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Safety and Infection Control NCLEX Part #1 (25 Questions)
The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:
- A. Is highly sensitive to criticism
- B. Rebels against scheduled activities
- C. Still depends on the parents
- D. Loves to tattle
Correct Answer: A. Is highly sensitive to criticism
Anticipatory guidance is provided by a health care professional to a parent/caregiver in providing an understanding of a child’s development and anticipating their growing needs. In a 6-year-old child, a precarious sense of self causes an overreaction to criticism and a sense of inferiority. Parents can help kids develop a sense of realistic competence by avoiding excessive praise and rewards, encouraging efforts rather than outcomes, and helping kids develop a growth mindset.
- Option B: By age 6, most children love the routine of a schedule. The more children participate in the process, the better they understand and follow the rules. This sense of ownership in the process is key to children this age who are transitioning from accepting outside authority to challenging it.
- Option C: By age 6, most children no longer depend on their parents for daily tasks. During the industry versus inferiority stage, children become capable of performing increasingly complex tasks. As a result, they strive to master new skills. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills.
- Option D: Tattling is more common at ages 4 to 5. By age 6, the child wants to make friends and be a friend. Friends and classmates play a role in how children progress through the industry versus inferiority stage. Through proficiency at play and schoolwork, children are able to develop a sense of competence and pride in their abilities.
While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session?
- A. Safety guidelines
- B. Preparation for surgery
- C. Toilet Training
- D. Nursery schools
Correct Answer: A. Safety guidelines
The nurse always should reinforce safety guidelines when teaching parents how to care for their children. By giving anticipatory guidance the nurse can help prevent any accidental injuries. When possible, an age-appropriate diet and fluids should be continued. Oral rehydration therapy using a commercial pediatric oral rehydration solution is the preferred approach to mild or moderate dehydration.
- Option B: Because surgery is not a treatment for gastroenteritis, this topic is inappropriate. The management of acute gastroenteritis is directed at preventing or treating the dehydration that so often accompanies this disease.
- Option C: Toilet training is too early for an 8-month old infant. Most children begin to show signs of readiness for toilet training when they’re between 18 and 24 months old, though some may not be ready until later than that. And boys often start later and take longer to learn to use the potty than girls.
- Option D: For parents of an 8-month-old infant, it is too early to discuss nursery schools. Most preschools start accepting kids around the age of 2.5 to 3 years old, but since every child is different, this isn’t a magic number. Preschool readiness really depends more on developmental factors than chronological age.
Nurse Betina should begin screening for lead poisoning when a child reaches which age?
- A. 3 months
- B. 12 months
- C. 24 months
- D. 30 months
Correct Answer: B. 12 months
The nurse should start screening a child for lead poisoning at age 12 months and perform repeat screening at age 24, 30, and 36 months. The Advisory Committee on Childhood Lead Poisoning Prevention recommends that all children enrolled in Medicaid be screened for elevated blood lead levels at 12 and 24 months of age or at 36 to 72 months of age if they have not previously been screened.
- Option A: High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron-deficiency anemia at 6 months. Early use and overuse of cow’s milk exacerbates existing causes of iron deficiency in infants. Less often, the problem is due to a severe blood loss or something interfering with the body’s ability to absorb iron, such as a medication the infant is taking or a chronic illness involving the stomach or intestines.
- Option C: The American Academy of Pediatrics (AAP) recommends that a risk assessment be performed for lead exposure at well-child visits at 6 months, 9 months, 12 months, 18 months, 24 months, and at 3, 4, 5, and 6 years of age. A blood lead level test should be done only if the risk assessment comes back positive.
- Option D: The American Academy of Pediatrics (AAP), as part of an expert committee representing several national healthcare organizations, makes the following recommendation: routine obesity screening of children aged 2 years old or older should include a yearly assessment of weight. BMI changes should be monitored by calculating and plotting BMI on the Centers for Disease Control and Prevention (CDC) growth charts at every healthcare visit.
When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?
- A. Tachypnea
- B. Shallow respirations
- C. A reduced white blood cell count
- D. A decreased platelet count
Correct Answer: A. Tachypnea
The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations. As the body attempts to compensate for worsening acidosis, the respiratory rate increases to reduce the pCO2 and maintain a compensated physiological pH.
- Option B: Initially, the breathing is rapid, but as it worsens, it gradually becomes deep and labored. Extra ketones in the body cause acid to build up in the blood. Because of this, the respiratory system is triggered to start breathing faster. Faster breathing helps expel more carbon dioxide, which is an acidic compound in the blood.
- Option C: An elevation of the white blood cell (WBC) count is a nonspecific finding, but it should prompt consideration of septicemia, which causes lactic acidosis. Severe anemia with compromised oxygen delivery may cause lactic acidosis.
- Option D: Altered platelet counts are not specific signs of metabolic imbalance. Acidosis compromises the clotting process and accelerates fibrinogen consumption with no effect on fibrinogen production, resulting in a deficit in fibrinogen availability.
After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching?
- A. “We’ll follow these instructions until our child has completely grown and developed.”
- B. “Well follow these instructions until our child’s symptoms disappear.”
- C. “Our child must maintain these dietary restrictions until adulthood.”
- D. “Our child must maintain these dietary restrictions lifelong.”
Correct Answer: D. “Our child must maintain these dietary restrictions lifelong.”
Celiac disease is an autoimmune reaction to a protein called gluten. A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical manifestations of the disease. A gluten-free diet should be followed by avoiding barley, rye, wheat, oats, and triticale. Once the diagnosis of celiac disease is made, patients need regular follow up to ensure that they are compliant with a gluten-free diet and not developing any complications.
- Option A: It is recommended that all people diagnosed with celiac disease follow a strict gluten-free diet. This adherence is best done under the supervision of specialists, including a dietician. In general, symptoms improve on the gluten-free diet within days to weeks. Non-compliance can be unintentional in an individual who may be still ingesting gluten without realizing it.
- Option B: Currently, the only recommended treatment for celiac disease is the gluten-free diet. This makes a significant impact on the lives of people affected and can be challenging to maintain. There is continuous work on possible non-dietary therapies that enable people with celiac disease to tolerate gluten. One of the main focuses of the research in this area is immune modulators.
- Option C: The prognosis for patients with the correct diagnosis and treatment is good. Unfortunately, compliance with a gluten-free diet is very difficult and relapses are common. Some patients do not respond to a gluten-free diet or corticosteroids; they have a poor quality of life.
A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expect to find?
- A. Open anterior fontanel and closed posterior fontanel
- B. Closed anterior and posterior fontanels
- C. Closed anterior fontanel and open posterior fontanel
- D. Open anterior and posterior fontanels
Correct Answer: B. Closed anterior and posterior fontanels
By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months. Fontanelles, often referred to as “soft spots,” are one of the most prominent anatomical features of the newborn‘s skull. Fontanelle morphology may vary between infants, but characteristically they are flat and firm.
- Option A: The most common conditions associated with a large anterior fontanelle or a delay in its closure are as listed: Down syndrome, achondroplasia, congenital hypothyroidism, rickets, and elevated intracranial pressures. Infants of African descent statically have larger fontanelles that range from 1.4 to 4.7 cm, and in terms of sex, the fontanelles of male infants will close sooner compared to female infants.
- Option C: Often, the delayed closure of the posterior fontanelle is associated with hydrocephalus or congenital hypothyroidism. Unlike the anterior fontanelle, the posterior fontanelle is triangular and completely closes within about six to eight weeks after birth. On average, the posterior fontanelle is 0.5 cm in Caucasian infants and 0.7 cm in infants of African descent.
- Option D: An elevated thyroid-stimulating hormone level on a newborn screening usually detects congenital hypothyroidism, but an abnormally large anterior fontanel in conjunction with an open posterior fontanel can be an early sign of the disorder. Myxedema and growth deficiency are later signs.
Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:
Correct Answer: C. Cerebral edema
Due to the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Hyponatremic solutions (e.g. 4% dextrose and one-fifth normal saline), which deliver excess free water, may worsen hyponatremia and increase the risk of cerebral edema, and have no place in the management of meningitis.
- Option A: Fluid overload won’t cause dehydration. Children with meningitis require careful and regular monitoring of clinical signs of hydration state, including signs of overhydration, serum sodium, and laboratory markers of hypovolemia. Under most circumstances, any intravenous fluids given to a child with meningitis should be isonatremic e.g. Plasma-Lyte 148 or 0.9% sodium chloride (normal saline) with additional glucose.
- Option B: Hypovolemic shock would occur with an extreme loss of fluid of blood. Clinical signs of shock or hypovolemia are hypotension, poor peripheral perfusion, cool pale extremities, tachycardia with low volume pulses, high blood lactate or large base deficit. Children with more than one of these signs should be given 10-20ml per kg of normal saline as a bolus.
- Option D: It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Bacterial meningitis can cause overhydration by preventing the body from eliminating fluids the way it should. This can lead to hyponatremia, an electrolyte disturbance in which the sodium concentration in the blood plasma is lower than normal.
An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant?
- A. Encouraging the infant to hold a bottle
- B. Keeping the infant on bed rest to conserve energy
- C. Rotating caregivers to provide more stimulation
- D. Maintaining a consistent, structured environment
Correct Answer: D. Maintaining a consistent, structured environment
Nonorganic failure to thrive refers to decelerated or arrested physical growth and is related with poor developmental and emotional functioning. The nurse caring for an infant with this condition should maintain a consistent, structured environment that provides interaction with the infant to promote growth and development.
- Option A: Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. Feed the child slowly and carefully in a quiet environment; during feeding, the child might be closely snuggled and gently rocked; it may be necessary to feed the child every 2 to 3 hours initially.
- Option B: The infant should receive social stimulation rather than be confined to bed rest. Attempt to cuddle the child and talk to him or her in a warm, soothing tone and allow for play activities appropriate for the child’s age.
- Option C: The number of caregivers should be minimized to promote consistency of care. While caring for the child, point out to the caregiver the child’s development and responsiveness, noting and praising any positive parenting behaviors the caregiver displays.
The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:
- A. Bananas
- B. Color dyes
- C. Kiwifruit
- D. Latex
Correct Answer: D. Latex
Although the exact cause of latex allergy in people with spina bifida is unknown, it is said that continuous exposure to products containing rubber from diagnostic exams, multiple surgeries and bladder and bowl programs may contribute to it. Until better scientific explanations are available to specifically drive prevention and intervention, people with Spina Bifida should continue to avoid skin contact with latex protein in the environment including foods with similar proteins, and avoid inhalation of powder that contains latex.
- Option A: Children, Families, and adults should be aware that caution should be taken regarding what has come to be labeled “latex fruit syndrome.” The protein allergen (example, Hev b 6 hevein) in some latex products makes up a considerable amount of the total protein. This has been shown to have significant cross-reactivity to certain proteins (chitinases) in bananas, avocados, and chestnuts, for example.
- Option B: Some children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy. Hair coloring products contain many ingredients that can irritate the skin and cause allergic reactions. Most cases of allergic contact dermatitis stemming from exposure to hair dye are caused by an ingredient called paraphenylenediamine (PPD).
- Option C: If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s likely to be allergic to latex because these food items can trigger an allergic reaction. There are at least 25 other fruits that may have some level of cross-reactivity with latex. For example, potatoes, eggplant, and kiwi have been described as potential concerns.
Cristina, a mother of a 4-year-old child, tells the nurse that her child is a very poor eater. What’s the nurse’s best recommendation for helping the mother increase her child’s nutritional intake?
- A. Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon character
- B. Allow the child to feed herself
- C. Only serve the child’s favorite foods
- D. Allow the child to eat at a small table and chair by herself
Correct Answer: B. Allow the child to feed herself
The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Developmental milestones play a role in a less-than-ravenous appetite. When babies begin walking or running, for example, they often prefer playing and moving around to sitting down and eating. Kids around 2 or 3 years of age also eschew meal time as a way to assert their independence.
- Option A: Special dishes would enhance the primary recommendation. Get creative with the presentation. Make food fun with creative shapes and colours or even fancy little plates and cutlery.
- Option C: The child should be offered new foods and choices, not just served her favorite foods. Keep offering foods they don’t “like.” Kids are often reticent to eat new foods, so offering it regularly helps it become more familiar.
- Option D: Using a small table and chair would also enhance the primary recommendation. If the child knows how to eat with a spoon, don’t get tempted to feed him if he isn’t eating. It may come across as force-feeding and will further lead to a slump in his appetite.
Nurse Roy is administering total parenteral nutrition (TPN) through a peripheral I.V. line to a school-age child. What is the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?
- A. 5% glucose
- B. 10% glucose
- C. 15% glucose
- D. 17% glucose
Correct Answer: B. 10% glucose
The amount of glucose that’s considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. A dextrose solution of 10% is used initially; if it is tolerated and central access is present, a more concentrated dextrose solution of up to 30 to 35% can be used if needed.
- Option A: Five percent glucose isn’t sufficient nutritional replacement, although it’s safe for peripheral veins. Most patients receive dextrose concentrations of less than 20%. Once the fat and protein calories have been calculated, the balance of calories is provided as intravenous carbohydrate.
- Option C: 15% of glucose through the peripheral veins may put the veins at risk for extravasation. Parenteral nutrition solutions are typically given via central venous catheters due to their high osmolarity and risks with extravasation if delivered peripherally. However, central venous lines are not without risk and consequently infants requiring them are cared for in intensive care settings.
- Option D: Any amount above 10% must be administered via central venous access. Hypertonic dextrose solutions (above approximately 600 mOsmol/liter) may cause thrombosis if infused via a peripheral vein. It is, therefore, advisable to administer such solutions via an intravenous catheter placed in a large central vein, preferably the superior vena cava.
- A. Increased heart rate
- B. Decreased urine output
- C. Increased interest in play
- D. Decreased appetite
Correct Answer: C. Increased interest in play
One of the most valuable clues to pain is a behavior change. A toddler who is pain-free likes to play. In toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the main indicator for assessments in this age group. Nonverbal behaviors, such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective measures of pain than self-reports.
- Option A: An increased heart rate may indicate increased pain. Uncontrolled pain may elevate blood pressure, pulse rate, adrenaline and cortisol serum levels by simultaneously stimulating the sympathetic-autonomic nervous system and release of adrenal hormones.
- Option B: Decreased urine output may signify dehydration. The body’s initial responses to dehydration are thirst to increase water intake and decreased urine output to try to conserve water loss. The urine will become concentrated and more yellow in color. As the level of water loss increases, more symptoms can become apparent.
- Option D: A child in pain is less likely to consume food or fluids. Some behaviors are contrary to other proposed behaviors in a study, for example, reduction of activity or quiet versus jerking, arching back, or kicking. Others are very broad, for example, having disturbed sleep, eating less than usual, being irritable, and playing less than usual. While these behaviors may arouse suspicion concerning the presence of pain, they are nonspecific and associated with a wide diversity of non painful conditions.
When planning care for a 8-year-old boy with Down syndrome, the nurse should:
- A. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age
- B. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays
- C. Assess the child’s current developmental level and plan care accordingly
- D. Direct all teaching to the parents because the child can’t understand
Correct Answer: C. Assess the child’s current developmental level and plan care accordingly
Nursing care plans should be planned according to the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially a child with mild limitations.
- Option A: Current practices in providing care to those with Down syndrome include the primary emphasis on the treatment of disease with increased attention allocated to health promotion and protection. Children with Down syndrome have several expected developmental and physical challenges. These include poor physical growth and delayed development with achieving milestones such as gross and fine motor skills, speech, and secondary sex characteristics.
- Option B: With appropriate therapy, the developmental delay may be minimized, and the child’s social quotient may be improved. Such training can provide a foundation for mainstreaming the child with Down syndrome in schools and the community
- Option D: Early intervention programs can improve the academic prognosis for children with Down syndrome. Cognitive function varies tremendously and cannot be predicted at birth. No relationship has been shown between the number of Down syndrome features present in a newborn and later cognitive function.
Nurse Vincent is teaching the parents of a school-age child. Which teaching topic should take priority?
- A. Explaining normalcy of fears about body integrity
- B. Keeping a night light on to allay fears
- C. Prevent accidents
- D. Encouraging the child to dress without help
Correct Answer: C. Prevent accidents
Accidents are the major cause of death and disability during the school-age years. Therefore, accident prevention should take priority when teaching parents of school-age children. In 2016, there were 20,360 deaths among children and adolescents in the United States. More than 60% resulted from injury-related causes, which included 6 of the 10 leading causes of death.
- Option A: Preschool (not school-age) children have fears concerning body integrity. Help prepare children for situations they may find frightening. Read a story about going to the dentist, or ask a firefighter to visit the school and allow children to handle the equipment while you stand nearby for reassurance.
- Option B: Preschool (not school-age) children are afraid of the dark. At about 3 ½, children often develop a variety of insecurities and physical ways of showing them. Fear of the dark and nightmares are common and may last quite a while. There is so much going on in the world of a 3-year-old-so much mastery, so many things they’ve already become familiar with. At the same time, however, children this age may be disturbed by characteristics they find unfamiliar.
- Option D: Preschool (not school-age) children should be encouraged to dress without help (with the exception of tying shoes). Preschoolers revel in their newfound independence. Being able to make such choices is a natural part of growing up, and gives threes and fours an exciting sense of themselves as powerful people.
The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority?
- A. Restocking the bedside supplies needed for a dressing change on the upcoming shift
- B. Documenting the care provided during her shift
- C. Emptying the trash cans in the assigned client room
- D. Changing the linens on the clients’ beds
Correct Answer: B. Documenting the care provided during her shift
Documentation should take top priority. Documentation is the only way the nurse can legally claim that interventions were performed. An end-of-shift report allows nurses to understand where their patients stand in regard to recovery by providing a picture of a patient’s improvement or decline over the last several hours. By knowing what has previously occurred in a patient’s treatment plan, nurses can proceed with the right steps to contribute to positive outcomes. Pertinent patient information to support the multidisciplinary team to deliver great care.
- Option A: Wrapping up a nursing shift is similar to starting one. At the end of their workday, nurses often conduct their final patient rounds to check on any last-minute needs, conduct final med passes, and assist patients with their final meals if the shift ends around dinnertime.
- Option C: Emptying trash cans can be done by the nurse but it is not mandatory. The nurse may make sure a policy on waste management is familiar to all staff. This includes ensuring that contaminated waste is disposed of correctly. Colour coding of different types of waste is used widely and it is important not to mix up the waste that is dealt with in different ways.
- Option D: This option would be appreciated by the nurses on the oncoming shift but aren’t mandatory and doesn’t take priority over documentation. Soiled linen is infectious to the patient. If a patient is unable to move or leave the bed, the nurse will need to change the bedsheets while the patient is occupied in bed.
Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should:
- A. Perform only two-person CPR
- B. Deliver 12 breaths/minute
- C. Place two fingers on the sternum, press down about 1.5 inches deep
- D. Use the heel of one hand for sternal compressions
Correct Answer: D. Use the heel of one hand for sternal compressions
The nurse should use the heel of one hand at the center of the chest, then place the heel of the other hand on top of the first hand and lace fingers together and give 30 compressions that are about 2 inches deep. For a child, compress the chest at least one-third the depth of the chest. This may be less than two inches for small children but will be approximately two inches for larger children (4-5 cm).
- Option A: For a small child, two-person rescue may be inappropriate. If the child does not respond and is not breathing (or if only gasping), have the second rescuer call 911/EMS and get an AED.
- Option B: For children, the compression to breath ratio is 15:2 for all age groups. If you cannot feel a pulse (or if you are unsure), begin CPR by doing 15 compressions followed by two breaths. If you can feel a pulse but the pulse rate is less than 60 beats per minute, you should begin CPR. This rate is too slow for a child.
- Option C: The nurse uses 2 fingers to give 30 quick compressions that are each about 1.5 inches deep appropriate for infants. Place 2 fingers just below that line on the breastbone and push down hard on the breastbone 1½ inches toward the backbone. Let the chest come back to its normal position after each compression. Compressions are done fast at a rate of 100 per minute.
A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?
- A. Obtaining history information from the parents
- B. Administering acetaminophen (Tylenol)
- C. Instituting droplet precautions
- D. Orienting the parents to the pediatric unit
Correct Answer: C. Instituting droplet precautions
Instituting droplet precautions by providing a private room and wearing a mask, gloves, and gown for all those who will interact with the child is a priority for a newly admitted patient with meningococcal meningitis until an appropriate antibiotic regimen has been given for 24 hours. Based on experience with military recruits, the nasopharyngeal carrier state is the primary factor for the transmission and development of meningitis.
- Option A: Obtaining history information doesn’t take priority. The patient with suspected or confirmed N. meningitidis should follow droplet precaution. This should be continued until after 24 hours of effective antibiotics administration.
- Option B: Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Antibiotic dose should be given as soon as meningitis is suspected and should not be delayed awaiting confirmatory studies. Lumbar puncture is performed as soon as possible as parenteral antibiotic therapy clears out meningococci from CSF in less than six hours.
- Option D: Orienting the parents to the unit doesn’t take priority. Meningococcal meningitis is a medical emergency presenting with severe sepsis syndrome, fever, petechiae, and ecchymosis requiring prompt resuscitation and antibiotic administration.
Shane tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor for the nurse to stress to the mother is:
- A. Developmental level of the child’s peers
- B. Consistency in approach
- C. The mother’s positive attitude
- D. Developmental readiness of the child
Correct Answer: D. Developmental readiness of the child
There is no right age to toilet train a child. Readiness to begin toilet training depends on the individual child. If the child isn’t developmentally ready, the child and parent will become frustrated. Signs of potty training readiness include pulling at a wet or dirty diaper, awakening dry from a nap, hiding to go or going to an area to pee or poop, and having predictable bowel movements.
- Option A: Developmental levels of children are individualized and comparison to peers isn’t useful. In general, starting before age 2 (24 months) is not recommended. The readiness skills and physical development the child needs occur between age 18 months and 2.5 years.
- Option B: Consistency is important once toilet training has already started. Each child has his or her own style of behavior, which is called temperament. In planning your approach to toilet training, it is important to consider your child’s temperament.
- Option C: The mother’s positive attitude is important when the child is ready. The parents should try not to feel pressured to toilet train the child. If the parents are feeling pressured to train the child because of caregiver considerations or family members’ views, their anxiety about toilet training can create anxiety in the child.
An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure?
- A. The nurse-manager
- B. The registered nurse caring for the infant
- C. The social worker who placed the infant in the foster home
- D. The foster mother
Correct Answer: D. The foster mother
When children are minors and aren’t emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. Foster carers do not have parental responsibility but should have delegated authority/decision-making power for consent for most treatments.
- Option A: The nurse manager has no legal right to give consent in this scenario. Each situation is different but as a rule foster carers should be able to sign consents for routine medicals, eye and sight tests, and routine dental examinations.
- Option B: The nurse has no legal right to give consent in this scenario. Foster carers should be given delegated authority wherever possible to consent to immunizations and the placement plan should clarify who can give consent in a medical emergency.
- Option C: The social workers have no legal rights to give consent in this scenario. It is important that foster carers understand their responsibilities around health care, medical treatment, and consent so that they can support a child’s physical, mental, and emotional health.
A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to:
- A. Prevent uric acid from precipitating in the ureters
- B. Enhance the production of uric acid to ensure adequate excretion of urine
- C. Prevent metabolic breakdown of xanthine to uric acid
- D. Ensure that the chemotherapy doesn’t adversely affect the bone marrow
Correct Answer: C. Prevent metabolic breakdown of xanthine to uric acid
The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. These clients can have increased uric acid levels due to release of uric acid from the dying cancer cells.
- Option A: Allopurinol and oxypurinol both inhibit xanthine oxidase, an enzyme in the purine catabolism pathway that converts hypoxanthine to xanthine to uric acid. Allopurinol undergoes metabolism in the liver, where it transforms into its pharmacologically active metabolite, oxypurinol.
- Option B: Urate production is accelerated by purine rich diets, endogenous purine production, and high cell breakdown, and it is responsible for a minority of cases of hyperuricemia. Foods rich in purine include all meats but specifically organ meats (kidneys, liver, “sweet bread”), game meats and some seafood (anchovies, herring, scallops).
- Option D: Allopurinol doesn’t act in the manner described in this option. To prevent tumor lysis syndrome, allopurinol shall be initiated 2 to 3 days before starting chemotherapy and continued until 3 to 7 days after chemotherapy.
A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear?
- A. Gloves
- B. Gown and gloves
- C. Gown, gloves, and mask
- D. Gown, gloves, mask, and eye goggles or eye shield
Correct Answer: D. Gown, gloves, mask, and eye goggles or eye shield
The transmission of SARS isn’t fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a client with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.
- Option A: For level 1 or standard infection control precaution wherein there is no suspected or known infectious agent, disposable gloves and disposable apron may be used. If there is a danger or risk of spraying or splashing, eye and face protection should be considered.
- Option B: Level 2 or direct/indirect contact precautions require the use of a disposable gown (which is fluid-resistant) and disposable gloves. This is used when there is a suspected or confirmed infectious agent spread by direct or indirect contact.
- Option C: Level 2 droplet precautions occur when there is a suspected or confirmed infectious agent spread by droplet route/ Personal protective equipment should include a disposable gown which is fluid-resistant, disposable gloves, and fluid-resistant surgical face mask and goggles.
A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk adolescent. How long after the test is administered should the result be evaluated?
- A. Immediately
- B. Within 24 hours
- C. In 48 to 72 hours
- D. After 5 days
Correct Answer: C. In 48 to 72 hours
Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a reaction should appear in 48 to 72 hours. Two visits are required in this test. First visit to get the test administered, and the second visit to get the reading of the test after 48 to 72 hours of test placement.
- Option A: Immediately after the test is too soon to observe a reaction. The results of this test are interpreted by measuring the hypersensitivity reaction (delayed-type hypersensitivity) to tuberculin purified protein derivative, derived from Mycobacterium tuberculosis.
- Option B: Within 24 hours is too soon to observe a reaction. The peak of the induration reaction occurs after 24 hours of the test injection. Induration of the skin at the injection site occurs secondary to cell infiltration.
- Option D: Waiting more than 5 days to evaluate the test is too long because any reaction may no longer be visible. It takes about 6 to 8 weeks after exposure to the bacteria for the PPD test to be positive.
Nurse Oliver is teaching a mother who plans to discontinue breast-feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?
- A. Whole milk and baby food
- B. Iron-rich formula only
- C. Skim milk and baby food
- D. Iron-rich formula and baby food
Correct Answer: B. Iron-rich formula only
The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. All children need iron. It is important at all stages of a child’s development. Babies fed only breast milk, only formula, or a mix of breast milk and formula have different needs when it comes to iron.
- Option A: The Academy doesn’t recommend whole milk until age 12 months. Once the infant is past one year old, they may be given whole cow’s milk or reduced-fat (2%) milk, provided they have a balanced diet of solid foods (cereals, vegetables, fruits, and meats). But limit his intake of milk to 2 cups (about 16 ounces) per day or less.
- Option C: Skim milk is only appropriate until after age 2 years. Babies and toddlers need fat in their diets for a variety of reasons, including healthy brain development. So it’s usually recommended that kids 1 to 2 years old drink whole milk. Then, if their growth is steady, it’s safe to switch to low-fat or nonfat (skim) milk.
- Option D: A child can start eating solid foods at about 6 months old. First foods that need to be introduced should be soft and easy to swallow such as mashed vegetables or porridge. Make sure to choose foods that contain iron. Iron found in foods comes in two forms: heme and nonheme iron.
Gracie, the mother of a 3-month-old infant, calls the clinic and states that her child has a diaper rash. What should the nurse advise?
- A. “Leave the diaper off while the infant sleeps.”
- B. “Use baby wipes with each diaper change.”
- C. “Switch to cloth diapers until the rash is gone”
- D. “Offer extra fluids to the infant until the rash improves.”
Correct Answer: A. “Leave the diaper off while the infant sleeps.”
Leaving the diaper off while the infant sleeps helps to promote air circulation to the area, improving the condition. Air out the infant’s skin by letting him or her go without a diaper and ointment for short periods of time, perhaps three times a day for 10 minutes each time, such as during naps.
- Option B: Baby wipes contain alcohol, which may worsen the condition. Moist washcloths, cotton balls and baby wipes can aid in cleaning the skin, but be gentle. Don’t use wipes with alcohol or fragrance.
- Option C: Switching to cloth diapers isn’t necessary; in fact, that may make the rash worse. The best way to keep the infant’s diaper area clean and dry is by changing diapers immediately after they are wet or soiled. Until the rash is better, this may mean getting up during the night to change the diaper.
- Option D: Extra fluids won’t make the rash better. When possible, let the infant go without a diaper. Exposing skin to air is a natural and gentle way to let it dry. To avoid messy accidents, try laying the infant on a large towel and engage in some playtime while he or she is bare-bottomed.
Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?
- A. Call an ambulance immediately
- B. Administer ipecac syrup
- C. Punish the child for being bad
- D. Call the poison control center
Correct Answer: D. Call the poison control center
Before interviewing in any way, the parents should call the poison control center for specific directions to avoid death or permanent disability associated with ingestion of poisonous substances. If there is suspicion that a child has been exposed to a poison – whether swallowed, spill on the skin, splashed in the eye, or inhaled – or if a child has been given the wrong medicine or wrong dose of medicine, the parents should phone the Poisons Information Center immediately.
- Option A: The parents may have to call an ambulance after calling the poison control center. The Poisons Information Centre will get a brief history from the parents about what happened and will provide the appropriate advice. Many poisoning exposures in children are mild and can be safely managed at home – staff from the Poisons Information Centre will tell them what to do.
- Option B: Ipecac syrup is no longer used and is recommended by the poison control center. Ipecac has been found to have minimal health benefits and is ultimately ineffective at purging the body of poisonous substances. It was initially discontinued due to production costs and lack of raw materials.
- Option C: Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe. The best protection against poisoning is to make sure that children do not have access to any poisons or medicines.
Safety and Infection Control NCLEX Part #2 (25 Questions)
- A. Impaired urinary elimination related to fluid loss
- B. Ineffective airway clearance related to edema
- C. Disturbed body image related to physical appearance
- D. Risk for infection related to epidermal disruption
Correct Answer: B. Ineffective airway clearance related to edema
Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Exposure to materials burn can cause inhalation injury.
- Option A: Acute renal failure is one of the major complications of burns and it is accompanied by a high mortality rate. Most renal failures occur either immediately after the injury or at a later period when sepsis develops. Late-onset renal failure is usually the consequence of sepsis and is often associated with other organ failure.
- Option C: Burn injuries are among the most serious causes of radical changes in body image. The subject of body image and self-image is essential in rehabilitation, and the nurse must be aware of the issues related to these concepts and take them seriously into account in drafting out the nursing programme.
- Option D: Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (>105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues. This situation often is accompanied by signs of sepsis and changes in the burn wound such as black, blue, or brown discoloration of the eschar.
A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?
Correct Answer: B. Worsening dyspnea
Dyspnea and other signs of respiratory distress signify fluid volume excess (overload), which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. The excess fluid circulating around the body can cause water logging of the lungs, leading to breathlessness. If fluid overload goes on for a long term it eventually leads to heart failure.
- Option A: An elevated temperature may indicate a fluid volume deficit. Hypohydration increases heat storage by reducing sweating rate and skin blood flow responses for a given core temperature. Hypertonicity and hypovolemia both contribute to reduced heat loss and increased heat storage.
- Option C: Gastric distention may suggest excessive oral fluid intake or infection. Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth of the stomach and waist. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right.
- Option D: Conditions that cause blood or body fluid loss can cause hypovolemia, as can inadequate fluid intake. If persistent or severe, diarrhea and vomiting can deplete body fluids. All living organisms must maintain an adequate fluid balance to preserve homeostasis. Water constitutes the most abundant fluid in the body, at around 50% to 60% of the body weight.
Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation?
- A. Absence of intercostals or substernal retractions
- B. Oxygen saturation of 95%
- C. Mild work of breathing
- D. History of steroid-dependent asthma
Correct Answer: D. History of steroid-dependent asthma
A history of steroid-dependent asthma, a contributing factor to this client’s high-risk status, requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. Because of severe adverse effects of steroids, these patients are in need of therapies that can minimize their steroid requirements and control their asthma.
- Option A: Intercostal retractions are due to reduced air pressure inside the chest. This can happen if the upper airway (trachea) or small airways of the lungs (bronchioles) become partially blocked. Therefore, the absence of these findings indicates normal airways.
- Option B: Although an SpO2 <95% is considered abnormal in the CTAS and in most asthma and pneumonia guidelines, there is no description of the standard value. Furthermore, although conventional wisdom states that pulse oximetry levels ≥95% should be considered normal, data from previous studies suggest that the normal oxygen saturation range should lie between 97% and 100%. Therefore, oxygen saturation levels of 95% and 96% in school-aged children may correlate with an increased risk of an underlying clinical disease.
- Option C: Mild work of breathing is a normal finding. During acute exacerbations, children may have significantly increased work of breathing or audible wheezing, which may be appreciated by caregivers and prompt presentation for further evaluation.
Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?
- A. Obtaining skull X-ray
- B. Measuring head circumference
- C. Performing a lumbar puncture
- D. Magnetic resonance imaging (MRI)
Correct Answer: B. Measuring head circumference
Measuring head circumference is the most important assessment technique for recognizing possible hydrocephalus, and is a key part of routine infant screening. Congenital hydrocephalus is usually present at birth. An unusually large head is a significant sign of congenital hydrocephalus.
- Option A: X-rays of the skull may show erosion of sella turcica, or so-called “beaten copper cranium” appearance, but are seldom helpful or indicated with the availability of better imaging techniques. Ultrasonography through anterior fontanelle may be used in infants for evaluating the ventricular system and progression of hydrocephalus.
- Option C: A lumbar puncture isn’t appropriate. CSF analysis could be done to help with the diagnosis and to exclude residual infection. Neuroimaging plays a central role in confirming the diagnosis in suspected cases, identifying the cause and possible treatment. In cases of acute hydrocephalus, an emergency head computed tomographic (CT) scan is the first option to assess the ventricular size.
- Option D: MRI may be used to confirm the diagnosis. Magnetic resonance imaging (MRI) of the brain is the study of choice as it shows better the posterior fossa structures, can differentiate between brain tumors and degenerative diseases and can differentiate NPH from cerebral atrophy.
An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching?
- A. Apply hydrocortisone cream under the cast using sterile applicator
- B. Apply cool air under the cast with a blow-dryer
- C. Use sterile applicators to scratch the itch
- D. Apply cool water under the cast
Correct Answer: B. Apply cool air under the cast with a blow-dryer
Itching underneath a cast can be relieved by directing the blow-dryer, set, on the cool setting, toward the itchy area. Therefore, one of the best ways to relieve moisture is, of course, to dry it off. The client may find ways to blow cool air into and through the cast. The client may be able to do that using specific settings on a hairdryer, for example.
- Option A: Do not stick objects such as coat hangers inside the splint or cast to scratch itching skin. Do not apply powders or deodorants to itching skin. If itching persists, contact a doctor.
- Option C: Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be cautioned not to put any object down the cast in an attempt to scratch. Scratching in this way could lead to an open wound or developing sores.
- Option D: Moisture weakens plaster and damp padding next to the skin can cause irritation. Use two layers of plastic or purchase waterproof shields to keep the splint or cast dry while showering or bathing.
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do first?
- A. Assess vital signs
- B. Institute seizure precautions
- C. Assess neurologic status
- D. Place in respiratory isolation
Correct Answer: D. Place in respiratory isolation
The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy, and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection. The patient with suspected or confirmed N. meningitidis should follow droplet precaution. This should be continued until after 24 hours of effective antibiotics administration.
- Option A: Prompt recognition and immediate initiation of treatment are of utmost importance in the management of bacterial meningitis. Patients can present with abnormal vital signs, including fever, tachypnea, tachycardia, and hypotension. Hypotension with elevated pulse rate is suggestive of early vascular instability.
- Option B: Complications of meningococcal meningitis can arise early or late in the disease course and can adversely impact morbidity and mortality. Late complications of meningococcal meningitis include chronic pain, skin scarring, and neurologic impairment. Other common complications include hearing impairment, visual impairment, and seizures.
- Option C: Assessment should be performed after the patient is placed on respiratory isolation in order to avoid infecting other patients. Prompt antibiotic administration, especially within one hour, has been proven to improve morbidity and mortality, as well as prevent complications such as increased intracranial pressure and septic shock.
- A. Reverse isolation
- B. Respiratory isolation
- C. Contact isolation
- D. Standard precautions
Correct Answer: C. Contact isolation
Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin-resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient’s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia.
- Option A: Reverse isolation refers to the practice of healthcare workers and visitors wearing barriers (i.e., gown, gloves, mask, etc.) routinely upon entry to the client room, for the purpose of preventing client exposure to external microbes. Certain immunocompromised clients have been shown to benefit from specific additional “interventions”. These interventions create a “Protective Environment”.
- Option B: Respiratory isolation is used for diseases that are spread through particles that are exhaled. Those having contact with or exposure to such a patient are required to wear a mask. Respiratory isolation guidelines for patients admitted from the ED with pneumonia were developed and validated in a study. These guidelines provide satisfactory guidance for isolation of patients at risk for PTB in a high-TB-prevalence population.
- Option D: Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect DHCP and prevent DHCP from spreading infections among patients.
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions?
- A. A diagnosis of AIDS and cytomegalovirus
- B. A positive PPD with an abnormal chest x-ray
- C. A tentative diagnosis of viral pneumonia
- D. Advanced carcinoma of the lung
Correct Answer: B. A positive PPD with an abnormal chest x-ray
The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion. Airborne precautions are required whenever entering a patient’s room or environment who has been diagnosed with or is being tested for with high suspicion of anthrax, tuberculosis, measles, chickenpox, or disseminated herpes zoster or other pathogens that can be transmitted through airflow that are 5 micrometers or smaller in size and remain in the environment for long periods of time.
- Option A: According to the OSHA database, HIV, hepatitis B and C, tuberculosis, malaria, measles, herpes, chickenpox, and various other bacterial infections are known for being transmitted through blood-containing fluids and products. Blood-borne precautions include wearing gloves, face mask, protective eyewear or goggles, and proper handling of sharp objects with appropriate disposal.
- Option C: Prevention, especially in the form of immunization against influenza and measles, can significantly decrease the incidence of viral pneumonia. The traditional role of viral pneumonia was as a disease found predominantly in the very young, the elderly, and those exposed to influenza. In the past, the diagnosis of viral pneumonia was predicated on it being somewhat a diagnosis of exclusion.
- Option D: Smoking is the most common cause of lung cancer. It is estimated that 90% of the cases of lung cancer are attributable to smoking. The risk is highest in males who smoke. The risk is further compounded with exposure to other carcinogens, such as asbestos. It is hypothesized that repeated exposure to carcinogens, cigarette smoke, in particular, leads to dysplasia of lung epithelium.
Which of the following is the first priority in preventing infections when providing care for a client?
- A. Wearing gowns and goggles
- B. Using a barrier between client’s furniture and nurse’s bag
- C. Handwashing
- D. Wearing gloves
Correct Answer: C. Handwashing
Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.
- Option A: Isolation gowns are generally the preferred PPE for clothing but aprons occasionally are used where limited contamination is anticipated. If contamination of the arms can be anticipated, a gown should be selected. Goggles provide barrier protection for the eyes; personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles.
- Option B: In terms of airflow blocking, a barrier height of at least 40 cm above the desk level (at 80 cm) is recommended to prevent the coughing flow of an infected person, considering an unknown location in the open office and subject to a modified ventilation mode.
- Option D: Gloves are the most common type of PPE used in healthcare settings. However, gloves should never replace the practice of handwashing. The nurse should learn to work from clean to dirty. This is a basic principle of infection control. In this instance, it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas.
An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible?
- A. Eating utensils
- B. Hands
- C. Milk products
- D. Droplet nuclei
Correct Answer: D. Droplet nuclei.
The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. Although usually a lung infection, tuberculosis is a multi-system disease with protean manifestation. The principal mode of spread is through inhalation of infected aerosolized droplets.
- Option A: The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, speaks, or sings. People nearby may breathe in these bacteria and become infected.
- Option B: Hands are the primary method of transmission of the common cold. When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow. From there, they can move through the blood to other parts of the body, such as the kidney, spine, and brain.
- Option C: The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera.
A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action?
- A. Place a urine collection bag and specimen cup at the bedside
- B. Order a stat admission CBC
- C. Pad the side rails of his bed
- D. Place a cooling mattress on his bed
Correct Answer: C. Pad the side rails of his bed
The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence. Febrile seizure status is defined as a seizure lasting longer than 30 minutes. Therefore, prompt treatment of prolonged seizures of a febrile nature is as necessary as prompt treatment of prolonged seizures arising from other etiologies.
- Option A: Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A patient with a normal general and neurologic exam, whose history is consistent with a simple febrile seizure, does not need a further laboratory, imaging, or neurophysiologic evaluation.
- Option B: Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A lumbar puncture may be a consideration in the setting of fever and seizures. For a patient with the appropriate history of a febrile seizure and a rapid return to baseline, no lumbar puncture is necessary.
- Option D: A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. There is no specific treatment for simple or complex febrile seizures other than appropriate treatment for underlying etiologies driving the ongoing febrile illness. Antipyretics have not been shown to prevent a recurrence of febrile seizures.
A young adult is being treated for second and third-degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement?
- A. “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bathwater.”
- B. “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”
- C. “I must wear my Jobst elastic garment all day and can only remove it when I’m going to bed.”
- D. “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
Correct Answer: D. “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. While many factors must be considered in dressing selection, the goals in selecting the most appropriate dressing should include providing protection from contamination (bacterial or otherwise) and from physical damage, allowing gas exchange and moisture retention, and providing comfort to enhance functional recovery.
- Option A: Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open and removes dead tissue.
- Option B: The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul-smelling drainage must be reported immediately.
- Option C: The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing.
An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is:
- A. Speak soothingly and provide quiet music
- B. Encourage family phone calls
- C. Limit visits by staff
- D. Position in a bright, busy area
Correct Answer: A. Speak soothingly and provide quiet music
The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. Client develops a feeling of security in the presence of a calm staff person.
- Option B: Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Therapeutic skills need to be directed toward putting the client at ease, because the nurse who is a stranger may pose a threat to the highly anxious client.
- Option C: The client needs frequent visits by the staff to orient him and to assess his safety. The client’s safety is utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.
- Option D: Putting the client in a bright, busy area would probably add to his confusion. Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked.
Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure?
- A. She says to her husband, “Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food.”
- B. “I understand it will be several weeks before all the radiation leaves my body.”
- C. “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”
- D. “I brought several craft projects to do while the radium is inserted.”
Correct Answer: C. “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”
People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. The radiation doesn’t travel very far from the treatment area. So it is usually safe to be with other people. However, as a precaution, the client will need to avoid very close contact with children and pregnant women for a time.
- Option A: The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. Foods to avoid or reduce during radiation therapy include sodium (salt), added sugars, solid (saturated) fats, and an excess of alcohol. Some salt is needed in all diets.
- Option B: As soon as the radiation source is removed, the client is no longer contaminated with radioactivity. The radiation stays in the body for anywhere from a few minutes to a few days. Most people receive radiation therapy for just a few minutes. Sometimes, people receive internal radiation therapy for more time. If so, they stay in a private room to limit other people’s exposure to the radiation.
- Option D: Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place. Treatment planning usually involves positioning the body, making marks on the skin and taking imaging scans. The radiation therapy team determines whether the client will lie on their back, stomach or side during treatment.
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 puts on a mask, a gown, and gloves before entering the room of a client in strict isolation.
- B. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
- C. The nurse aide is not wearing gloves when feeding an elderly client.
- D. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.
Correct Answer: B. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
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 a mask, gown, and gloves. Personnel involved in treating high-risk infections should be specialized in isolation work and be healthy, not immunosuppressed, and if possible should be vaccinated, if a vaccine is available.
- Option A: Strict isolation refers to suspected highly infectious and transmissible virulent and pathogenic microbes, highly resistant bacterial strains and agents that are not accepted in any form of distribution in the society or in the environment. Patients in need of strict isolation should be placed in a separate isolation ward or building.
- Option C: 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.
- Option D: A client with active tuberculosis should be on respiratory precautions. Airborne precautions are used in addition to standard precautions to prevent disease transmission from individuals known or suspected to have diseases spread by fine particles, including, TB.
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. Discuss dressing change technique with the nurse at a later date.
- B. Congratulate the nurse on the use of good technique.
- C. Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
- D. Interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing.
Correct Answer: C. Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
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. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.
- Option A: Before discussion of dressing technique with the staff nurse, the charge nurse should ensure that the new nurse knows the proper infection control technique during dressing changes to prevent contaminating the client’s surgical wound.
- Option B: Approval of an inappropriate technique would not lead to necessary changes. The new staff nurse needs further education on how to properly handle dressing changes for a surgical wound, especially the proper infection control techniques. If the new staff nurse demonstrates correct infection control technique and proper dressing changes, then the charge nurse may offer them praise for their work and diligence.
- Option D: 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. Proper infection control technique is of utmost importance during dressing changes of a surgical wound to avoid complications.
Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is:
- A. Correct illumination of the environment
- B. Amount of regular exercise
- C. The resting pulse rate
- D. Status of salt intake
Correct Answer: A. Correct illumination of the environment
To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Providing lighting in key places can reduce fall risk and avoid obstacles during mobility. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate.
- Option B: Exercises can improve muscle strength, balance, coordination, and reaction time. Physical conditioning reduces the incidence of falls and avoids injury that is sustained when a fall happens. However, the amount of regular exercise is not the most important factor to assess. It is only indirectly related.
- Option C: The resting pulse rate is not related to preventing falls. Instead, place assistive devices and commonly use items within reach. This provides easy access to assistive devices and personal care items. Items such as call bell, telephone, and water should be kept close to avoid frequent reaching.
- Option D: The salt intake is not directly related to preventing falls. Instead, advise the client to wear shoes or slippers with non-slip soles when walking. Wearing non-slip footwear helps prevent slips and falls.
Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis?
- A. “If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.”
- B. “If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline.”
- C. “If I question the sterility of any dressing material, I should not use it.”
- D. “I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.”
Correct Answer: C. “If I question the sterility of any dressing material, I should not use it.”
If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. Sterile technique is essential to help prevent surgical site infections (SSI), an unintended and oftentimes preventable complication arising from surgery. SSI is defined as an “infection that occurs after surgery in the area of surgery” (CDC, 2010, p. 2).
- Option A: Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. Preventing and reducing SSI are the most important reasons for using sterile technique during invasive procedures and surgeries.
- Option B: The 4 X 4s should be soaked prior to donning the sterile gloves. Normal saline would not keep the gauze sterile after being dropped on the floor. The client would need to replace the unsterile gauze with a new, sterile pack.
- Option D: Once the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a need for further instruction. Sterile objects must only be touched by sterile equipment or sterile gloves.
A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?
- A. Masks should be worn with all client contact
- B. A private room is always indicated
- C. Isolation gowns are not needed
- D. Gloves should be worn for contact with non intact skin, mucous membranes, or soiled items
Correct Answer: D. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. These precautions treat all blood and body fluids as potentially infectious for diseases that are transmitted in the blood. The organisms spreading these diseases are called blood-borne pathogens.
- Option A: Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Masks and protective eyewear, such as goggles or a face shield, help protect the eyes, mouth, and nose from droplets of blood and other body fluids. Always wear a mask and protective eyewear if doing a procedure that may expose oneself to splashes or sprays of blood or body fluids.
- Option B: A private room is only indicated if the client’s hygiene is poor. Blood and body fluid precautions are recommendations designed to prevent the transmission of HIV, hepatitis B, hepatitis C, and other diseases while giving first aid or other health care that includes contact with body fluids or blood.
- Option C: Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. Gowns or aprons protect the personnel from splashes of blood or body fluids. Always wear a gown or apron if doing a procedure that may expose oneself to splashes or sprays of blood or body fluids.
The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions?
- A. An aide wears gloves to feed a helpless client.
- B. A pregnant worker refuses to care for a client known to have AIDS.
- C. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood.
- D. An assistant puts on a mask and protective eyewear before assisting the nurse to suction a tracheostomy.
Correct Answer: D. An assistant puts on a mask and protective eyewear before assisting the nurse to suction a tracheostomy.
Masks and protective eyewear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum.
- Option A: Gloves are not necessary when feeding, since there is no contact with mucous membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin.
- Option B: There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions. Use new gloves for every patient. Wear protective eyewear, masks, or face shields (with safety glasses or goggles) during procedures likely to generate droplets of blood or body fluids. In general, protective eyewear, masks, and clothing are not needed for routine care of AIDS virus-infected persons.
- Option C: Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an instrument such as a hemostat should be used to recap. The hand should never be used.
Jayson, a 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism?
- A. Sharing pacifiers
- B. Coughing on each other
- C. Bathing together
- D. Eating off the same plate
Correct Answer: C. Bathing together.
Direct contact is the mode of transmission for staphylococcus. S. aureus are one the most common bacterial infections in humans and are the causative agents of multiple human infections, including bacteremia, infective endocarditis, skin and soft tissue infections (e.g., impetigo, folliculitis, furuncles, carbuncles, cellulitis, scalded skin syndrome, and others), osteomyelitis, septic arthritis, prosthetic device infections, pulmonary infections (e.g., pneumonia and empyema), gastroenteritis, meningitis, toxic shock syndrome, and urinary tract infections.
- Option A: S. aureus does not normally cause infection on healthy skin, however, if it is allowed to enter the internal tissues or bloodstream, these bacteria may cause a variety of potentially serious infections. Depending on the strains involved and the site of infection, these bacteria can cause invasive infections and/or toxin-mediated diseases.
- Option B: S. aureus is not spread through droplets or airborne means. Staphylococcus aureus (including drug-resistant strains such as MRSA) are found on the skin and mucous membranes, and humans are the major reservoir for these organisms. It is estimated that up to half of all adults are colonized, and approximately 15% of the population persistently carry S. aureus in the anterior nares.
- Option D: Prevention of S. aureus infections remains challenging. Despite many efforts, a routine vaccination for S. aureus infections has remained elusive. As a result, efforts have relied on infection control methods such as hospital decontamination procedures, handwashing techniques, and MRSA transmission prevention guidelines.
Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client:
- A. Verbalizes the role of sexual activity in the spread of the disorder.
- B. States he will make arrangements to drop his college classes.
- C. Acknowledges the need to avoid all contact sports.
- D. Says he will avoid close contact with his three-year-old niece.
Correct Answer: A. Verbalizes the role of sexual activity in the spread of the disorder.
HIV is spread through direct contact with body fluids such as blood and through sexual intercourse. Casual contact with other people does not pose a risk of transmission of HIV. Review modes of transmission of disease, especially if newly diagnosed. This corrects myths and misconceptions; promotes safety for the client and others. Accurate epidemiological data are important in targeting prevention interventions.
- Option B: Unless the client is feeling very ill, there is no need for him to drop his college classes. Determine level of independence or dependence and physical condition. Note extent of care and support available from family and SO and need for other caregivers.
- Option C: Contact sports are not contraindicated unless there is a significant chance of bleeding and direct contact with others. Casual contact with other people does not pose a risk of transmission of HIV.
- Option D: There is no need to limit casual contact with children. The nurse may discuss extent and rationale for isolation precautions and maintenance of personal hygiene. This may promote cooperation with the regime and may lessen feelings of isolation.
Which question is least useful in the assessment of a client with AIDS?
- A. Are you a drug user?
- B. Do you have many sex partners?
- C. What is your method of birth control?
- D. How old were you when you became sexually active?
Correct Answer: D. How old were you when you became sexually active?
The age at which sexual activity began is not relevant as it does not usually provide information that identifies the presence of risk factors for AIDS. A large number of patients may only have an asymptomatic infection after the exposure. The usual time from exposure to onset of symptoms is 2 to 4 weeks, although, in some cases, it can be as long as 10 months.
- Option A: Drug use is a risk factor for AIDS where people can get the disease by sharing the needles or equipment with an infected individual. In the United States, a critical risk factor for HIV propagation among young people is the use of drugs before having sex, including marijuana, alkyl nitrites (“poppers”), cocaine, and ecstasy.
- Option B: Multiple sex partners is a risk factor for AIDS. Other risk factors associated with acquiring HIV infection include men who have sex with men, unsafe sexual practices, the use of intravenous drugs, vertical transmission, and blood transfusions or blood products.
- Option C: Birth control methods are important to prevent a baby from being born with the AIDS virus. Use a clean condom at all times when having sexual intercourse. Preferably use a condom that contains a water-based lubricant, which is more protective.
Mrs. Parker, 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 Mrs. M. 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
Correct Answer: C. Maneuvering safely after orientation to the room.
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. The client should be familiarized with the bed, location of the bathroom, furniture, and other environmental hazards that can cause older patients to trip or fall.
- Option A: Independently ambulating around the unit is not appropriate because the unit environment can change and injury could result. Place assistive devices and commonly use items within reach. This provides easy access to assistive devices and personal care items. Items such as call bell, telephone, and water should be kept close to avoid frequent reaching.
- Option B: Assistance is necessary because of the client’s visual deficit. It is unlikely the client can see well enough to read the materials. Ensure the client’s eyesight is regularly checked and explain the importance of wearing eyeglasses if needed. Make sure glasses and hearing aids are always worn.
- Option D: Using the bedpan is an unnecessary restriction on the client as she can be oriented to the bathroom or to call for assistance. Instruct the client how to ambulate at home, including using safety measures such as handrails in the bathroom.
A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to:
- A. Prevent metabolic breakdown of xanthine to uric acid
- B. Prevent uric acid from precipitating in the ureters
- C. Enhance the production of uric acid to ensure adequate excretion of urine
- D. Ensure that the chemotherapy doesn’t adversely affect the bone marrow
Correct Answer: A. Prevent metabolic breakdown of xanthine to uric acid
The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. These clients can have increased uric acid levels due to release of uric acid from the dying cancer cells.
- Option B: Allopurinol and oxypurinol both inhibit xanthine oxidase, an enzyme in the purine catabolism pathway that converts hypoxanthine to xanthine to uric acid. Allopurinol undergoes metabolism in the liver, where it transforms into its pharmacologically active metabolite, oxypurinol.
- Option C: Urate production is accelerated by purine-rich diets, endogenous purine production, and high cell breakdown, and it is responsible for a minority of cases of hyperuricemia. Foods rich in purine include all meats but specifically organ meats (kidneys, liver, “sweet bread”), game meats, and some seafood (anchovies, herring, scallops).
- Option D: Allopurinol doesn’t act in the manner described in this option. To prevent tumor lysis syndrome, allopurinol shall be initiated 2 to 3 days before starting chemotherapy and continued until 3 to 7 days after chemotherapy.
Safety and Infection Control NCLEX Part #3 (25 Questions)
While working in a pediatric clinic, you receive a telephone call from the parent of a 10-year-old who is receiving chemotherapy for leukemia. The client’s sibling has chickenpox. Which of these actions will you anticipate taking next?
- A. Administer varicella-zoster immune globulin to the client
- B. Educate the parent about the correct use of acyclovir (Zovirax)
- C. Prepare the client for admission to a private room in the hospital
- D. Teach the parents regarding contact and airborne precaution
Correct Answer: A. Administer varicella-zoster immune globulin to the client
Varicella-zoster immune globulin administration can prevent the development of chickenpox in high-risk clients and will typically be prescribed. The varicella-zoster immunoglobulin is used to manage patients who are immunocompromised. In addition, a live attenuated vaccine has been available since 1995. There is high seroconversion following the vaccine which is long lasting. Adverse effects of the vaccine are rare.
- Option B: In children, acyclovir decreases symptoms by one day if taken within 24 hours of the start of the rash, but it has no effect on complication rates, and it is not recommended for individuals with normal immune function.
- Option C: Hospitalization may be required if the child develops a varicella-zoster virus infection. For most children who develop chickenpox, the outcome is excellent. However, in immunocompromised individuals, there is increased morbidity and mortality.
- Option D: Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella. It is acquired by inhalation of infected aerosolized droplets. This virus is highly contagious and can spread rapidly. The initial infection is in the mucosa of the upper airways.
Which action will you take to most effectively reduce the incidence of hospital-associated urinary tract infections?
- A. Ensure that clients have enough adequate fluid intake
- B. Teach assistive personnel how to provide good perineal hygiene
- C. Perform dipstick urinalysis for clients with risk factors for UTI
- D. Limit the use of indwelling foley catheter (IFC)
Correct Answer: D. Limit the use of indwelling foley catheter (IFC)
The most effective way to reduce the incidence of UTIs in the hospital setting is to avoid using retention catheters. Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter.
- Option A: Adequate fluid intake may improve the symptoms of UTI, however, it can help mildly with the prevention of hospital-acquired UTI. The DRInK-Up study provides preliminary evidence suggesting that increasing daily fluid intake by small amounts may have a potentially positive effect on the number of UTIs experienced. However, further research is still needed.
- Option B: Routine hygiene of the urethral meatus surface should be performed during daily bathing or showering. Urethral cleaning with povidone-iodine solution or soap and water has not been shown to prevent CA-UTIs. However, there is evidence that frequent urethral cleaning can lead to mucosal irritation and breakdown that may increase the risk of infection.
- Option C: Avoid breaking the collecting system to obtain urine specimens for analysis and bacterial culture. To obtain urine specimens, the sampling port for the urine collection must be used. If this is not available, urine can be aspirated with a sterile needle and syringe from the distal end of the catheter using aseptic technique.
You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of these nursing actions can you delegate to an LPN/LVN?
- A. Assess risk for further skin breakdown
- B. Plan ways to improve the client’s oral protein intake
- C. Obtain wound cultures during dressing changes
- D. Educate the client about home care of the leg ulcer
Correct Answer: C. Obtain wound cultures during dressing changes.
LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. It is within the scope of practice of a licensed practical nurse (LPN) to contribute to the initial assessment of wounds through the gathering and recording of assessment data and to perform basic and advanced wound care in collaboration with the RN or licensed independent practitioner (LIP) on an ongoing basis.
- Option A: The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
- Option B: Only RNs can develop the care plan and make changes, although LPNs can contribute suggestions. All of these skills are taught in nursing school but are not included in the LPN curriculum, which is focused on bedside tasks.
- Option D: Teaching is a complex action that should be carried out by a licensed nurse. An LPN can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
You are the pediatric unit charge nurse today and are working with a new RN. Which action by the new RN requires the most immediate action on your part?
- A. The new RN wears goggles to change linens of a client who has diarrhea caused by C. difficile.
- B. The new RN places a child who has chemotherapy-induced neutropenia into a negative-pressure room.
- C. The new RN admits a new client with respiratory syncytial virus (RSV) infection to a room with another child who has RSV.
- D. The new RN tells the nursing assistant to use an N95 respirator mask when caring for a child who has pertussis.
Correct Answer: B. The new RN places a child who has chemotherapy-induced neutropenia into a negative-pressure room.
Clients who are neutropenic should be placed in positive-airflow rooms; placement of the child in a negative airflow room will increase the likelihood of infection for this client. Clean, filtered air is constantly pumped into the room. This is done to keep contagious diseases out of the room. With this type of isolation room, the client may be able to feel air blowing out of the room under a closed door.
- Option A: Goggles are not needed for changing the linens of clients infected with C. difficile; however, these protections do not increase the risk to the clients. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of clients with C. diff. Visitors may also be asked to wear a gown and gloves. When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands.
- Option C: Although private rooms are preferred for clients who need droplet precautions, such as clients with RSV infection, they can be placed in rooms with other clients who are infected with the same microorganism.
- Option D: The use of an N95 respirator is not necessary for pertussis. Wearing a surgical mask within 3 feet of the client provides protection from the spread of pertussis. Oftentimes, close household contacts are the source of the child’s infection; therefore, providers should also wear masks when within 3 feet of symptomatic parents or siblings.
A client comes to the outpatient clinic where you work complaining of abdominal pain, diarrhea, shortness of breath and epistaxis. Which of the following actions would you take first?
- A. Screening clients for upper respiratory tract symptoms
- B. Call an ambulance to take the client immediately to the hospital
- C. Ask the client about any recent travel to Asia or the Middle East
- D. Determine whether the client has had recommended immunizations
Correct Answer: C. Ask the client about any recent travel to Asia or the Middle East.
The client’s clinical manifestation suggests possible avian influenza (bird flu). If the client has traveled recently in Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. The other actions may also be appropriate but are not the initial action to take for this client, who may transmit the infection to other clients or staff members
- Option A: Most patients present with symptoms consistent with a flu-like viral illness. In these patients, especially during a known avian influenza outbreak, a thorough history is necessary to evaluate for clues that the illness is due to avian influenza.
- Option B: Whenever there is a possible outbreak of avian influenza, the essential way to reduce the severity and population impact are to reduce the spread of the virus. Since human-to-human transmission is uncommon, the focus should be on reinforcing appropriate sanitation habits in the population, especially those that work around birds or that are involved in food preparation.
- Option D: There is currently an FDA-licensed vaccine for the H5N1 strain of avian influenza in the United States. In the case of an H5N1 outbreak in the United States, the CDC and public health officials may decide to vaccinate at-risk populations to reduce spread.
A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first?
- A. Obtain blood, urine, and sputum for cultures
- B. Infuse normal saline at 100ml/hr
- C. Administer methylprednisolone (Solu-Medrol) 1 gram/IV
- D. Place the client on contact and airborne precautions
Correct Answer: D. Place the client on contact and airborne precautions.
Since SARS is a severe disease with a high mortality rate, the initial action should be to protect other clients and health care workers by placing the client in isolation. If an airborne-agent isolation (negative pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room.
- Option A: SARS-CoV testing for diagnosis should be done via PCR from samples obtained from at least two sites and as early in the illness as possible and then repeated five to seven days later if symptoms continue.
- Option B: There are potential agents for use against SARS. Lopinavir-ritonavir has shown some activity in vitro only thus far. Additionally, the experimental agent for Ebola, Remdesivir, has shown activity against both SARS and MERS coronaviruses.
- Option C: There is no specific treatment for severe acute respiratory syndrome (SARS), and supportive care is emphasized. To date, no antiviral agents have been found to be beneficial, nor were glucocorticoids shown to have a beneficial effect.
Four clients with infections arrive at the emergency department with some existing infection, however, only one private room is available. Which of the following clients is the most appropriate to assign to the private room?
- A. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C).
- B. A client with diarrhea caused by C. difficile.
- C. A client with a wound infected with VRE.
- D. A client with a cough who may have Koch disease
Correct Answer: D. A client with a cough who may have Koch disease.
Clients with infections that require airborne precautions (such as TB) need to be in private rooms. Secondary environmental controls consist of controlling the airflow to prevent contamination of air in areas adjacent to the source airborne infection isolation (AII) rooms, and cleaning the air by using high-efficiency particulate air (HEPA) filtration, or ultraviolet germicidal irradiation.
- Option A: Standard precautions are required for the client with toxic shock syndrome. At a minimum, standard precautions should be used in the hospital setting to prevent transmission to patients and staff. The CDC has recommended for the first 24 hours of effective antibiotics to have the patient in both contact and droplet isolation.
- Option B: Use contact precautions for patients with known or suspected CDI. Place these patients in private rooms. If private rooms are not available, they can be placed in rooms (cohort) with other CDI patients. Wear gloves and a gown when entering CDI patient rooms and during their care.
- Option C: Clients with infections that require contact precautions (such as C.difficile and VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. Wear gloves (clean, non-sterile gloves are adequate) when entering the room of a VRE-infected or colonized patient because VRE can extensively contaminate such an environment. When caring for a patient, a change of gloves might be necessary after contact with a material that could contain high concentrations of VRE.
You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infections?
- A. A client who has a non-tunneled central line in the left internal jugular vein.
- B. A client with an implanted port in the right subclavian vein.
- C. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.
- D. A client who has a midline IV catheter in the left antecubital fossa.
Correct Answer: A. A client who has a non-tunneled central line in the left internal jugular vein.
Several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, the skin of the neck and chest having a high number of microorganisms, and the line is tunneled. The concern that physicians have with non-tunneled catheters is that they have a short duration of use. Because of this, they should be removed as soon as possible in order to prevent complications like infections or thrombosis.
- Option B: Implanted ports are placed under the skin and so are less likely to be associated with catheter infection than a nontunneled central IV line. For long-term use, implanted ports are preferred as they have better cosmetic results and less infection as compared to non-tunneled catheters and tunneled catheters.
- Option C: PICC lines can remain inserted for weeks to months. They are indicated in situations where the patient needs an intravenous delivery of antibiotics or chemotherapy drugs while preserving the integrity of the peripheral vascular system.
- Option D: Peripherally inserted IV lines such as midline catheters and PICC lines are associated with a lower incidence of infection. A peripherally inserted central catheter or a PICC line is a thin, flexible tube that is inserted into an upper arm vein and then guided into the superior vena cava on the right side of the heart.
A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse delegate to an LPN/LVN?
- A. Assess the client’s hydration status
- B. Explain the purpose of ordered stool cultures to the client and family
- C. Administer metronidazole (Flagyl) 500 mg PO as ordered to the client
- D. Review the client’s medical history for any risk factors for diarrhea
Correct Answer: C. Administer metronidazole (Flagyl) 500 mg PO as ordered to the client
LPN/LVN education and scope of practice and education include the administration of medications. The administration of medications is recognized as the responsibility of the Registered Nurse (RN) and *Licensed Practical Nurses (LPNs). All orders for medications must be legible, complete, and non-ambiguous.
- Option A: The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation, and evaluation.
- Option B: Teaching is a complex activity that should be carried out by a licensed nurse. An LPN can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
- Option D: Assessment of risk factors for diarrhea should be done by a licensed nurse. A Licensed Practical Nurse (LPN) may not perform an initial assessment. Initial assessments are to be performed by a Registered Nurse (RN). The initial assessment is to be used to determine a patient’s baseline and develop an initial nursing plan of care.
You are a school nurse. Which action will you take to have the most impact on the incidence of infectious disease in the school?
- A. Provide written information about infection control to all patients.
- B. Ensure that students are immunized according to national guidelines.
- C. Make soap and water readily available in the classrooms.
- D. Teach students how to cover their mouths when coughing.
Correct Answer: B. Ensure that students are immunized according to national guidelines.
The incidence of once common infectious diseases such as measles, chickenpox, and mumps has been most effectively reduced by immunization of all school-aged children. School immunization requirements exist to protect students and members of their community from serious vaccine-preventable diseases by ensuring high vaccination rates.
- Option A: Relevant studies showed that implementation of health education for school students was conducive for students to consciously adopt healthy behaviors and lifestyle, eliminating or mitigating risk factors that affect spread of infectious diseases, preventing infectious diseases, and promoting health and improving quality of life.
- Option C: Soap and water are also helpful in reducing the incidence of infectious diseases at school. Alcohol-based antiseptics for hand hygiene are an appealing innovation because of their efficacy in reducing hand contamination and their ease of use, especially when sinks and supplies for hand washing are limited.
- Option D: Recommended cough etiquette maneuvers did not block the release and dispersion of a variety of different diameter droplets to the surrounding environment. Droplets smaller than one-micron size dominate the total number of droplets leaked when practicing assessed maneuvers.
You are caring for a newly admitted client with increasing dyspnea and dehydration who has possible avian influenza (bird flu). Which of these prescribed actions will you implement first?
- A. Provide oxygen using a non-rebreather mask
- B. Infuse 5% dextrose in water at 75ml/hr
- C. Administer the first dose of oseltamivir (Tamiflu)
- D. Obtain blood and sputum specimens for testing
Correct Answer: A. Provide oxygen using a non-rebreather mask.
Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse’s initial action should be to start oxygen therapy. Patients with respiratory compromise should be placed on supplemental oxygen and monitored closely for signs of deterioration as these patients are at high risk of requiring intubation and mechanical ventilation. The other interventions should be implemented after addressing the client’s respiratory problem.
- Option B: Treatment may include hospitalization and supportive care, such as intravenous fluids. Additionally, studies suggest that antiviral drugs help minimize the severity of bird flu in people. However, changes in the virus may limit its effectiveness in the future.
- Option C: The World Health Organization released Rapid Advice Guidelines in 2007, outlining consensus treatment recommendations for H5N1 influenza outbreaks. These recommendations include neuraminidase inhibitors (especially oseltamivir) for strongly suspected or confirmed cases of H5N1.
- Option D: The preferred source of a sample for testing is a nasopharyngeal swab or aspirate, but other body fluids are usable if the nasopharyngeal swab or aspirate is not available. RT-PCR identification of the virus in viral cultures is the standard of care for diagnosis of AIV, and viral detection is typically possible within a few days of disease onset.
A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first?
- A. Obtain stool specimens for culture
- B. Place the client on contact precaution
- C. Notify the physician about the loose stools
- D. Instruct the client about correct handwashing
Correct Answer: B. Place the client on contact precaution
The client’s age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be able to place him on contact precautions to prevent the spread of C. difficile to other clients. Clostridium difficile is a gram-positive bacterium that is the cause most implicated in antibiotic-associated diarrhea. The other actions are also needed and should be taken after placing the client on contact precautions.
- Option A: Patients with new-onset 3 or more loose or unformed stools in 24 hours with no obvious other etiology should be checked for testing for C. difficile infection. Stool examination for C. difficile toxins or toxigenic C. difficile bacillus is the commonly used diagnostic test used to diagnose C. difficile infection.
- Option C: The management of C. difficile infection includes a multi-step approach of discontinuing the usage of inciting antibiotics, isolating the patient, and administering the antibiotic based on the severity of the infection.
- Option D: General strategies such as early detection of the disease, placing the patient under isolation with a dedicated toilet and contact precautions, promoting hygiene measures such as improved hand hygiene, and environmental cleaning are effective measures in preventing infections from C. difficile infections.
Which of the following information about a client who has meningococcal meningitis has the best indicator that you can discontinue droplet precautions?
- A. Pupils are equal and reactive to light
- B. Temperature is lower than 100°F (37.8°C)
- C. Appropriate antibiotics have been given for 24 hours
- D. Cough is productive of clear, nonpurulent mucus
Correct Answer: C. Appropriate antibiotics have been given for 24 hours.
Current CDC evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy for 24 hours. Antibiotic dose should be given as soon as meningitis is suspected and should not be delayed awaiting confirmatory studies. The other information may indicate that the client’s condition is improving but does not indicate that droplet precaution should be discontinued.
- Option A: Meningeal irritability can be confirmed by provocative tests like Kernig and Brudzinski sign. A thorough neurologic exam should be performed looking for alteration in mental status, as well as any focal deficits.
- Option B: Older children and adults will present with headaches, fever, photophobia, vomiting, neck stiffness, and altered mental status. Patients can present with abnormal vital signs, including fever, tachypnea, tachycardia, and hypotension. Hypotension with elevated pulse rate is suggestive of early vascular instability.
- Option D: The classic triad of neck stiffness, fever, and altered mental status is a more specific sign for meningitis. Infants can present with a variety of non-specific symptoms, which include lethargy, irritability, and in some cases bulging fontanelles.
You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with rubeola (measles). Which of these factors is of most concern in determining whether to admit the child to your unit?
- A. No negative-airflow rooms are available on the unit
- B. The infection control nurse liaison is not on the unit today
- C. There are several children receiving chemotherapy on the unit
- D. The unit is not staffed with the usual number of RNs
Correct Answer: A. No negative-airflow rooms are available on the unit
Because clients with rubeola require the implementation of airborne precautions, which include placement in a negative airflow room, this child cannot be admitted to the pediatric unit. An airborne isolation room is also known as a negative pressure room. This negative pressure room is usually a single-occupancy patient-care room frequently used to isolated individuals with confirmed or suspected airborne infections. The other circumstances may require actions such as staff reassignments but would not prevent the admission of a client with rubeola.
- Option B: The absence of the infection control nurse liaison should not prevent the admission of the child with rubeola. Before transferring a patient with an airborne infection, one must always communicate with the relevant department first. The earlier the airborne prevention methods are adopted, the lower the risk of transmission to other patients and healthcare staff.
- Option C: The clients receiving therapy can be transferred to a different location far from the isolation room. The door to the room of the isolation area must be kept closed to maintain negative pressure even if the client is not in the room. The windows in the room should remain closed at all times; opening the window may cause the reversal of airflow, which counters the benefits of a negative pressure room.
- Option D: Only healthcare providers immunized to the organism in question should enter a room where airborne precautions are in place for varicella or measles. A respirator is not necessary for immunized individuals but is required for non-immunized workers who provide care.
A client who states that he may have been contaminated by anthrax arrives at the ED. The following actions are part of the ED protocol for possible anthrax exposure or infection. Which action will you take first?
- A. Assess the client for signs of infection
- B. Notify hospital security personnel about the client
- C. Escort the client to a decontamination room
- D. Administer ciprofloxacin (Cipro) 250 mg PO
Correct Answer: C. Escort the client to a decontamination room
To prevent contamination of staff or other clients by anthrax, decontamination of the client by removal and disposal of clothing and showering is the initial action in possible anthrax exposure. Clients should remove contaminated clothing and store it in labeled, plastic bags. Clothing should be handled as little as possible to avoid agitation. Clients should shower thoroughly with soap and water.
- Option A: Assessment of the client for signs of infection should be done before decontamination. Initial symptoms of inhalation anthrax are mild and nonspecific and may include fever, malaise, fatigue, and a mild cough or chest discomfort; acute symptoms of respiratory distress, fever, and shock follow, with death occurring shortly thereafter.
- Option B: Notification of security personnel is necessary in the case of possible bioterrorism, but this should occur before decontaminating and caring for the client. During the 2001 anthrax outbreak, the New York City Department of Health and Mental Hygiene established the Cutaneous Anthrax Rapid Referral System for rapid referral and early diagnosis of anthrax cases (Redd 2005). This system functioned to efficiently assess patients but also provided a mechanism for rapid centralized reporting, which could be a good surveillance model in the setting of known mass exposure to anthrax.
- Option D: According to the CDC guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax. Early initiation of appropriate antibiotics is paramount for patient survival of IA. Initial therapy for adults with IA due to a strain with unknown antibiotic susceptibilities should include ciprofloxacin OR doxycycline PLUS one or two additional antibiotics effective against anthrax.
A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply.
- A. Goggles
- B. Gown
- C. Gloves
- D. Shoe covers
- E. N95 respirator
- F. Surgical face mask
Correct Answer: B, C, & E
Because herpes zoster is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves.
- Option A: Goggles are not needed for airborne or contact precautions. Wear a surgical mask and goggles or face shield if there is a reasonable chance that a splash or spray of blood or body fluids may occur to the eyes, mouth, or nose.
- Option B: Wear a gown if skin or clothing is likely to be exposed to blood or body fluids. If PPE or other disposable items are saturated with blood or body fluids such that fluid may be poured, squeezed, or dripped from the item, discard into a biohazard bag. PPE that is not saturated may be placed directly in the trash.
- Option C: Wear gloves when touching blood, body fluids, non-intact skin, mucous membranes, and contaminated items. Remove PPE immediately after use and wash hands. It is important to remove PPE in the proper order to prevent contamination of skin or clothing.
- Option D: Wear shoe covers to provide a barrier against possible exposure to airborne organisms or contact with a contaminated environment. Shoe covers should also be worn as part of Full Barrier Precautions. Full Barrier Precautions are the combination of airborne and contact precautions, plus eye protection, in addition to standard precautions.
- Option E: Put on a NIOSH-certified fit-tested N-95 respirator just before entry to an area of shared air space and wear at all times while in the area of shared air space. Remove and discard the respirator just after exiting the area. The respirator may be discarded into the regular trash unless contact precautions must also be followed. In this case, place the respirator in a plastic zip-lock bag, seal and then discard into the trash.
- Option F: Surgical face mask filters only large particles and will not provide protection from herpes zoster. Airborne and contact precautions until disseminated infection is ruled out. Airborne and contact precautions until lesions are dry and crusted.
As the infection control nurse in an acute care hospital, which action will you take to most effectively reduce the incidence of health-care-associated infections?
- A. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug resistant organisms.
- B. Screen all newly admitted clients for colonization or infection with MRSA.
- C. Require nursing staff to don gowns to change wound dressings for all clients.
- D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.
Correct Answer: D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.
Because the hands of healthcare workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use.
- Option A: Because administration of antibiotics to individuals who are colonized by bacteria may promote the development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection.
- Option B: Although some hospitals have started screening newly admitted clients for MRSA, there is no evidence that this decreases the spread of infection. Although results of MRSA screening are not intended to guide empirical treatment, they may offer an additional benefit among patients in whom clinical infection with S. aureus develops.
- Option C: Wearing a gown to care for clients who are not on contact precautions is not necessary. They must be worn when undertaking all direct care procedures with patients, when there is a likelihood of contact with blood, secretions, excretions or body fluids (Loveday et al, 2014).
You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions?
- 3. Remove gloves
- 4. Take off goggles
- 5. Take off the gown
- 1. Remove N95 respirator
- 2. Perform hand hygiene
Correct Answer: 3, 4, 5, 1, 2
The sequence will prevent contact of the contaminated gloves and gowns with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients.
- The outside of the gloves is contaminated, therefore, if the hands are contaminated during glove removal, the nurse should immediately wash their hands or use alcohol-based hand sanitizer. Using the gloved hand, the nurse should grasp the palm area of the other gloved hand, peel off the first glove, and hold the removed glove in the gloved hand. Slide the fingers of the ungloved hand under the remaining glove at wrist and peel off the second glove over the first glove, then discard it in a waste container.
- Goggles or face shields should be removed from the back by lifting headband or ear pieces. If the item is reusable, the nurse may place it in a designated receptacle for reprocessing. Otherwise, it can be discarded in a waste container.
- The nurse should keep in mind that the front of the gown and the sleeves are contaminated. To remove the gown, the nurse should unfasten the gown ties, taking care that the sleeves don’t contact the body when reaching for the ties. The gown should be pulled away from the neck and shoulders, touching the inside of the gown only, then turning it inside out. Finally, the gown should be rolled or folded into a bundle and discarded in a waste container.
- The front of the respirator should never be touched because it is contaminated. To remove the respirator, the nurse should grasp the bottom ties or elastics of the respirator, then the ones at the top, and remove them without touching the front.
- After doffing, it is imperative for the nurse to wash their hands immediately or use an alcohol-based hand sanitizer immediately after removing all of the PPE. Hand hygiene should also be performed in between steps if hands become contaminated.
You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? Select all that apply
- A. N95 respirator
- B. Surgical Mask
- C. Gloves
- D. Goggles
- E. Gown
Correct Answer: C & E
A gown and gloves should be used when coming in contact with linens that may be decontaminated by the client’s wound secretions. Contact precautions (gloves and gowns) are used during clinical encounters with clients who are colonized or infected with MRSA. The other items are not necessary because transmission by splashes, droplets, or airborne means will not occur when the bed is changed.
- Option A: A surgical N95 (also referred as a medical respirator) is recommended only for use by healthcare personnel (HCP) who need protection from both airborne and fluid hazards (e.g., splashes, sprays). These respirators are not used or needed outside of healthcare settings.
- Option B: Surgical masks are Class II medical devices. These masks meet certain fluid barrier protection standards and flammability requirements (that is, Class I or Class II, per 16 CFR 1610.4). Surgical masks are also tested for particulate and bacterial filtration efficiencies and biocompatibility and are considered personal protective equipment (PPE).
- Option C: Gloves must be worn when contact with blood or body fluids, mucous membranes, non intact skin, or potentially contaminated objects or the environment is anticipated. Since hand contamination may occur due to holes, leaks, tears, or improper removal, gloves are not a substitute for proper hand hygiene. Hand hygiene must be performed following removal of gloves.
- Option D: Safety goggles are tight-fitting eye protection that completely cover the eyes, eye sockets and the facial area around the eyes and provide protection from impact, dust, mists, and splashes. Safety goggles can be worn over prescription lenses.
- Option E: Gowns must be worn to protect the arms and prevent soiling or contamination of clothing during procedures and direct care activities when caring for patients on Contact Precautions.
You are preparing to care for a 6-year-old who has just undergone allogeneic stem cell transplantation and will need protective environment isolation. Which nursing tasks will you delegate to a nursing assistant? Select all that apply.
- A. Teaching the client to perform thorough hand washing after using the bathroom.
- B. Talking to the family members about the reasons for the isolation.
- C. Stocking the client’s room with the needed PPE items.
- D. Reminding visitors to wear a respirator mask, gloves, and gown.
- E. Posting the precautions for protective isolation on the door of the client’s room.
Correct Answer: C, D, & E
Because all staff who care for clients should be familiar with the various types of isolation, the nursing assistant will be able to stock the room and post the precautions on the client’s door. CNAs work directly with clients and nurses, helping with the many physical and complex tasks for client care.
- Option A: Teaching is a complex action that should be carried out by a licensed nurse. A nursing assistant can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
- Option B: Client discussion of the reason for protective isolation falls within the RN-level scope of practice. A certified nursing assistant helps clients with direct health care needs, often under the supervision of a nurse.
- Option C: Gathering and stocking medical supplies is a nursing assistant’s responsibility. Different hospitals and facilities will have unique requirements and responsibilities for their CNAs. But in essence, certified nursing assistants help perform critical tasks that ensure the clients are well-cared for and safe during their hospital stay
- Option D: Reminding visitors about previously taught information is a task that can be done by the nursing assistant, although the RN is responsible for the initial teaching. It is within an LPN’s scope of practice to assist the RN with collecting data and monitoring client findings
- Option E: The nursing assistant may post helpful information within the hospital rooms for the benefit of educating the client and others. Furthermore, they can also tidy up the client’s room and change the linens. It also means getting the chance to have regular, one-on-one contact with clients—the compassionate relationships that can help people make it through times of illness with dignity.
A 26-year-old client is diagnosed with scarlet fever. Which of the following is the most appropriate type of isolation for this client?
- A. Airborne
- B. Contact
- C. Droplet
- D. Standard
Correct Answer: Answer: C. Droplet.
Scarlet fever is an infection caused by Group A Streptococcus bacteria. This bacteria lives in the throat and nose and is highly contagious. It is spread by droplet transmission when an infected individual coughs or sneezes. Droplet Precautions are used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit. These droplets are relatively large particles that cannot travel through the air very far.
- Option A: Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV).
- Option B: Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient’s environment.
- Option D: Standard precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non intact skin, and mucous membranes may contain transmissible infectious agents.
A newly admitted client with streptococcal pharyngitis (tonsillitis) has been placed on droplet precaution. Which of the following statements indicates the best understanding for this type of isolation?
- A. Must maintain a spatial distance of 3 feet
- B. The client can be placed in a room with another client with measles (rubeola)
- C. A special mask (N95) should be worn when working with the client
- D. Gloves should be only worn when giving direct care
Correct Answer: A. Must maintain a spatial distance of 3 feet.
The most common forms of transmission of an organism in a client with tonsillitis are through coughing, sneezing, and talking. Droplets can travel no more than 3ft so precautions should be maintained when there is a possibility of entering this distance.
- Option B: Client requires a private room. Ensure appropriate client placement in a single room if possible. In acute care hospitals, if single rooms are not available, utilize the recommendations for alternative client placement considerations in the Guideline for Isolation Precautions.
- Option C: An N95 mask is not required for this client. A face mask instead can be used when dealing with the client. Don mask upon entry into the patient room or patient space. Instruct clients to follow Respiratory Hygiene/Cough Etiquette recommendations.
- Option D: Gloves, gowns, face masks and eye protection should be worn in giving direct care. A face mask is worn upon entry into the client room. PPE must be removed at the point of exit; do not reuse face masks.
Malcolm is newly assigned as a triage nurse, on his first day of work, the following clients arrive at the ED. Which among the clients require the most rapid action to protect other clients in the ED from infection?
- A. An infant with a runny nose and whose older brother has pertussis.
- B. A travel blogger who needs tuberculosis testing after an exposure to a person with TB during his trip.
- C. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection.
- D. A pregnant woman with a blister-like rash on the face and is possibly having varicella.
Correct Answer: D. A pregnant woman with a blister-like rash on the face and is possibly having varicella.
Chickenpox (Varicella) is transmitted by airborne and that can be easily transferred to the other clients in the emergency unit. The pregnant woman with the rash should be isolated right away from other clients through placement in a negative-pressure room. In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the fetus. Varicella infection in pregnant women could spread via the placenta and infect the fetus.
- Option A: Droplet precautions should be instituted for the client with pertussis, but this can be done after isolating the client with possible varicella. Strict isolation is important while the client remains infectious. Pertussis is contagious throughout the catarrhal phase and for 3 weeks after the onset of the paroxysmal phase. In patients treated with antibiotics, isolation should be continued for at least 5 days after treatment is initiated.
- Option B: The client who has been exposed to TB does not place the other clients at risk for infection because there are no symptoms of active TB. The body’s ability to effectively limit or eliminate the infective inoculum is determined by the immune status of the individual, genetic factors and whether it is a primary or secondary exposure to the organism.
- Option C: Contact precautions should be instituted for the client with MRSA infection. Contact precautions include the use of gowns, gloves, and possibly masks during clinical encounters with clients with MRSA infection. Infection control also may include keeping clients in isolated rooms or the same rooms of other clients who have a MRSA infection.
A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client’s care?
- A. Monitor the results of the laboratory culture and sensitivity test.
- B. Educate the client and family members on ways to prevent transmission of VRE.
- C. Implement contact precautions when handling the client.
- D. Collaborate with other departments when the client is transported for an ordered test.
Correct Answer: C. Implement contact precautions when handling the client.
All hospital personnel who care for the client are responsible for correct implementation of contact precautions. They are responsible for ensuring that the convenience, hygiene and safety of patients are well-established during their entire stay in the medical facility.
- Option A: Nursing assistants may not monitor the laboratory results of the client. Certified nursing assistants may only check and record a patient’s vital signs daily. The CNA also measures the client’s height and weight, monitors intake and output and collects specimens to test.
- Option B: Teaching is a complex action that should be carried out by a licensed nurse. A nursing assistant can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
- Option D: Collaboration is not within the scope of the nursing assistant’s practice. When the client must be moved, the assistants also transfer the client between the bed and a wheelchair. If the client is able to stand, the CNA may walk the individual to an appointment or for exercise.
Which of the following infection control activities should be delegated to an experienced nursing assistant?
- A. Screening clients for upper respiratory tract symptoms
- B. Disinfecting blood pressure cuffs after clients are discharged
- C. Demonstrating correct handwashing techniques to client and family
- D. Asking clients about the duration of antibiotic therapy
Correct Answer: B. Disinfecting blood pressure cuffs after clients are discharged
Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. Depending on daily needs, this can involve changing soiled sheets, cleaning up spills, changing bedpans, setting up equipment, and reducing the spread of germs and infection in the client’s living area.
- Option A: The daily direct contact that the nursing assistant has with a client also gives them the opportunity to identify bruises, blood in urine, and other injuries and report them to medical staff who can initiate care.
- Option C: Teaching is a complex action that should be carried out by a licensed nurse. A nursing assistant can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
- Option D: Inquiring about medication therapy is the nurse’s responsibility. However, nursing assistants serve as a channel between clients and nurses and physicians so that all client issues are communicated.