NCLEX safety and infection prevention practice questions

Answer: C — Airborne precautions: an airborne infection isolation room and a fit-tested N95 or higher respirator.

Tuberculosis spreads through droplet nuclei that stay airborne, so the client needs an airborne infection isolation room and staff need a fit-tested N95 or higher-level respirator. A surgical mask and a shared room do not protect against airborne particles.

Checked against: CDC Transmission-Based Precautions, Airborne Precautions; OpenStax Medical-Surgical Nursing 11.8 Tuberculosis

Answer: C — Have the client wear a mask during transport.

For droplet precautions, transport is limited to medically necessary trips, and the client is instructed to wear a mask during transport as source control. Gown and gloves alone do not contain respiratory droplets.

Checked against: CDC Transmission-Based Precautions, Droplet Precautions: Patient transport

Answer: D — Contact precautions, with a gown and gloves for any contact with the client or the client's surroundings.

VRE spreads through contaminated equipment, surfaces and hands, so contact precautions apply, including a gown and gloves for any contact with the client or the client's environment and dedicated equipment when possible. It is not an airborne or droplet infection.

Checked against: CDC Transmission-Based Precautions, Contact Precautions; OpenStax Fundamentals of Nursing 10.2 (VRE example)

Answer: A — Gloves.

In the CDC removal sequence, gloves come off first because their outside is the most contaminated, followed by goggles or face shield, then the gown, then the mask or respirator, with hand hygiene immediately after all PPE is removed.

Checked against: CDC Guideline for Isolation Precautions (2007), Appendix A Figure: Example of Safe Donning and Removal of PPE (source)

Answer: B — It is now considered contaminated and must be replaced.

Any sterile object held below the waist, including a sterile-gloved hand, is considered nonsterile. That is why the nurse brings a second pair of sterile gloves in case sterility is broken.

Checked against: OpenStax Fundamentals of Nursing, 10.3 Sterile Technique, Preparing and Maintaining a Sterile Field (source)

Answer: B — A restraint order can never be written as a standing or as-needed (PRN) order.

Federal guidelines for facilities receiving Medicare and Medicaid prohibit standing or PRN orders for restraint or seclusion, and restraints must be discontinued at the earliest possible time. Restraints are a last resort for safety, never for convenience.

Checked against: OpenStax Clinical Nursing Skills, 9.5 Limited Movement Devices, Nursing Considerations for Restraint Management (source)

Answer: A — Padded mitts.

The least restrictive restraint that keeps the client safe should be chosen; padded mitts prevent grasping tubes while leaving full range of motion. Wrist, vest and four-point restraints restrict movement much more.

Checked against: OpenStax Clinical Nursing Skills, 9.5 Limited Movement Devices, Use of Restraints and Table 9.7 Types of Physical Restraints (source)

Answer: C — Turn the client on the side, support the head with a pillow and remove nearby hazards.

During a seizure the nurse removes hazards, lets the body move freely, places a pillow under the head and turns the client to the side to keep the airway clear. Nothing should be put in the mouth of a seizing client.

Checked against: OpenStax Medical-Surgical Nursing, 17.5 Seizures, Table 17.15 (care during seizures) (source)

Answer: D — Drop it, uncapped, into a nearby puncture-resistant sharps container.

Under the OSHA bloodborne pathogens standard, contaminated needles are not bent, recapped or removed except in specific allowed situations, and sharps go into puncture-resistant, labeled, leakproof containers kept close to where sharps are used.

Checked against: OSHA 29 CFR 1910.1030 Bloodborne Pathogens, (d)(2)(vii) and (d)(4)(iii)(A)

Answer: B — Yellow (delayed).

Yellow tags are for serious injuries such as open fractures or large wounds that need treatment but are not immediately life-threatening. Red is for immediate threats such as airway obstruction or shock, green for minor injuries and black for those deceased or not expected to survive.

Checked against: OpenStax Medical-Surgical Nursing, 34.5 Hospital Preparedness for Disasters, Emergency Policies and Procedures (Table 34.1) (source)

Answer: A — Assess the client for adverse effects and provide any needed interventions.

When a medication error occurs, the nurse's first responsibility is the client's safety: monitor for adverse effects and intervene. The nurse then notifies the provider and nurse manager or charge nurse and documents the event, often in an incident report.

Checked against: OpenStax Fundamentals of Nursing, 11.3 The Medication Administration Process (medication errors) (source)

Answer: D — A nurse who is pregnant has been assigned to the client.

Staff who are pregnant or trying to become pregnant should not care for a client with a sealed radioactive implant. Grouping care (time), keeping distance, using shielding and handling a dislodged source only with tongs are all correct precautions.

Checked against: OpenStax Medical-Surgical Nursing, 31.3 Care of the Patient with Cancer, Radiation Therapy (precautions with sealed radioactive implants) (source)