) pull the pin, aim the hose at the fire's base, squeeze the handles, and sweep from side to side slowly to ensure even coverage and extinguish flames
Answer:
(d) pull the pin, aim the hose at the fire's base, squeeze the handles, and sweep from side to side slowly to ensure even coverage and extinguish flames
Rationale:
Remember the mnemonic PASS to guide you: Pull pin, Aim at base of the fire, Squeeze the handles, and Sweep from side to side to ensure even and complete coverage. Options (a), (b), and (c) do not demonstrate proper use of a fire extinguisher.
Question 8.
The nurse is preparing to administer Protonix 40 mg PO to a client. The medication dispenser system is out of the tablets, but the nurse realizes that he can override and pull out IV Protonix instead. The client has a patent IV, and the nurse decides this will save time instead of calling the pharmacy for the missing medication. Which of the six rights of medication administration has the nurse violated?
(a) right dose
(b) right time
(c) right route
(d) right patient
(e) right medication
(f) right documentation
Answer:
(c) right route
Rationale:
The nurse cannot give a medication via a route other than what was ordered without contacting the health care provider and obtaining a new order. The nurse should notify the pharmacy so that the missing medication can be replaced. Options (a), (b), (d), (e), and (f) do not address the route of administration.
Question 9.
The nurse is caring for a client with influenza. Which precautions would the nurse expect to be in place for this client?
(a) contact
(b) droplet
(c) airborne
(d) protective environment
Answer:
(b) droplet
Rationale:
Droplet precautions focus on diseases that are spread by large droplets (greater than 5 microns) expelled into the air and by being within 3 feet of a client. Contact precautions are used for direct and indirect contact with clients and their environments. Airborne precautions are used with diseases that are transmitted by droplets smaller than 5 microns.
These smaller droplets remain in the air longer and necessitate the use of an N95 respirator. These clients require a negative pressure or negative airflow room. Protective environments focus on a very limited client population that require a room with positive airflow greater than 12 exchanges per hour through HEPA filters.
Question 10.
A nurse is preparing to administer IV Rocephin for infection to a client. The client has a central venous line infusing blood but no other IV access. The blood still has 30 minutes left to infuse. The Rocephin is due now. How should the nurse proceed?
(a) hold the Rocephin since it will be too late to give it after the blood completes infusing
(b) draw up the Rocephin in a syringe after reconstitution and inject it into the blood bag so it can infuse with the blood
(c) stop the blood, flush the line with 0.9% NS, administer the Rocephin, and then flush the line with the NS before restarting blood
(d) allow the blood to finish infusing before giving Rocephin; the Rocephin will be administered during an acceptable time frame for "on time" administration
Answer:
(d) allow the blood to finish infusing before giving Rocephin; the Rocephin will be administered during an acceptable time frame for "on time" administration
Rationale:
Blood must be given within a certain time frame, and delaying the administration may cause the blood to expire. Most facilities allow a 30-minute to 1 -hour time frame for "on time" medication administration. Option (a) is incorrect because a 30-minute delay will not be too late. Option (b) is incorrect because IV medications are never given in tubing that is infusing blood, blood products, or TPN. Option (c) is incorrect because it involves stopping blood and infusing medication through the same tubing as the blood.
Question 11.
The nurse is setting up a room for an admission. Which equipment would the nurse remove from service and then notify maintenance? Select all that apply.
(a) a bed that is missing a rail but is still usable
(b) an IV pump with a current safety inspection sticker
(c) a rolling recliner with all wheels in the fully locked position
(d) a new extension cord for a radio that a previous client left behind
(e) a feeding pump with a frayed electrical cord and a current safety inspection sticker
Answer:
(a) a bed that is missing a rail but is still usable
(d) a new extension cord for a radio that a previous client left behind
(e) a feeding pump with a frayed electrical cord and a current safety inspection sticker
Rationale:
A bed missing a rail is a possible safety hazard and should not be used, even if it is otherwise serviceable. Extension cords pose a fall risk, and outside equipment that has not been inspected for safety may not be used in a health care facility, especially items typically purchased for home use. Equipment with a frayed cord is an electrical hazard and should not be used regardless of its safety inspection label.
Question 12.
The nurse is caring for a client who is paralyzed on the left side due to a stroke. The unlicensed assistive personnel (UAP) is assisting the nurse with a bed bath. Which action by the UAP requires intervention by the nurse?
(a) The UAP places dirty linen on the floor during the bed change.
(b) The UAP first washes his hands and dons gloves before beginning the bath.
(c) The UAP drapes the client for privacy and warmth during the course of the bath.
(d) The UAP asks the client if she needs to use the bedpan before beginning the bath.
Answer:
(a) The UAP places dirty linen on the floor during the bed change.
Rationale:
Placing dirty linen on the floor can transfer microorganisms and increase the risk of spreading infection. Dirty or clean linen should never be placed on the floor. Hand washing and using gloves help lower the spread of infection and are part of universal or standard precautions. Draping the client shows respect for the client's modesty and helps prevent the client from becoming too cold. Asking about toileting needs before the bath allows for removal of soiled linen if the client has an accident with the bedpan before clean linen is placed on the bed.
Question 13.
The nurse is preparing to perform suctioning on a client with a tracheostomy who is not on a mechanical ventilator. Which of the following actions by the nurse are appropriate? Select all that apply.
(a) The nurse instills normal saline into the airway before suctioning.
(b) The nurse applies intermittent suction for 15 seconds while pulling the catheter straight out.
(c) The nurse hyperoxygenates the client with the manual resuscitation bag before suctioning.
(d) The nurse quickly inserts the catheter during inspiration until resistance is met or the client coughs.
(e) The nurse quickly inserts the catheter during expiration until resistance is met or the client coughs.
(f) The nurse applies intermittent suction for 10 seconds while rotating the catheter back and forth between the dominant thumb and forefinger.
Answer:
(c) The nurse hyperoxygenates the client with the manual resuscitation bag before suctioning.
(d) The nurse quickly inserts the catheter during inspiration until resistance is met or the client coughs.
Rationale:
The client is hyperoxygenated before suctioning to decrease suction-induced hypoxemia. Inserting the catheter upon inspiration minimizes oxygen loss from suctioning while the client is exhaling. When resistance is met or the client coughs, the nurse should pull the catheter back 1 cm to avoid trauma to the tracheal mucosa. Pulling back prevents the catheter tip from resting against the mucosal wall and stimulates cough.
Normal saline is no longer used routinely in tracheal suctioning unless ordered by the health care provider due to the risk of bronchospasm or introducing organisms to the respiratory tract. Intermittent suctioning should be performed for no more than 10 seconds to avoid hypoxemia. Rotating the catheter upon removal helps avoid injury to the mucosal lining.
Question 14.
The nurse hos given o client on injection ond then notes thot the shorps contoiner is full. NA^hich is the correct action by the nurse?
(a) exchange the full container for a new one
(b) place the syringe on top of the container so it will not roll off
(c) force the syringe into the top of the container as well as it will fit
(d) put the syringe into her pocket and dispose of it in another room
Answer:
(a) exchange the full container for a new one
Rationale:
The full container should be replaced with a new one. Sharps should never be placed on top of the container or forced into it, as this increases the risk of a needlestick injury. A dirty sharp should never be placed in a pocket because it is now contaminated from the client, even if the safety device is covering the needle.
Question 15.
The nurse is caring for a client with a left pneumothorax and a water-seal chest tube. Which of the following indicates a need for further action by the nurse? Select all that apply.
(a) The client is resting in a semi-Fowler's position.
(b) The client is resting in a Trendelenburg's position.
(c) The suction control chamber has constant gentle bubbling.
(d) Constant bubbling is present in the water seal after clamping off suction.
(e) Tidaling is present in the water seal chamber and corresponds to respiration.
Answer:
(b) The client is resting in a Trendelenburg's position.
(d) Constant bubbling is present in the water seal after clamping off suction.
Rationale:
A client with a chest tube should not be placed in a Trendelenburg's position as this will prevent drainage from going into the chest tube drainage device. Constant bubbling in the water seal after clamping off suction indicates an air leak. The nurse should check and tighten all connections and check the tubing for a leak. If a leak is noted in the tubing, replace the drainage device.
Check the insertion site by removing the dressing and verifying that the chest tube eyelets are not visible. If no leaks can be seen or heard at the insertion site, the lung is the source of the leak. If the leak persists after troubleshooting, notify the health care provider. A semi-Fowler's position is appropriate and facilitates drainage into the drainage system. Constant gentle bubbling in the suction control chamber and tidaling in the water seal chamber that corresponds to respiration are expected findings.
Question 16.
The nurse is caring for a client who just returned from a supratentorial craniotomy, during which a large tumor was removed. Which of the following interventions by the nurse are appropriate for this client? Select all that apply.
(a) elevate the head of the bed 30 degrees
(b) elevate the head of the bed 90 degrees
(c) monitor neurological status every 2 hours
(d) monitor for signs of increased intracranial pressure
(e) apply antiembolism stockings to the client once he is alert
(f) turn the client every 2 hours from the operative side to the nonoperative side
Answer:
(a) elevate the head of the bed 30 degrees
(d) monitor for signs of increased intracranial pressure
Rationale:
The head of the bed should be elevated 30 degrees to promote venous drainage and prevent hemorrhage caused by excessive blood flow to the brain. The client should be monitored for signs of increased intracranial pressure such as increased blood pressure with widening pulse pressure and altered level of consciousness. Elevating the head of the bed 90 degrees is incorrect as increased hip flexion should be avoided.
Neurological status should be monitored more frequently in the client immediately post-op, often every 15 minutes during the first hour, then every 30 minutes for the second hour, or according to health care provider orders. Antiembolism stockings should be in place either when the client returns to the room or immediately upon arrival. The client should not be positioned on the operative side due to the risk of brain shift.
Question 17.
The nurse is caring for a client with an internal cervical radiation implant. When performing morning care, the nurse notes the implant lying on the bed. Which nursing action should be done first?
(a) notify the health care provider
(b) apply gloves and attempt to reinsert the implant
(c) retrieve the implant with long-handled forceps and place into a lead container
(d) don a lead apron and retrieve the implant with long-handled forceps and place into a lead container
Answer:
(c) retrieve the implant with long-handled forceps and place into a lead container
Rationale:
The nurse caring for the client with a radioactive implant should don a lead gown before performing any client care; therefore, the nurse only needs to retrieve the implant with long-handled forceps and place it into a lead container.
Clients with implants should have a lead container and long- handled forceps available in the room in case of dislodgement. Once the implant is retrieved, the health care provider should be notified. Attempting to reinsert the implant is beyond the scope of nursing practice and should be performed only by the health care provider.
Question 18.
The nurse is supervising the unlicensed assistive personnel (UAP) while providing care for a client with an internal radioactive implant. Which action by the UAP requires immediate intervention by the nurse?
(a) The UAP assists the client in setting up the meal tray.
(b) The UAP wears a dosimeter badge while performing client care.
(c) The UAP closes the door to the room upon entering and exiting.
(d) The UAP places soiled linen in a laundry cart and takes it to the soiled utility area.
Answer:
(d) The UAP places soiled linen in a laundry cart and takes it to the soiled utility area.
Rationale:
Soiled linen should remain in the room until the source of radiation is removed; the linen may then be disposed of as usual. Setting up the meal tray is part of client care and should not be overlooked, and all personnel caring for the client should wear dosimeter badges to measure the amount of radiation exposure. Closing the door upon entering and exiting and keeping the door closed minimizes the risk of radiation exposure to other clients and staff.
Question 19.
The nurse is preparing to administer metoprolol (Lopressor) to a new client. Which of the following actions by the nurse are correct? Select all that apply.
(a) hold for a heart rate greater than 80 bpm
(b) check the client's blood pressure and apical pulse
(c) check the client's allergies before giving any medications
(d) verify the client's identity using two patient identifiers
(e) tell the client not to take the medication with grapefruit juice
Answer:
(b) check the client's blood pressure and apical pulse
(c) check the client's allergies before giving any medications
(d) verify the client's identity using two patient identifiers
Rationale:
Before giving metoprolol, the nurse should check the blood pressure and apical pulse. If the apical pulse is less than 60, the nurse should hold the medication and contact the health care provider. The nurse should always check for allergies before administering any medications. Joint Commission safety guidelines require that at least two patient identifiers are used before administering medications.
The client's name, date of birth, and medical record number on the bracelet should match the chart. The nurse would not hold metoprolol for a heart rate greater than 80 bpm. There are no indications that grapefruit juice should be avoided when taking this medication.
Question 20.
The nurse is caring for a client with Guillain-Barre syndrome. Due to paralysis, the client is unable to press the call button with his f nger. The nurse must make accommodations for this client to be able to call for help. Which action by the nurse is correct?
(a) leave the client's door open and instruct him to yell loudly for help
(b) ask a family member to stay around the clock so she can call for the client
(c) round on the client as often as possible since there are no alternatives
(d) utilize a call light adapter that will allow the client to call for help by turning his head to activate a special button
Answer:
(d) utilize a call light adapter that will allow the client to call for help by turning his head to activate a special button
Rationale:
Special call light adapters are available for clients with limited mobility of the hands. Clients with Guillain-Barre syndrome tend to maintain the ability to turn the neck. Call light adapters can be placed on the pillow so that the client can turn his head and press the call light.
A client should never be left without alternatives to call for help, so options 1 and 3 are incorrect. Often families cannot stay around the clock, so this may not be a reasonable request; even if someone stays with the client, having the ability to call for help on his own adds a layer of security and comfort for the client.
Question 21.
A nurse is educating a group of student nurses about proper body mechanics to prevent injury to the nurse. Which of the following would the nurse include in her teaching?
(a) bend over from the waist to pick up objects
(b) hold weight as close to the body as possible when carrying something heavy
(c) when pulling a client up in bed, position the bed as low as possible to the floor
(d) try to lift clients with only one nurse to assist to avoid taking too many nurses off the floor
Answer:
(b) hold weight as close to the body as possible when carrying something heavy
Rationale:
When carrying heavy objects, the weight should be held as close to the body as possible to avoid back strain. When bending over to pick something up, the nurse should bend her knees to avoid back injury. When pulling clients up in bed, the bed should be at a comfortable height so that no one has to bend over to lift the client. Safety is a priority, and the nurse should utilize as many nurses as needed for safe lifting. Whenever possible, mechanical lift devices should be used to minimize back strain for the nurse and ensure client safety.
Question 22.
A nurse is preparing to start an IV on a client. Which action by the nurse increases the risk of infection in this client?
(a) The nurse washes his hands and applies gloves before starting the IV.
(b) After placing the IV, the nurse removes his gloves and washes his hands.
(c) The nurse prepares strips of tape to secure the IV and sticks them to the tray table.
(d) The nurse cleans the area with alcohol or another approved skin cleanser and allows it to dry.
Answer:
(c) The nurse prepares strips of tape to secure the IV and sticks them to the tray table.
Rationale:
Securing pieces of tape to a tray table or bed rail introduces pathogens from contaminated surfaces to the client's skin when applied. This increases the risk of pathogens entering the puncture site and causing infection in the client. If additional tape needs to be applied after the clear dressing, it should be removed from the roll just prior to application, without touching it to other surfaces.
Washing the hands before and after placing an IV helps minimize the risk of infection. Use of alcohol or other approved skin cleanser helps remove pathogens and minimize the risk of infection. These products should dry completely before attempting to place the IV.
Question 23.
The nurse is teaching a group of parents with infants and toddlers about poisoning. Which information would the nurse include in her teaching? Select all that apply.
(a) place all chemicals on a high shelf out of reach
(b) do not induce vomiting if the child is unconscious
(c) call the Poison Control Center before inducing vomiting
(d) keep the number of the Poison Control Center near the phone
(e) if the child ingests household cleaners or grease, induce vomiting
Answer:
(b) do not induce vomiting if the child is unconscious
(c) call the Poison Control Center before inducing vomiting
(d) keep the number of the Poison Control Center near the phone
Rationale:
Vomiting should never be induced in an unconscious person. The Poison Control Center should be called before inducing vomiting. The number should be posted on or near each phone in households with small children. Placing chemicals on a high shelf does not prevent access; many toddlers become adept climbers and can reach dangerous items anyway. Chemicals should be locked in a cabinet with child-proof locks for maximum safety. Vomiting should never be induced in persons who have consumed lye, household cleaners, or grease.
Question 24.
A home health nurse is visiting a client who is due for a dressing change for a diabetic foot ulcer. While at the client's home, the nurse notes open cleaning products sitting on the counter next to a plate of chicken. Which is the best response by the nurse?
(a) notify the health care provider about the hazardous conditions found in the client's home
(b) explain to the client that this situation is unsafe, then offer to check her home for other hazards she may not be aware of
(c) perform the dressing change without commenting on the chemicals, then notify social services to intervene
(d) do not say anything; the nurse is there to address the client's dressing change and not criticize the client's housekeeping
Answer:
(b) explain to the client that this situation is unsafe, then offer to check her home for other hazards she may not be aware of
Rationale:
The client may not be aware of the danger of keeping chemicals so close to food, so the nurse should gently explain to the client in a respectful manner. The nurse can then say that a home safety inspection for other hazards is free and ask if the client would like one. The nurse can point out fall hazards, such as slippery rugs, or a frayed cord on a lamp that may start a fire.
The nurse should always be on the lookout for environmental hazards to the client so that corrective action may be taken. There is no need to notify the health care provider or social services in this instance. The nurse should never keep quiet about situations that may place the client in jeopardy.
Question 25.
The nurse is teaching a family about safety from poisons. The nurse would include which statements in her teaching? Select all that apply.
(a) "If someone accidentally ingests poison, try to induce vomiting unless the person is unconscious."
(b) "If the person vomits, save the vomitus in case it is requested by the Poison Control Center or emergency department."
(c) "Post the phone number of the Poison Control Center near the phone if you have small children."
(d) "If the Poison Control Center recommends going to the hospital, drive as fast as you can safely do so."
(e) "Older adults are at risk of accidentally overdosing on prescription medications due to poor eyesight or memory loss."
Answer:
(b) "If the person vomits, save the vomitus in case it is requested by the Poison Control Center or emergency department."
(c) "Post the phone number of the Poison Control Center near the phone if you have small children."
(e) "Older adults are at risk of accidentally overdosing on prescription medications due to poor eyesight or memory loss."
Rationale:
If the person vomits, saving the vomitus may help identify the substance ingested, especially in younger children. Quickly identifying the poisonous substance is key to intervention with an antidote. All homes with small children should post the number of the Poison Control Center near the telephone for quick access in an emergency, or the number should be programed into cell phones. Older adults may forget that they have already taken their medication or not be able to clearly read medication labels, which can lead to accidental overdose.
Vomiting should never be induced unless instructed to do so by Poison Control. If the person needs to be transported to the hospital, emergency services should be called for an ambulance. The ambulance can get to the hospital quicker, and EMTs can start an IV and begin supportive treatment immediately. The nurse should never advise a client to drive quickly to the hospital, as this puts the client at risk for an accident.
Question 26.
A nurse in the emergency department is notified that several critically injured clients will be coming in following the collapse of a high-rise apartment building. Which action by the nurse
is the priority?
(a) notify the charge nurse to call in extra staff
(b) activate the facility's emergency response plan
(c) check the crash cart supplies and restock extra items
(d) determine which current clients can be sent back to the waiting area
Answer:
(b) activate the facility's emergency response plan
Rationale:
Activating the emergency response plan is the first priority and the most critical. Once the plan is activated, the appropriate person will call in extra staff. Restocking items that will most likely be needed would be addressed by the response plan and delivered from central supply by support staff. The charge nurse or other designated personnel would then move noncritical clients to a safe area and open up beds for incoming clients.
Each facility's response plan may vary slightly, but it will address all protocols needed to ensure quick, efficient distribution of personnel and resources. Mock disasters and drills help facilities stay current and update the emergency response plan as needed.
Question 27.
The nurse is preparing to review transmission-based precautions with other nurses on the unit. Which statement regarding transmission-based precautions would the nurse include in her teaching?
(a) "Measles and adenovirus require airborne precautions."
(b) "Barrier protection requires a private room for the client."
(c) "Droplet precautions are used for clients with meningitis."
(d) "Contact precautions are used for clients with disseminated varicella zoster."
Answer:
(c) "Droplet precautions are used for clients with meningitis."
Rationale:
Droplet precautions, along with standard precautions, are used with clients infected with meningitis. Measles requires airborne precautions, while adenovirus requires droplet precautions. Barrier protection calls for either a private room or a cohort client with the same infection. Disseminated varicella zoster requires airborne precautions.
Question 28.
A group of nurses are reviewing surgical asepsis. Which statement by one of the nurses requires further teaching on the topic?
(a) "Full-strength chlorhexidine will sterilize the skin."
(b) "The edges of a sterile field are considered unsterile."
(c) "If a sterile object touches an unsterile object, the sterile object is considered contaminated."
(d) "Sterile objects that are out of view or below waist level are considered unsterile."
(e) "Airborne microorganisms can contaminate sterile objects and make them unsterile."
Answer:
(a) "Full-strength chlorhexidine will sterilize the skin."
Rationale:
The skin cannot be sterilized, according to the principles of surgical asepsis. The edges of a sterile field are considered unsterile. If a sterile object touches an unsterile object, the sterile object is considered contaminated. Sterile objects that are out of view or below waist level are considered unsterile. Sterile objects can become contaminated by airborne microorganisms.
Question 29.
The nurse is instructing a student nurse about proper donning and doffing of personal protective equipment (PPE). Which statement by the student nurse indicates an understanding of the order in which to apply PPE?
(a) "When removing PPE, gloves are removed last."
(b) "When removing PPE, the mask is removed before the gown."
(c) "The PPE should be applied just inside the door of the client's room."
(d) "The gown is put on first, then the gloves, then eye protection, and the mask last."
Answer:
(b) "When removing PPE, the mask is removed before the gown."
Rationale:
When removing PPE, gloves are removed first, then eye protection, followed by the mask, and then the gown. Hand hygiene is performed last. PPE should be applied preferably before entering the client's room. When donning PPE, hand hygiene is first, followed by the gown, mask, eye protection, and lastly, gloves.
Question 30.
The nurse is caring for an elderly client with a history of Alzheimer's and falls. The nurse understands which to be the priority nursing diagnosis for this client?
(a) risk for injury
(b) impaired skin integrity
(c) altered body image due to confusion
(d) impaired physical mobility due to dementia with Lewy bodies
Answer:
(a) risk for injury
Rationale:
The priority nursing diagnosis is risk for injury. Client safety is always the priority, especially with a client who has a history of falls and Alzheimer's or confusion. Impaired skin integrity is an important nursing diagnosis but is not the priority for this client. There is nothing to indicate that this client has altered body image; risk for injury would take priority over altered body image. Impaired physical mobility due to dementia with Lewy bodies is a medical diagnosis, not a nursing diagnosis.
Question 31.
The nurse is preparing to administer an antihypertensive and an anticoagulant to a client. Which should the nurse do first before administering the medication?
(a) verify the client's allergies
(b) verify the client's name and room number
(c) ask the client to state her name and date of birth
(d) scan the client's wristband and medication barcode
(e) verify the client's name, date of birth, and medical record number with the medication order
Answer:
(e) verify the client's name, date of birth, and medical record number with the medication order
Rationale:
The nurse should verify the client's identify by comparing the name, date of birth, and medical record number on the armband with the medication order. The 2012 National Patient Safety Goals require using at least two identifiers to avoid medication errors. Verifying the client's allergies should be done after correctly identify the client. Verifying the client's name and room number is not as accurate.
Asking the client to state her name and date of birth is not reliable in persons with altered mental status or in a nonresponsive client. Scanning the wristband and barcode should be done only after the two identifiers are completed, just prior to administering the medications.
Question 32.
The nurse is performing discharge teaching to a client who gave birth to her first child. Which statement by the client indicates a need for further teaching?
(a) "I will put my baby to sleep on her tummy."
(b) "My baby's first visit to the doctor should be 3 to 5 days after birth."
(c) "I should keep my baby in an approved car seat while riding in the car."
(d) "I will keep the numbers of my pediatrician and the poison control center handy."
Answer:
(a) "I will put my baby to sleep on her tummy."
Rationale:
Infants should be placed on their backs for sleeping. Placing an infant on her stomach for sleep increases the risk of sudden infant death syndrome (SIDS). The American Academy of Pediatrics recommends that newborns have the first checkup 3 to 5 days after birth. Infants should use an approved car seat when riding in a car, and never use car seats that have been in a crash or bought secondhand, as their safety status is unknown. Keeping important numbers such as the pediatrician and poison control center handy saves time in an emergency.
Question 33.
Mix and Match: Match the transmission-based precaution used with a disease.
|
Disease |
Precaution |
|
measles |
contact |
|
Shingles |
droplet |
|
Tuberculosis |
droplet |
|
mumps |
contact |
|
Diphtheriza |
airbone |
|
Influenza |
contact |
|
Herpes simplex |
airbone |
|
c.diff |
droplet |
|
MRSA |
airbone |
Answer:
|
Disease |
Precaution |
|
measles |
airbone |
|
Shingles |
airbone |
|
Tuberculosis |
airbone |
|
mumps |
airbone |
|
Diphtheriza |
droplet |
|
Influenza |
droplet |
|
Herpes simplex |
droplet |
|
c.diff |
contact |
|
MRSA |
contact |
Question 34.
Which precaution must a nurse take when checking the blood pressure of an HIV-positive client?
(a) wear gloves
(b) wear a gown
(c) use contact precautions
(d) wash hands
Answer:
(d) wash hands
Rationale:
Washing hands is sufficient since taking a client's blood pressure does not involve contact with blood or secretions. The other listed precautions would be appropriate if blood or secretions is involved.
Question 35.
The pediatric nurse is preparing a child with acute lymphocytic leukemia for discharge. The discharge plan should include all but which of the following statements?
(a) restrict naps to allow more complete rest at night
(b) increase intake of protein, iron, and vitamin C to provide nutrients required for hemoglobin production
(c) keep a food diary to evaluate dietary intake
(d) restrict antacids, tetracyclines, and phosphorous salt
Answer:
(a) restrict naps to allow more complete rest at night
Rationale:
Arranging rest periods throughout the day helps promote the client's ability to participate in an array of desired activities. Increasing intake of protein, iron, and vitamin C aids in hemoglobin production. Keeping a food diary helps document actual nutritional intake. Restricting antacids, tetracyclines, and phosphorous salts will avert absorption of iron.
Question 36.
The nurse teaches a group of fire fighters about the spread of tuberculosis (TB). Which statement by a fire fighter indicates the teaching has been effective?
(a) "I could getTB if I come in contact with blood from an infected person."
(b) "I can share a cup of coffee with someone who is infected with TB."
(c) "I could get TB if I inhale infected droplets when an infected individual coughs."
(d) "I need to refrain from shaking hands with an infected person."
Answer:
(c) "I could get TB if I inhale infected droplets when an infected individual coughs."
Rationale:
TB bacteria is spread through the air from one person to another. When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow. TB is not transmitted through blood, sharing a cup of coffee, or shaking hands with an infected person.
Question 37.
After administering the annual Mantoux tuberculin skin test to employees, the nurse instructs the staff to return within how many hours after administration to have the results determined?
(a) 12 to 24 hours
(b) 24 to 48 hours
(c) 48 to 72 hours
(d) 72 to 84 hours
Answer:
(c) 48 to 72 hours
Rationale:
The Center for Disease Control recommends the skin test be read 48 - 72 hours after administration. A test is considered positive if an induration of 5 - 15 millimeters is observed at the injection site. Results read after 72 hours are not accurate and another skin test needs to be conducted.
Question 38.
A client is diagnosed with Meniere's disease. Which nursing diagnosis would take priority for this client?
(a) risk for injury
(b) disturbed body image
(c) low self-esteem
(d) impaired skin integrity
Answer:
(a) risk for injury
Rationale:
Meniere's disease occurs when the pressure of the fluid in part of the inner ear gets too high. As a result, the client is at risk for injury related to altered mobility because of gait disturbance and vertigo. While hearing loss may occur, this does not result in disturbed body image, low self-esteem, or impaired skin integrity.
Question 39.
While driving, the client forgets how to get home. Which lobe could be dysfunctional?
(a) temporal
(b) parietal
(c) occipital
(d) frontal
Answer:
(d) frontal
Rationale:
The frontal lobe regulates intellectual functions, such as complex problem solving. The temporal lobe regulates memory, speech, and comprehension. The parietal lobe regulates reading ability, writing ability, and spatial relationships. The occipital lobe is responsible for vision function.
Question 40.
At the scene of an accident, which intervention applies to a client with a suspected neck injury?
(a) administer CPR
(b) keep the person warm
(c) do not move the client
(d) ask the client to state her name and birthday
Answer:
(c) do not move the client
Rationale:
Do not move a client whose neck is in an awkward position or who is unconscious. Instead, keep the client immobilized and get help immediately. In this situation, CPR is not needed for the client. Keeping the client warm is necessary but not a priority. Asking the client to state her name and birthday may be appropriate if a brain injury is suspected, not a neck injury.
Question 41.
Which treatment should be included in the immediate management of acute appendicitis?
(a) prevent fluid volume deficit
(b) administer antibiotic therapy
(c) reduce anxiety
(d) relieve pain
Answer:
(d) relieve pain
Rationale:
Relieving pain is the most immediate need for management. Preventing fluid volume deficit by infusion of IV fluids should occur once the client has experienced initial control of pain. Administration of antibiotic therapy will be important during the recovery phase. Reducing anxiety is important and will be partially addressed with the reduction of pain.
Question 42.
Medical management of a client with acute diverticulitis should include which treatment?
(a) increased fiber in diet
(b) administration of antibiotics
(c) pain medication administration
(d) liquid diet for 1 - 2 days
Answer:
(b) administration of antibiotics
Rationale:
Acute diverticulitis results from inflammation of the diverticula, typically from an infection. As such, the priority treatment is administration of antibiotics to address the root cause of the condition. Gradually increasing fiber in the diet will occur during the recovery stage of the disease. Pain medication for residual pain would be a second management approach after initiation of antibiotic protocol. To promote rest of the intestinal tract, a liquid diet is advisable for an undeterminable time.
Question 43.
An enema is prescribed for a client with suspected appendicitis. The nurse should take which action?
(a) tell the client to lie on his left side
(b) explain the procedure to the client
(c) compile necessary equipment
(d) question the physician about the order
Answer:
(d) question the physician about the order
Rationale:
An enema is contraindicated for a client with suspected appendicitis as increased intestinal motility may aggravate the suspected appendicitis. When enema administration is appropriate, the other answers are correct.