Online NCLEX Practice Test about
Safety and Infection Control I

1. The home health nurse is visiting a 91-year-old man who lives with his 88-year-old wife. He is legally blind and suffered broken hip 5 years ago. He ambulates with difficulty with aid of a walker. The highest priority nursing diagnosis for him is:

a. Self-care deficit, toileting
b. Knowledge deficit regarding blindness
c. High risk for injury
d. Impaired adjustment

2. A 10-month-old child is admitted to the hospital from the clinic with a history of 2 days fever, anorexia, crying and poor sleeping. The infant is diagnosed with probable meningitis. In which of the following situations should the nurse place the child?

a. in strict isolation
b. in respiratory isolation
c. with other older infants
d. with another child with meningitis

3. While formulating a care plan, the nurse would consider which of the following clients for a nursing diagnosis of “potential for injury?”

a. A client with ulcerative colitis
b. A client with presbyopia
c. A client with asthma
d. A client with Parkinson’s disease

4. A client intentionally overdose on salicylate preparation. Which complication should the nurse carefully monitor for and intervene promptly?

a. Paralytic ileus
b. Hepatotoxicity
c. Pulmonary edema
d. Thrombus formation

5. A client who states that he is allergic to penicillin has an order to receive cefazolin (Ancef). The nurse’s initial response is to:

a. Ask the client if he has taken cefazolin (Ancef) before
b. Consult with the physician or a clinical pharmacist
c. Administer cefazolin (Ancef) immediately
d. Observe the client closely for urticaria

6. An older infant who has been injured in an automobile accident has to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing splint. The nurse would advise the mother to do which of the following?

a. Notify the physician immediately to adjust the treatment plan
b. Confine the infant to one room in the apartment
c. Keep the infant in the splint at night, removing it during the day
d. Remove any unsafe items from the area in which the infant is mobile

7. A client undergoes an endoscopy for diagnostic purposes. The priority for administering nursing care following the procedure would include?

a. Administering analgesics for pain
b. Withholding food until a gag reflex is present
c. Positioning the client on the right side
d. Observing the client for rectal bleeding

8. A client has recently been admitted with a medical diagnosis of dementia. Alzheimer’s type. When obtaining an assessment, the nurse should remember for safety purposes to ascertain what crucial information?

a. Sleep patterns and behaviors
b. Skin turgor
c. The degree of memory impairment
d. The level of distractibility

9. As a nurse is inserting a nasogastric tube, the client begins to gag. Which action should the nurse take?

a. Remove the inserted tube and notify the physician of the client’s status
b. Stop the insertion, allow the client to rest, then continue inserting the tube
c. Encourage the client to take deep breaths through the mouth while the tube is being inserted
d. Pause until the gagging stops, tell the client to take few sips of water and swallow as the tube is inserted

10. Which of the following actions is correct when collecting a urine specimen from a client’s indwelling urinary catheter?

a. Collect the urine from the drainage collection bag
b. Disconnect the catheter from the drainage tubing to collect urine
c. Remove the indwelling catheter and insert a sterile straight catheter to collect urine
d. Insert a sterile needle with syringe through a tubing port cleaned with alcohol to collect specimen

11. A nurse knows that which of the following actions is included in the principles of asepsis?

a. Maintain a sterile environment
b. Keep the environment as clean as possible
c. Test for microorganisms in the environment
d. Clean an environment until it’s free from germs

12. An immunocompromised child is being admitted to a four-bedded are in the pediatric intensive care unit. The nurse is aware that which client should moved to make room for the new admission?

a. A child with plaster immobilization of a closed fracture
b. A child with aspiration pneumonia
c. A child with vaso-occlusive
d. A child with a full-thickness thermal burn

13. A primigravid client at 37 weeks’ gestation has been hospitalized for several days with severe Pregnancy-induced hypertension (PIH). While caring for the client, the nurse observes that the client is beginning to have a seizure. What is the priority intervention?

a. Pad the side rails of the client’s bed
b. Turn the client to the right side
c. Insert a padded tongue blade into the client’s mouth
d. Call for immediate assistance in the client’s room

14. A primiparous client who delivered vaginally 8 hours ago desires to take a shower. Which of the following should the nurse anticipate to assess in the client?

a. Fatigue
b. Fainting
c. Diuresis
d. Hygiene needs

15. The nurse is instructing the unlicensed assistant how to prevent plantar flexion (foot drop) in an immobilized client. Which of the following techniques should the nurse tell the assistant to incorporate into the plan of care?

a. Abduction and flexion
b. Abduction and extension
c. Adduction and flexion
d. Adduction and extension

16. The nurse is instructing the unlicensed assistant in how to care for a client who is receiving chemotherapy. What self-care precautions should the nurse tell the assistant to take when caring for the client?

a. The assistant must have the nurse handle the disposal of any client excreta
b. Universal body precautions are sufficient for protecting the assistant
c. Gowns, mask, and gloves required for any contact with the client
d. Wear surgical gloves when handling the client’s excreta

17. A client who overdosed on barbiturates is being transferred to the in-patient psychiatric unit from the intensive care unit. The nurse receiving the client would anticipate which of the following as a priority?

a. Nutrition
b. Sleep
c. Safety
d. Hygiene

18. When assessing an aggressive client, which of the following client behaviors would warrant the nurse’s most prompt reporting and use of the safety precautions?

a. Crying when talking about his divorce
b. Starting a petition to delay bedtime
c. Declining attendance at a daily group therapy session
d. Naming another client as his adversary

19. As a result of the effects of managed care, hospitalization is often reserved for emergency care. Which of the following situations would the nurse recognize as having the least priority for admission?

a. Potential for self-harm
b. Potential for harm to others
c. Grave disability (unable to care for self care)
d. Decline in functioning at work

20. The nurse is unfamiliar with a new piece of OR equipment that is scheduled to be used today. What is the best course of action?

a. Ask another nurse for instructions on how to use it
b. Wait until she has attended a class on using the equipment before using it
c. Get another nurse who is familiar with the equipment to operate it
d. Read the instructions provided with the equipment

21. As nurse in a skilled nursing facility/nursing home, you are supervising several CNAs. Which CNA best understands the use of restraints? The CNA who:

a. Places all clients in bed with the side rails up
b. Applies a jacket restraint for the client who pulls out IV lines
c. Fastens the ends of the restraints to the side rails
d. Fasten the restraints with a half bow knot to an area the client cannot reach

22. A client is receiving internal radiation therapy for cancer of the cervix. Which of the following statements by the client indicates to the nurse that the patient understands precautions necessary during her treatment?

a. “I should get out of bed and walk around in my room at least every other hour.”
b. “My seven-year-old twins should not come to visit me while I’m receiving treatment.”
c. “I will try not to cough, because the force might make me expel the applicator.”
d. “I know that my primary nurse has to wear one of those badges like the people in the X-ray department wears, but they aren’t necessary for anyone else who comes in here.”

23. When conducting a class for unlicensed assistive personnel (UAPs), the nurse teaches them that the most important infection control measure that they can use is:

a. Universal precautions
b. Wearing gloves
c. Avoiding unkempt client
d. Handwashing

24. A nurse is managing the care of an AIDS client with generalized weakness and severe vision loss due to CMV retinitis. Which of the following interventions is the most important for the nurse to perform?

a. Place a “visually impaired “sign over the head of the bed
b. Refer the client to support groups for the visually impaired
c. Instruct the client to call for assistance before getting out of bed and place the call bell within reach
d. Encourage the client to verbalize feelings related to the vision loss

25. An end-stage AIDS client requires suctioning PRN. When performing this task, the nurse must utilize which of the following protective barriers in order to exercise appropriate universal precaution?

a. A mask and eye protection
b. Sterile gloves and eye protection
c. A mask and sterile gloves
d. A mask, eye protection and sterile gloves

26. A client is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). The nurse would initiate which isolation precautions?

a. Standard precautions are sufficient
b. Standard precautions and protective isolation
c. Standard precautions including gloves and mask when in direct contact with the client
d. Standard precautions including gloves and gown when in direct contact with the client

27. A 70-year-old woman with severe macular degeneration is admitted to the hospital the day before scheduled surgery. The nurse’s preoperative goals for the client would include:

a. Independently ambulating around the unit
b. Reading the routine preoperative education materials
c. Maneuvering safely after orientation to the room
d. Using a bedpan for elimination needs

28. The parents of a one-year-old are discussing the safety needs of their daughter with the nurse. Which statement indicates a need for further education on safety practices?

a. “We should fence our yard soon.”
b. “One of us will always be with her while she is in the bathtub.”
c. “We don’t need the stair gate anymore; she’s good at walking.”
d. “The safest position for her car seat is in the middle of the back seat.”

29. A client has an IV in the dorsal surface of the hand. The nurse suspects that there is an occlusion in the line. Which of the following is the best intervention?

a. Remove the IV immediately and restart it in another area
b. Elevate the hand, apply heat, and call the physician
c. Flush the line forcefully with normal saline and massage the IV site
d. Gently aspirate, then flush the line, only if there is no resistance

30. Which of the following nurse’s notes most clearly accurate why it was necessary to place a client in restraints?

a. Verbally abusive to other client’s, refuses to discuss behavior
b. Frequently at the nurse’s station, demanding to know rights as a client
c. Informed client of inappropriate behavior, but does not listen to staff direction
d. Did not respond to verbal-redirection, continued to ban fist on the seclusion room wall

31. Which of the following is necessary for nurses to protect themselves from HIV?

a. Universal precaution
b. Handwashing
c. Enteric precautions
d. Respiratory precautions

32. The nurse counsels a mother of an 8-month-old child to make sure the floors are free of small objects when her child is crawling on the floor. The major rationale for this instruction is that:

a. An 8-month-old can easily pick up small objects
b. Sharp can injure the fragile skin of an 8-month-old
c. It is a health hazard for babies to pick things up off the floor
d. The infant could hide small objects, making them difficult to locate

33. Which of the following is usually the initial clinical manifestation of gonorrhea in men?

a. Impotence
b. Scrotal pain
c. Penile lesion
d. Urethral discharge

34. The nurse observes a student nurse entering a patient’s room wearing a gown, gloves, mask, and goggles. The nurse knows that the student is caring for a patient with a diagnosis of:

a. Lyme disease
b. Methicillin-resistant Staphylococcus Aureus (MRSA) abdominal wound
c. Meningococcal meningitis
d. Pneumocystis carinii pneumonia (PCP)

35. A 45-year-old patient with leucopenia is in protective isolation. The nurse should intervene, if which of the following was observed?

a. The patient’s wife enters the patient’s room wearing a mask, gown and gloves
b. The patient’s food is delivered to the patient’s room on china with nondisposable eating utensils
c. A basket of fresh fruit is delivered to the patient’s room
d. A large card signed by the patient’s room

36. A registered nurse accompanies a new graduate nurse to insert a Foley catheter in a woman who is confused. During the insertion procedure, the new graduate nurse breaks sterile technique. The registered nurse should:

a. Stop the procedure and report the incident to the nursing supervisor
b. Allow the new graduate to complete the procedure and discuss it later
c. Obtain a new catheter insertion and demonstrate the procedure
d. Take the new graduate nurse aside and discuss what was observed

37. The nurse is assigned to care for a patient diagnosed with hepatitis A. the patient complains of pruritus. It would be most important for the nurse to:

a. Apply calamine lotion to affected areas
b. Keep fingernails manicured smoothly to minimize skin excoriation
c. Apply warms packs three times a day
d. Eliminate foods in high potassium from the diet

38. To assure a safe hospital environment for a 2-year-old girl, the nurse should:

a. Place her in a youth bed
b. Move stacking toys out of her reach
c. Pad the crib rails
d. Move equipment out of her reach

39. During the induction stage for treatment of leukemia, which of the following items brought by the family should the nurse remove from the room?

a. A bible
b. A picture
c. A sachet of lavender
d. A hairbrush

40. What is the most effective measure the nurse can employ to prevent wound infection when changing a client’s dressing after coronary artery bypass surgery?

a. Observe careful handwashing procedures
b. Cleanse the incisional area with antiseptic
c. Use pre-packaged sterile dressings to cover the incision
d. Place soiled dressings in a waterproof bag before disposing them

41. The nurse formulates a teaching plan for the client with aplastic anemia. Which of the following is the most significant concept to teach for health maintenance?

a. Eat animal protein and dark green leafy vegetables every day
b. Avoid exposure to others with acute infections
c. Practice yoga and meditation to decrease stress and anxiety
d. Get 8 hours of sleep at night and take naps during the day

42. What factors besides the degree of neutropenia does the nurse assess in determining the client’s risk for infection?

a. Length of time neutropenia has existed
b. Health status before neutropenia
c. Body build and weight
d. Resistance to infection in childhood

43. The nurse is instructing the unlicensed assistant how to correctly position a client who has had a recent total hip replacement. In which position should the nurse tell the assistant to place the operated leg when the client is lying on the non-operative site?

a. Abduction and flexion
b. Abduction and extension
c. Adduction and flexion
d. Adduction and extension

44. The nurse is instructing the unlicensed assistant in how to care for a client who is receiving chemotherapy. What self-care precautions should the nurse tell the assistant to take when caring for the client?

a. The assistant must have the nurse handle the disposal of any client excreta
b. Universal body precautions are sufficient for protecting the assistant
c. Gowns, mask, and gloves required for any contact with the client
d. Wear surgical gloves when handling the client’s excreta. e. Place contaminated linen in approved container; linen must be washed separately. f. The assistant is told she must not handle such cases if she is pregnant or lactating.

45. A client who overdosed on barbiturates is being transferred to the in-patient psychiatric unit from the intensive care unit. The nurse receiving the client would anticipate which of the following as a priority?

a. Nutrition
b. Sleep
c. Safety
d. Hygiene

46. When assessing an aggressive client, which of the following client behaviors would warrant the nurse’s most prompt reporting and use of the safety precautions?

a. Crying when talking about his divorce
b. Starting a petition to delay bedtime
c. Declining attendance at a daily group therapy session
d. Naming another client as his adversary

47. As a result of the effects of managed care, hospitalization is often reserved for emergency care. Which of the following situations would the nurse recognize as having the least priority for admission?

a. Potential for self-harm
b. Potential for harm to others
c. Grave disability (unable to care for self care)
d. Decline in functioning at work

48. The nurse is unfamiliar with a new piece of OR equipment that is scheduled to be used today. What is the best course of action?

a. Ask another nurse for instructions on how to use it
b. Wait until she has attended a class on using the equipment before using it
c. Get another nurse who is familiar with the equipment to operate it
d. Read the instructions provided with the equipment

49. As nurse in a skilled nursing facility/nursing home, you are supervising several CNAs. Which of the following actions of the CNA are correct with regards to the use of restraints?

a. Places all clients in bed with the side rails up.
b. Applies a jacket restraint for a client who is extremely agitated and is combative.
c. Applies a jacket restraint for the client who pulls out IV lines.
d. Fastens the restraints on the frame of the bed.
e. Fastens the ends of the restraints to the side rails
f. Fasten the restraints with a half bow knot to an area the client cannot reach

50. A client is receiving internal radiation therapy for cancer of the cervix. Which of the following statements by the client indicates to the nurse that the patient understands precautions necessary during her treatment?

a. “I should get out of bed and walk around in my room at least every other hour.”
b. “My seven-year-old twins should not come to visit me while I’m receiving treatment.”
c. “I will try not to cough, because the force might make me expel the applicator.”
d. “I know that my primary nurse has to wear one of those badges like the people in the X-ray department wears, but they aren’t necessary for anyone else who comes in here.”

51. When conducting a class for unlicensed assistive personnel (UAPs), the nurse teaches them that the most important infection control measure that they can use is:

52. A nurse is managing the care of an AIDS client with generalized weakness and severe vision loss due to CMV retinitis. Which of the following interventions is the most important for the nurse to perform?

a. Place a “visually impaired “sign over the head of the bed
b. Refer the client to support groups for the visually impaired
c. Instruct the client to call for assistance before getting out of bed and place the call bell within reach
d. Encourage the client to verbalize feelings related to the vision loss

53. An end-stage AIDS client requires suctioning PRN. When performing this task, the nurse must utilize which of the following protective barriers in order to exercise appropriate universal precaution?

a. A mask
b. An eye protection
c. A sterile gloves
d. A clean gloves
e. A gown
f. A cap

54. A client is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). The nurse would initiate what type of isolation precaution?

55. A 70-year-old woman with severe macular degeneration is admitted to the hospital the day before scheduled surgery. The nurse’s preoperative goals for the client would include:

a. Independently ambulating around the unit
b. Reading the routine preoperative education materials
c. Maneuvering safely after orientation to the room
d. Using a bedpan for elimination needs

56. The parents of a one-year-old are discussing the safety needs of their daughter with the nurse. Which statement indicates a need for further education on safety practices?

a. “We should fence our yard soon.”
b. “One of us will always be with her while she is in the bathtub.”
c. “We don’t need the stair gate anymore; she’s good at walking.”
d. “The safest position for her car seat is in the middle of the back seat.”

57. The physician schedules a paracentesis for a client with ascites. Immediately before the paracentesis, the nurse should:

a. Instruct the client to void
b. Position the client on the side
c. Measure the client’s abdominal girth
d. Have the client drink a glass of water

58. The nurse is caring for a cardiac client who is taking digoxin (Lanoxin), docusate sodium (Colace), furosemide (Lasix), and isosorbide dinitrate (Isordil). Which of the following side effects can be caused by a potential drug interaction?

a. Hypokalemia
b. Constipation
c. Headache
d. Hypotension

59. The nurse knows that client receiving total parenteral nutrition will have the IV tubing changed:

a. Every 24 hours
b. Every 48 hours
c. Every 72 hours
d. Every time a new bag/ bottle is hung

60. Clients with tuberculosis may come out of isolation after:

a. Sputum is negative for acid-fast bacilli
b. 3-5 days passed
c. Cough has reduced significantly
d. Fever is reduced





ANSWERS AND RATIONALE

1) C
- the facts that the client is legally blind and has difficulty ambulating place him at risk for injury.

2) B
- the organisms that cause meningitis are transmitted by the spread of droplets. To protect the nursing staff and the family, a child with the probable diagnosis of meningitis is placed in a private room in respiratory isolation until appropriate IV antibiotics have been administered for 24 hours.

3) D
- clients who are diagnosed with Parkinson’s disease are unsteady in their gait and their posture has changed their center of gravity; therefore, this increases the likelihood of falls

4) C
- severe metabolic acidosis. Is a complication of salicylate/aspirin overdose, which is a contributing factor to the development of pulmonary edema. More commonly, an increase in bleeding coagulation time, rather than a thrombus formation, result with salicylate ingestion.

5) A
- a client who has an allergy to penicillin may have a cross-sensitivity to cefazolin (Ancef), a first generation cephalosporin, and the drug should be given with caution. The nurse should ask the client whether he has taken cefazolin before. The nurse should inform the pharmacy of the client’s allergy after asking the client about prior use of cefazolin. The medication should not be administered until the nurse first requires about the client’s exposure to cefazolin and then consults with the pharmacist or physician. Observing the client for urticaria is appropriate but is not initial response.

6) D
- safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the physician to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as ordered by the physician to ensure optimal healing.

7) B
- the client can aspirate if fluids or food are given before the gag reflex returns. Pain medication is not a priority. Positioning the client on the right side is not a priority. Rectal bleeding would not be a concern following an endoscopy, but it would be after a colonoscopy.

8) A
- all of the choices should be a part of the assessment. However, knowing that the client seldom sleeps between 3 am and 6 pm is critical for planning for the client’s safety. It is important to know whether the client wanders at night.

9) D
- swallowing helps advance the tube by causing the epiglottis to cover the opening of the trachea, thus helping to eliminate gagging and coughing. Removing the tube is unnecessary as gagging is an expected response to this procedure. Deep breathing opens the trachea, allowing the tube to possibly advance into the lungs.

10) D
- wearing clean gloves, cleaning the port with alcohol, and then obtaining the specimen with a sterile needle ensures the specimen and the closed urinary drainage system won’t be contaminated. A urine sample must be new urine and the urine in the bag could be several hours’ old and growing bacteria. The urinary drainage system must be kept closed to prevent microorganisms from entering. A straight catheter is used to relieve urinary retention, obtain a sterile urine specimen, measure the amount of post void residual urine. It isn’t necessary to remove an indwelling catheter to obtain a sterile urine specimen unless the physician requests the whole system be changed.

11) B
- asepsis is the process of avoiding contamination from the outside sources by keeping the environment clean. A clean environment has a reduced number of microorganisms, but isn’t necessarily sterile (the absence of all microorganisms). Testing for microorganisms or culturing isn’t indicated in the promotion of asepsis.

12) D
- This child is most likely to be infectious, as sepsis and pneumonia are common sequelae of severe burns.

13) D
- The first action by the nurse should be to call for immediate assistance in the client’s room, because this is an emergency. Throughout the seizure, the nurse should note the time and length of the seizure and continue to monitor the status of both the client and fetus. The side rails should have been padded at the time of the client’s admission to the hospital as part of seizure precautions. The client should be turned to her left side to improve placental perfusion. Inserting a tongue blade is not recommended because it can further obstruct the airway or cause injury to the client’s teeth.

14) B
- Clients sometimes feel faint or dizzy when taking a shower for the first time after delivery because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes a shower after delivery. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in shower the nurse should cover the client to protect her privacy, stay with the client and call for assistance.

15) B
- after total hip replacement surgery, the leg should be maintained in a position of abduction and extension. A foam abduction pillow is usually placed between the legs to maintain this position. Placing the leg in an adducted and/or flexed position can lead to a dislocation of the prosthesis.

16) D
- when handling any of the client’s excreta during the administration of chemotherapy, health personnel should wear surgical gloves to prevent exposure to any chemotherapeutic toxin contained in the excreta. It is not necessary for the nurse to handle the disposal of any body fluids; assistive personnel must know how to protect themselves from potential exposure. Universal body precautions are always used, but it is important that surgical gloves be used for adequate protection. It is not necessary to wear gown, mask and gloves for every client.

17) C
- client safety is the priority to prevent further self-harm. Nutrition, sleep and hygiene are important concerns, but they are secondary to safety.

18) D
- the client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition delay bedtime would be a positive, declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.

19) D
- although a decline in functioning is important, this situation would have the least priority when compared with other situations that put the client or others in danger of direct or indirect harm.

20) C
- only those with knowledge of the equipment should operate it. It is important to learn how to operate the equipment, but it is essential to have someone knowledgeable operate it today. Although reading the instruction is important, hands-on practice before using it for the first time is better.

21) D
- the half bow knot is a secure knot that will not loosen, but can be easily released by the nurse in an emergency. Not all clients need the side rails up. Many falls are associated with clients climbing over the side rails while trying to get out of bed. It is best to use a restraint that restricts as little as possible. It would be better to use mitt restraints for a client with a tendency to pull out IV lines rather than a chest restraint that prevents falling or walking. The ends of the restraints should be fastened to the bed frame, which is more stable than the side rails.

22) B
- visitors younger than 18 years of age, and pregnant visitors, are not allowed during internal radiation therapy. The patient will be on strict bed rest, although she may move from side to side and the head of the bed may be elevated 45 degrees. Because of her relative immobility; this may patient will require back care; she should be encouraged to cough and deep breathe to promote adequate gas exchange and keep respiratory secretions mobile. The likelihood of dislodging the applicator is very small. All members of health care team who are involved with the patient’s care should have film badges or pocket ion chambers to monitor their exposure to the radiation source.

23) D
- frequent handwashing has been demonstrated to be the single most effective method of infection control.

24) C
- ensuring client safety is of the utmost importance. The client should be instructed to utilize the call bell before getting out of bed, and the nurse should place it, and a urinal or bedpan, within the client’s reach.

25) D
- protective barrier precautions must be utilized whenever there is contact with the blood or body fluids of any client. When suctioning a client, in addition to sterile gloves, a mask and eye protection must be worn to protect the mucous membranes of the eyes, nose and mouth.

26) D
- contact precautions need to be included with direct person-to-person contact for infection.

27) C
- maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely.

28) C
- most children at 12-months of age are not proficient walkers. They may know how to climb up stairs but not how to come down the stairs. Their sense of balance is not stable. They have no judgment.

29) D
- if an occlusion is suspected, the nurse should attempt to gently aspirate, and then flush the line only if there is no resistance. If there is resistance, the IV should be removed and a new one should be inserted in another site.

30) D
- the only indication for utilizing restraints is to prevent a client from injuring him or herself or others.

31) A
- universal precaution is a requirement to protect both patients and nurse. Other options will not stop the spread of HIV.

32) A
- 8-month-old infants have the ability to use their fingers and thumbs in opposition (pincer grasp); this enable them to pick up small objects and put them in their mouths and aspirate them.

33) D
- urethritis is usually the initial clinical manifestation of gonorrhea in men. The symptoms include a profuse, purulent discharge and dysuria. Complications are uncommon, but they include prostatitis and sterility. Impotence, scrotal pain and penile lesions are not associated with gonorrhea.

34) C
- the transmission of meningococcal meningitis is by direct contact and droplets; symptoms include headache, fever, nuchal rigidity and is treated with antibiotics; droplet precaution must be observed

35) C
- fresh fruits or flowers should not be allowed in the room with a patient with leukopenia because it is a possible source of infection.

36) C
- best for the patient and helpful to the graduate nurse; procedure needs to be performed using strict aseptic technique. Demonstration is better than discussion, would not meet patient needs.

37) A
- calamine lotion will make the patient more comfortable and alleviate itching; calamine lotion is astringent and protectant. Applying warm packs will make skin very dry and increase discomfort.

38) D
- this is an exploratory stage; child may injure himself by reaching for equipment and playing with it. Equipment may have special appeal because adults use it and imitation is a distinguishing characteristic of play at the toddler age.

39) C
- The induction phase of chemotherapy is aggressive treatment to kill leukemia cells. The client is severely immunocompromised and severely at risk for infection. Flowers, herbs and plants should be avoided during this time. The client’s Bible, pictures and other personal belongings can be cleaned before being brought into the room to prevent contact with pathogenic and nonpathogenic organisms.

40) C
- Many factors helps prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipments, cleansing the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash hands before and after changing dressings. Careful handwashing is also important in helping reduce other infections often acquired in hospitals, such as urinary tract and respiratory systems infections.

41) B
- Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict asepsis technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. 8 hours of rest and naps are good for spacing and pacing activity and rest.

42) A
- The one factor that may be more important than the degree of neutropenia in determining the risk for infection is the duration of the neutropenia

43) B
- after total hip replacement surgery, the leg should be maintained in a position of abduction and extension. A foam abduction pillow is usually placed between the legs to maintain this position. Placing the leg in an adducted and/or flexed position can lead to a dislocation of the prosthesis.

44) D, E, F
- when handling any of the client’s excreta during the administration of chemotherapy, health personnel should wear surgical gloves to prevent exposure to any chemotherapeutic toxin contained in the excreta. It is not necessary for the nurse to handle the disposal of any body fluids; assistive personnel must know how to protect themselves from potential exposure. Universal body precautions are always used, but it is important that surgical gloves be used for adequate protection. It is not necessary to wear gown, mask and gloves for every client. Option e and f are true statements and that pregnant and lactating women should not have any contact with chemotherapeutic agents since it is teratogenic.

45) C
- client safety is the priority to prevent further self-harm. Nutrition, sleep and hygiene are important concerns, but they are secondary to safety.

46) D
- the client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition delay bedtime would be a positive, declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.

47) D
- although a decline in functioning is important, this situation would have the least priority when compared with other situations that put the client or others in danger of direct or indirect harm.

48) C
- only those with knowledge of the equipment should operate it. It is important to learn how to operate the equipment, but it is essential to have someone knowledgeable operate it today. Although reading the instruction is important, hands-on practice before using it for the first time is better.

49) B, C, D, F
- the half bow knot is a secure knot that will not loosen, but can be easily released by the nurse in an emergency. Not all clients need the side rails up. Many falls are associated with clients climbing over the side rails while trying to get out of bed. It is best to use a restraint that restricts as little as possible. It would be better to use mitt restraints for a client with a tendency to pull out IV lines rather than a chest restraint that prevents falling or walking. The ends of the restraints should be fastened to the bed frame, which is more stable than the side rails.

50) B
- visitors younger than 18 years of age, and pregnant visitors, are not allowed during internal radiation therapy. The patient will be on strict bed rest, although she may move from side to side and the head of the bed may be elevated 45 degrees. Because of her relative immobility; this may patient will require back care; she should be encouraged to cough and deep breathe to promote adequate gas exchange and keep respiratory secretions mobile. The likelihood of dislodging the applicator is very small. All members of health care team who are involved with the patient’s care should have film badges or pocket ion chambers to monitor their exposure to the radiation source.

51) Proper hand washing
- Frequent handwashing has been demonstrated to be the single most effective method of infection control.

52) C
- ensuring client safety is of the utmost importance. The client should be instructed to utilize the call bell before getting out of bed, and the nurse should place it, and a urinal or bedpan, within the client’s reach.

53) A, B, C
- protective barrier precautions must be utilized whenever there is contact with the blood or body fluids of any client. When suctioning a client, in addition to sterile gloves, a mask and eye protection must be worn to protect the mucous membranes of the eyes, nose and mouth.

54) Contact isolation precaution
- Contact precautions need to be included with direct person-to-person contact for infection.

55) C
- maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely.

56) C
- most children at 12-months of age are not proficient walkers. They may know how to climb up stairs but not how to come down the stairs. Their sense of balance is not stable. They have no judgment.

57) A
- the bladder should be empty to avoid injury during insertion of the abdominal trocar.

58) A
- hypokalemia is a common interaction that occurs between digoxin and furosemide. The nurse must be careful to monitor for hypokalemia when this combination is prescribed. Hypotension is not sequelae of any interaction but may occur in the presence of cardiac disease, or as a side effect of many cardiac medications.

59) A
- the Communicable Disease Center (CDC) recommends that TPN tubing be changed every 24 hours. Regular tubings are changed every 48-72 hours. Changing the tubing every time a new bag/bottle is hung is neither necessary nor cost-effective.

60) A
- the client can come out of isolation when the sputum is clear of the organism

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