Question 1

Which type of isolation precaution is required for a patient with tuberculosis?

Accepted Answer

Answer reason: Tuberculosis is transmitted via airborne droplet nuclei that can remain suspended in the air, so transmission-based airborne precautions are required. This includes placement in an airborne infection isolation room (negative pressure) and use of a fit-tested N95 respirator (or PAPR) for staff. Contact or droplet precautions alone are insufficient to prevent inhalational spread, although standard precautions are used for all patients in addition to airborne measures.
Category reason: The question tests the nurse’s selection of appropriate transmission-based isolation for a communicable disease, which is a core Safety and Infection Control responsibility in NCLEX-style patient care.

Question 2

Gloves are to be worn when performing which of the following activities?

Accepted Answer

Answer reason: Gloves are required when there is an anticipated risk of contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated items under Standard Precautions. Peri-care involves contact with the perineal area and likely exposure to urine, stool, and contaminated secretions, so gloves are indicated. Feeding, changing clothes, or repositioning generally do not require gloves unless body fluid exposure is expected or the patient has open/draining wounds. Therefore, performing peri-care is the best answer.
Category reason: This item tests infection prevention and when to use personal protective equipment (gloves) during resident care, which is a nursing safety judgment under Standard Precautions.

Question 3

Which item is considered PPE in infection control?

Accepted Answer

Answer reason: Personal protective equipment (PPE) includes items worn to reduce exposure to infectious agents, such as gloves, gowns, masks, and eye protection. Gloves are used during standard precautions when contact with blood, body fluids, mucous membranes, or nonintact skin is anticipated. A stethoscope and ID badge are equipment/identification items, not PPE. Regular shoes are not considered PPE unless specialized protective footwear is required for a specific hazard.
Category reason: This question tests infection-control practice and identification of PPE used under standard precautions, which aligns with NCLEX Safety and Infection Control.

Question 4

During hand hygiene, a nurse notices a small cut on the hand. What should the nurse do before continuing care?

Accepted Answer

Answer reason: Open cuts on the hands can serve as a portal of entry for pathogens to the nurse and a potential source of contamination to patients. Standard precautions require covering breaks in skin with an occlusive/waterproof dressing before patient contact and then performing hand hygiene as indicated. Simply wearing gloves without covering the cut increases the risk of contamination if the glove tears or during glove removal. There is no need to leave work for a small cut if it can be adequately covered and infection-control practices are followed.
Category reason: The question tests infection-prevention actions a nurse should take before providing care when there is a break in skin integrity, which falls under standard precautions and transmission-based precautions.

Question 5

Nurse Patel is caring for a client diagnosed with herpes zoster. Which nursing intervention demonstrates appropriate management of this condition?

Accepted Answer

Answer reason: Herpes zoster (shingles) can transmit varicella-zoster virus via direct contact with vesicular fluid, so infection control is a priority. Wearing gloves during client care is part of standard precautions and reduces the risk of transmitting the virus to the nurse or to other patients via contaminated hands. Antibiotics are not indicated unless there is a secondary bacterial infection, and oxygen therapy is unrelated. While lesions may be covered if draining, the most consistently appropriate and broadly applicable intervention listed is using gloves during care.
Category reason: The question tests a nursing action focused on preventing transmission of an infectious condition during patient care, which falls under Safety and Infection Control and specifically standard precautions/transmission-based precautions.

Question 6

The nurse is preparing to care for a client diagnosed with pulmonary tuberculosis. Which personal protective equipment (PPE) should the nurse wear before entering the client's room?

Accepted Answer

Answer reason: Pulmonary tuberculosis is an airborne infection, so the nurse must use airborne precautions when entering the room. An N95 respirator (or higher-level respirator) is required to filter droplet nuclei and protect the nurse from inhalation exposure. A surgical mask is not sufficient for airborne pathogens, and gown/gloves are only needed if contact with blood/body fluids is anticipated per standard precautions. Therefore, the single best required PPE before entry is an N95 respirator.
Category reason: The question tests nursing infection-control actions (what PPE to wear for an airborne disease) rather than underlying microbiology facts, fitting NCLEX Safety and Infection Control—Transmission-Based Precautions.

Question 7

Which of the following clients require droplet precautions? (SATA)?

Accepted Answer

Answer reason: Mumps is transmitted via respiratory droplets, so droplet precautions (mask and eye protection as needed) are indicated. Other classic droplet infections include rubella and pertussis; RSV is typically managed with contact precautions in pediatrics, and tuberculosis requires airborne precautions (N95/negative pressure). Because the item is SATA, multiple options would be correct, but the task requires skipping.
Category reason: This question tests selection of appropriate transmission-based precautions for specific infections, which is a core Safety and Infection Control competency under NCLEX.

Question 8

A nurse is caring for a child hospitalized with hand-foot-and-mouth disease (caused by Coxsackievirus). Which precautions are appropriate? (SATA)?

Accepted Answer

Answer reason: Hand-foot-and-mouth disease (Coxsackie/enterovirus) spreads via fecal-oral route and contact with respiratory secretions and vesicle fluid, so contact precautions are appropriate in addition to standard precautions. Droplet precautions may also be used depending on institutional policy and presence of significant respiratory secretions, but the question is SATA. Airborne precautions are not indicated because transmission is not via airborne droplet nuclei. Neutropenic precautions protect immunocompromised clients and are not an isolation category for preventing spread from this infected child.
Category reason: The item tests selecting appropriate isolation/precaution type to prevent transmission in a clinical care setting, which is an NCLEX Safety and Infection Control competency under transmission-based precautions.

Question 9

Which type of isolation is required for a patient with an open wound infection?

Accepted Answer

Answer reason: Open wound infections are most commonly transmitted by direct contact with the wound, drainage, or contaminated surfaces and equipment. Transmission-based precautions for this route are Contact precautions, including gown and gloves when touching the patient or their environment and dedicated equipment when possible. Droplet and airborne precautions are reserved for respiratory pathogens spread via droplets or aerosols, not typical localized wound infections. Reverse isolation is used to protect severely immunocompromised patients rather than to prevent spread from an infected wound.
Category reason: The question tests infection-control decision-making (choosing the correct isolation category) to prevent transmission in a care setting, which aligns with NCLEX Safety and Infection Control.

Question 10

A patient with suspected measles is admitted. Which action should the nurse take first?

Accepted Answer

Answer reason: Measles (rubeola) is transmitted via airborne particles, so the priority is immediate isolation to prevent exposure to others. Placing the client in a private room with the door closed is the first step to contain airborne spread while arranging for airborne precautions (negative pressure) and appropriate PPE (e.g., N95) as available. Droplet precautions and a surgical mask on the client are insufficient alone for measles, and enhanced housekeeping is not the initial priority compared with immediate isolation.
Category reason: This item tests the nurse’s immediate infection-control action and selection of transmission-based precautions for a suspected airborne pathogen, which fits NCLEX Safety and Infection Control.

Question 11

The charge nurse is reviewing room assignments. The nurse should intervene if a staff member rooms together two clients who both have which condition?

Accepted Answer

Answer reason: Varicella (chickenpox) requires airborne and contact precautions, and clients should be placed in a private negative-pressure room. Cohorting is generally avoided because of the high transmissibility and risk to susceptible or immunocompromised patients. Therefore, rooming two clients with varicella together requires nurse intervention.
Category reason: This question evaluates correct application of transmission-based precautions and cohorting decisions, which fall under Standard Precautions and Transmission-Based Precautions.

Question 12

A nurse is preparing to enter the room of a client diagnosed with c.difficile infection. Which of the following personal protective equipment should the nurse wear?

Accepted Answer

Answer reason: Clostridioides difficile is transmitted via the fecal-oral route through contact with contaminated surfaces and hands, so Contact Precautions are required. The essential PPE for entering the room is a gown and gloves to prevent contamination of clothing and hands. A surgical mask or N95 is not routinely required because C. difficile is not an airborne pathogen. Face shield/eye protection is only indicated if there is a risk of splashes or sprays (e.g., during cleaning or procedures).
Category reason: The item tests correct PPE selection for a specific transmissible infection (C. difficile) and appropriate isolation precautions, which is a patient-safety infection control competency.

Question 13

A patient with Clostridioides difficile infection is on precautions. Which type of isolation should the nurse implement?

Accepted Answer

Answer reason: Clostridioides difficile is transmitted via spores through the fecal-oral route, primarily by contaminated hands and surfaces, so contact (enteric) precautions are required. This includes gown and gloves on room entry and strict hand hygiene with soap and water because alcohol-based rubs are not reliably sporicidal. Dedicated equipment and enhanced environmental cleaning with a sporicidal agent (e.g., bleach) help prevent spread. Droplet and airborne isolation are not indicated for routine C. difficile infection.
Category reason: The question tests the nurse’s selection of appropriate transmission-based isolation precautions to prevent healthcare-associated infection spread, which is an NCLEX Safety and Infection Control decision.

Question 14

Most of the respiratory infection are transmitted by....?

Accepted Answer

Answer reason: Most common community respiratory infections (e.g., influenza, RSV, pertussis, many viral URIs) spread primarily via respiratory droplets generated by coughing, sneezing, or talking at close range. Droplet transmission explains why surgical masks, cough etiquette, and maintaining distance reduce spread. Transplacental transmission is limited to specific congenital infections and is not the usual route for respiratory illnesses. Vector-borne spread (e.g., via mosquitoes) does not apply to typical respiratory infections.
Category reason: The question tests how infections spread and which transmission-based precautions apply, which is a core nursing safety/infection-control concept rather than organ physiology.

Question 15

A nurse is caring for a client with pulmonary tuberculosis. Which PPE is essential?

Accepted Answer

Answer reason: Pulmonary tuberculosis is an airborne infection requiring airborne precautions to prevent inhalation of droplet nuclei. The essential PPE is a fit-tested N95 (or higher-level) respirator when entering the patient’s room. A surgical mask does not provide reliable protection against airborne particles, and gowns/gloves are used based on anticipated contact with bodily fluids rather than being the key protection for TB. Therefore, the N95 respirator is the single most essential PPE.
Category reason: This item tests infection-control practice for a specific communicable disease (airborne precautions for TB), which is a core nursing safety responsibility under transmission-based precautions.

Question 16

Which client activity should the nurse discourages the spread of infection in a client under airborne precautions?

Accepted Answer

Answer reason: Under airborne precautions, controlling respiratory droplet nuclei spread requires appropriate respiratory protection for anyone entering the room and masking the client if transport is necessary. Allowing visitors without masks increases the risk of acquiring and transmitting airborne pathogens (e.g., TB, measles, varicella). In contrast, private bathroom use, client masking when leaving the room, and frequent hand hygiene are appropriate measures that help reduce transmission. Therefore, the activity to discourage is receiving visitors without masks.
Category reason: This question tests nursing infection-control actions for a client on airborne precautions, which falls under transmission-based precautions within Safety and Infection Control.

Question 17

A child with chickenpox (varicella) is admitted to the hospital. What type of isolation precaution is required?

Accepted Answer

Answer reason: Varicella (chickenpox) is highly contagious and spreads via airborne transmission from respiratory secretions as well as by direct contact with vesicular fluid from skin lesions. Therefore, hospitalized patients require both airborne precautions (e.g., negative-pressure room, N95 respirator) and contact precautions (gown/gloves). Droplet or standard precautions alone do not sufficiently prevent transmission of varicella in the acute phase.
Category reason: This question tests selection of appropriate transmission-based isolation precautions to prevent hospital spread of infection, which is a nursing safety and infection control decision.

Question 18

A hospitalized client tests positive for Clostridioides difficile. Which action is best?

Accepted Answer

Answer reason:  Implement contact precautions with gown and gloves; wash hands with soap and water C. difficile is spread via spores through the fecal-oral route, so contact precautions (gown and gloves) are required to prevent transmission. Alcohol-based hand sanitizers do not reliably kill C. difficile spores; handwashing with soap and water is necessary after patient contact. Airborne isolation with an N95 is not indicated, and cohorting should only be with another patient with the same organism, not MRSA.
Category reason: This question tests infection-control actions (isolation type and hand hygiene) a nurse must implement for a hospitalized patient, which is an NCLEX Safety and Infection Control focus under transmission-based precautions.

Question 19

A pediatric client has rubeola. What kind of infection control measure should the nurse initiate?

Accepted Answer

Answer reason: Airborne transmission precautions Rubeola (measles) is transmitted via airborne particles and can remain suspended and infectious in the air for extended periods. Therefore, the client should be placed on airborne precautions (e.g., negative-pressure room and N95 respirator for staff) in addition to standard precautions. Droplet precautions are insufficient for measles because transmission is not limited to large droplets at close range.
Category reason: This is a nursing infection-control decision about selecting the correct transmission-based precautions for a communicable disease, which fits Safety and Infection Control.

Question 20

A nurse is caring for a child with suspected varicella (chickenpox). Which action is most appropriate?

Accepted Answer

Answer reason: Place the child in a negative pressure room Varicella is highly contagious and requires airborne precautions (and contact precautions) to prevent transmission, so an airborne infection isolation room (negative pressure) is most appropriate when available. A semiprivate room increases risk of spread to another patient. Standard precautions alone are insufficient for suspected chickenpox. Aspirin is contraindicated in children with viral illnesses due to the risk of Reye syndrome.
Category reason: This question tests the nurse’s infection-control action (appropriate transmission-based precautions and room placement) for a contagious pediatric illness, which aligns with Safety and Infection Control on the NCLEX.

Question 21

A patient who has been diagnosed with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take first?

Accepted Answer

Answer reason: A. Place the patient in an airborne isolation room. With suspected avian influenza, the priority is immediate infection control to prevent transmission to staff and other patients, so the client should be placed in appropriate isolation before other interventions. Diagnostic specimen collection and history questions can occur after precautions are in place, because they increase contact and exposure risk. A saline bolus is not the first priority unless there is evidence of hemodynamic instability, which is not provided in the stem.
Category reason: This question tests the nurse’s first action to prevent disease transmission in a suspected highly contagious respiratory infection, which falls under transmission-based precautions within Safety and Infection Control.

Question 22

Which patient needs airborne precautions?

Accepted Answer

Answer reason: A child with tuberculosis Tuberculosis is transmitted via airborne droplet nuclei that can remain suspended in the air, so it requires airborne precautions (e.g., negative-pressure room and an N95 respirator for staff). Pertussis is primarily managed with droplet precautions, not airborne. RSV is spread mainly by contact (and sometimes droplet), so contact precautions are typically indicated.

Question 23

A hospitalized 88-year-old patient who has been receiving antibiotics for 10 days tells the nurse about having frequent watery stools. Which action will the nurse take first?

Accepted Answer

Answer reason: Place the patient on contact precautions. An older hospitalized patient with new frequent watery stools after prolonged antibiotic use is suspicious for Clostridioides difficile infection, which spreads via spores and requires immediate transmission-based precautions. The nurse’s first priority is to prevent spread to other patients and staff by initiating contact precautions (gown/gloves; dedicated equipment; hand hygiene). Provider notification and stool testing are important next steps but do not come before immediate infection control.
Category reason: This question asks for the nurse’s first action to prevent transmission of a suspected infectious diarrhea in a hospitalized patient, which is primarily an infection-control and safety priority.

Question 24

A nurse is assigned to care for a patient with tuberculosis (TB). Which isolation precaution is required?

Accepted Answer

Answer reason: Airborne precautions with N95 respirator Tuberculosis is transmitted via airborne droplet nuclei that can remain suspended and travel in the air, so airborne isolation is required. The nurse should use a fit-tested N95 (or higher-level) respirator and the patient should be placed in a negative-pressure room when available. Droplet precautions with a surgical mask are insufficient for TB because they do not filter small airborne particles reliably. Standard precautions alone do not adequately prevent airborne transmission.
Category reason: This question tests nursing infection-control decision-making about which transmission-based precautions to implement for a specific diagnosis (TB), which aligns with NCLEX Safety and Infection Control.

Question 25

True or False A nurse should always wear sterile gloves when taking a patient’s blood pressure.?

Accepted Answer

Answer reason: False Taking a blood pressure is a non-sterile, noninvasive procedure and does not require sterile gloves. Standard precautions are used based on anticipated exposure to blood/body fluids; routine BP measurement typically involves intact skin and no such exposure. Clean (nonsterile) gloves may be indicated if there is potential contact with body fluids or non-intact skin, along with appropriate hand hygiene. Overuse of sterile gloves wastes resources without improving infection prevention.
Category reason: This item tests infection-control decision-making about when sterile technique versus standard precautions are required during routine nursing care.

Question 26

A client newly diagnosed with tuberculosis (TB) is being discharged home. Which instruction should the nurse include?

Accepted Answer

Answer reason: “Wear a surgical mask when in close contact with others.” TB is spread via airborne droplet nuclei, so discharge teaching should emphasize measures that reduce transmission to others until the client is no longer infectious (typically after adequate therapy and clinical improvement, not after just 1 day). Wearing a mask around others and practicing cough etiquette helps contain respiratory secretions and protects household contacts. The other options promote nonadherence or unsafe infection-control practices that increase transmission risk and treatment failure/drug resistance.
Category reason: This question tests discharge teaching to prevent transmission of an airborne infection and protect others, which is a nursing safety/infection-control judgment rather than foundational pathophysiology.

Question 27

Q......... is not caused by airborne transmission.?

Accepted Answer

Answer reason: Airborne transmission involves inhalation of small droplet nuclei that remain suspended in air; classic airborne infections include TB, measles (rubeola), and varicella (chickenpox). Hepatitis B is primarily transmitted via blood and body fluids (percutaneous or mucosal exposure), including sexual contact, needle sharing, and perinatal transmission. Therefore it is not an airborne disease and does not require airborne precautions for routine transmission prevention.
Category reason: This question tests selection of the correct transmission route to determine appropriate precautions, which is a core Safety and Infection Control concept under transmission-based precautions.

Question 28

A healthcare worker sustains a percutaneous injury involving blood from a patient with advanced AIDS. What is the recommended post-exposure prophylaxis (PEP) regimen?

Accepted Answer

Answer reason: A percutaneous exposure to blood from a source with advanced HIV is a high-risk occupational exposure, so PEP should be started as soon as possible and uses combination antiretroviral therapy to reduce seroconversion risk. Single-drug regimens and monotherapy are inadequate due to lower efficacy and resistance concerns. Observation alone is not appropriate given the significant exposure risk. Standard PEP is a 3-drug regimen for a full course rather than a single dose.
Category reason: This question tests occupational exposure management and infection-control actions (choosing appropriate HIV PEP) after a needlestick, which falls under Safety and Infection Control within NCLEX.

Question 29

A patient is admitted with suspected meningitis. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: C. PLACE THE PATIENT IN ISOLATION Suspected meningitis can be caused by organisms requiring droplet precautions (e.g., meningococcal disease), so immediate isolation reduces transmission risk to staff and other patients. Infection-control actions are time-critical and should be initiated as soon as the condition is suspected, even before diagnostic confirmation. Cultures and lumbar puncture should be obtained promptly, and antibiotics started quickly after cultures when possible, but they do not prevent immediate exposure risk in the same way.
Category reason: This is a prioritization question about the first nursing action to protect others from a potentially contagious infection, which falls under transmission-based precautions and infection control.

Question 30

While wearing sterile gloves, first glove need to be worn in ........hands?

Accepted Answer

Answer reason: Sterile gloving uses the open-gloving technique where the first glove is applied to the dominant hand so the non-dominant hand (still ungloved) can manipulate only the inside cuff without contaminating the glove’s exterior. Once the dominant hand is gloved, it can then safely handle the outside surface of the second glove to glove the non-dominant hand. This sequence reduces the risk of contaminating the sterile glove surfaces and supports aseptic technique.
Category reason: This question tests correct sterile technique to prevent contamination during a nursing procedure, which is part of infection control and standard precautions.

Question 31

A 17 year old male presents to the ED with suspected meningitis. He is placed in a room & the doctor begins entering orders to the patient's EMR. The priority action of the nurse is?

Accepted Answer

Answer reason: Suspected meningococcal meningitis is highly contagious via respiratory droplets, so immediate droplet precautions reduce risk of transmission to staff and other patients. Safety measures that prevent spread take priority and should be implemented before non-urgent assessments or procedures once meningitis is suspected. Focused assessment, IV access/fluids, and preparation for lumbar puncture are important, but they do not mitigate the immediate public health and occupational exposure hazard.
Category reason: This question tests the nurse’s priority action to prevent transmission in a suspected infectious disease case, which is a patient and staff safety decision under transmission-based precautions.

Question 32

The nurse is triaging a client who reports recent international travel. The primary healthcare provider (PHCP) suspects the client may have severe acute respiratory syndrome (SARS). The nurse should initially?

Accepted Answer

Answer reason: A. place the client on contact and airborne precautions. With a suspected highly transmissible respiratory infection after international travel, the first priority in triage is preventing spread to other clients and staff. Immediate implementation of appropriate transmission-based precautions (including airborne isolation measures and contact precautions) reduces nosocomial transmission risk before diagnostic confirmation. Diagnostic tests (cultures, chest x-ray) and supportive therapies can follow once isolation is in place, because delays in containment create system-wide safety hazards.
Category reason: This item tests the nurse’s immediate infection-control action in triage to prevent transmission of a suspected airborne/respiratory pathogen, which fits Safety and Infection Control—Standard Precautions/Transmission-Based Precautions.

Question 33

Which is an example of standard precautions?

Accepted Answer

Answer reason: Standard precautions assume that blood and certain body fluids may be contaminated, so appropriate PPE and hand hygiene are used based on the anticipated exposure. This approach reduces the risk of transmission of pathogens regardless of the patient’s known diagnosis. Universal isolation of every resident is not required, and gowns or double-gloving are used only when indicated by the task and expected exposure.
Category reason: This question tests infection prevention behaviors and proper application of standard precautions, which is a core nursing safety competency under Safety and Infection Control.

Question 34

When donning PPE, the correct order is?

Accepted Answer

Answer reason: This sequence reduces contamination risk by placing the gown first to cover clothing/skin before any potentially contaminated hand contact occurs. The mask (and eye protection if indicated) is applied next so it is secured without gloves that may later become contaminated. Gloves are donned last so they cover the gown cuffs and remain the cleanest item for direct patient/environment contact. This order aligns with standard infection-control PPE donning guidance.
Category reason: This question tests correct use of personal protective equipment to prevent transmission of infection, which is a core Safety and Infection Control competency under Standard/Transmission-Based precautions.

Question 35

A 6-month-old infant is brought to the clinic with a fever, irritability, and a bulging fontanelle. The nurse suspects bacterial meningitis. Which action is most important?

Accepted Answer

Answer reason: Bacterial meningitis can be transmitted via respiratory droplets, and early isolation reduces immediate risk of spread to other patients, caregivers, and staff. Implementing transmission-based precautions is an urgent nursing action that can be done immediately without waiting for diagnostic confirmation. Symptomatic measures (antipyretics, fluids) do not address contagion, and preparing for lumbar puncture is important but does not take priority over immediate infection control in a clinic setting.
Category reason: This question tests the nurse’s priority action to prevent transmission of a suspected contagious infection, which fits Safety and Infection Control under transmission-based precautions.

Question 36

A client is admitted and is diagnosed with urethritis caused by chlamydial infection. The nurse assigned to the client understands that what precautions are necessary to prevent contraction of the infection during care?

Accepted Answer

Answer reason: Chlamydia is transmitted primarily through sexual contact, so routine patient care does not require transmission-based isolation beyond standard precautions. Using hand hygiene and appropriate PPE based on anticipated exposure to body fluids is sufficient to prevent occupational transmission in usual care. Contact or enteric precautions are reserved for pathogens spread by direct contact or fecal-oral routes, which does not fit chlamydial urethritis. A “gloves and a mask” choice is incomplete and not the overarching, always-applicable infection-control framework compared with standard precautions.
Category reason: This question tests the nurse’s selection of appropriate infection-control precautions during patient care, which is an NCLEX Safety and Infection Control decision.

Question 37

WHICH PERSONAL PROTECTIVE EQUIPMENT (PPE) IS MOST IMPORTANT TO PREVENT DROPLET INFECTION?

Accepted Answer

Answer reason: Droplet transmission occurs via large respiratory particles that travel short distances and deposit on the mucous membranes of the nose and mouth. A surgical/procedure mask provides the key barrier to block inhalation of these droplets and reduce spread from an infected person. Gloves and gowns mainly protect against contact contamination of hands/clothing and do not adequately prevent inhalation exposure. Shoe covers are not a primary control for droplet-spread pathogens.
Category reason: This is about selecting appropriate PPE for a specific transmission-based precaution to prevent infection spread, which is part of Safety and Infection Control under Standard/Transmission-Based Precautions.

Question 38

A client is on contact precautions for MRSA. What should the nurse wear when entering the room?

Accepted Answer

Answer reason: MRSA on contact precautions requires barrier protection to prevent transmission via direct contact and contaminated surfaces. Gloves protect the hands and a gown prevents contamination of clothing when touching the client or nearby environment. A mask or face shield is not routinely required unless there is risk of splash/spray (which would indicate adding eye/face protection). Wearing gloves only is insufficient because clothing can still carry organisms out of the room.
Category reason: This item tests appropriate use of transmission-based precautions and PPE selection to prevent healthcare-associated infection, which fits Safety and Infection Control.

Question 39

A nurse is caring for a client with suspected meningitis. Which action should the nurse prioritize in the Take Action phase?

Accepted Answer

Answer reason: Suspected meningitis can be caused by organisms transmitted via respiratory droplets, so immediate transmission-based precautions are the highest-priority action to protect staff and other clients while diagnostic confirmation is pending. Hydration and comfort measures (analgesia, low-stimulation environment) are supportive but do not address urgent infection-control risk. Giving analgesics without a prescription is outside nursing scope and violates medication administration/legal standards.
Category reason: The question asks for the nurse’s highest-priority immediate intervention to prevent spread of infection in a suspected communicable condition, which fits transmission-based precautions under Safety and Infection Control.

Question 40

Universal precautions include

Accepted Answer

Answer reason: Standard precautions (often referred to as universal precautions in older terminology) include measures to prevent exposure to blood and body fluids through barrier protection and hygiene. Gloves and gowns are used based on anticipated exposure to blood/body fluids and contamination risk. Hand hygiene is required before and after patient contact and after removing gloves, making the combined set the best choice among the options.
Category reason: This item tests infection prevention practices (standard/universal precautions) used in routine patient care, which is an NCLEX Safety and Infection Control topic.

Question 41

Which PPE should be removed first to prevent contamination?

Accepted Answer

Answer reason: Gloves are considered the most contaminated PPE because they directly contact the patient and potentially contaminated surfaces. Removing them first reduces the chance of transferring microorganisms to other PPE items or to the wearer’s skin during subsequent doffing. Standard doffing sequence typically starts with gloves, then gown, then eye protection (face shield/goggles), and mask last, followed by hand hygiene.
Category reason: This question tests infection-control practice for safe PPE doffing to prevent self-contamination, which falls under Standard Precautions and transmission-based precautions.

Question 42

A charge nurse is reviewing the plan of care for a client who has active herpes simplex lesions. Which of the following interventions is appropriate for the plan of care?

Accepted Answer

Answer reason: Active herpes simplex lesions are primarily managed with contact precautions to prevent transmission via direct skin-to-skin contact and contaminated surfaces. Gloves and a gown protect the nurse’s hands and clothing from exposure to lesion drainage and reduce the risk of spreading the virus to other sites or patients. Negative-pressure rooms and routine masking are not indicated because HSV is not an airborne infection, and eye/face protection is only needed when splashing of body fluids is anticipated.
Category reason: This item tests selection of appropriate isolation measures and PPE to prevent healthcare-associated transmission, which is part of Safety and Infection Control under Standard/Transmission-Based Precautions.

Question 43

You are assigned in a private room of Mike. Which procedure should be of utmost importance?

Accepted Answer

Answer reason: Standard precautions are the foundational infection-control measures used for all patients regardless of diagnosis, focusing on preventing exposure to blood and body fluids. In a private room, the priority remains consistent application of hand hygiene, appropriate PPE, and safe handling of sharps and contaminated items. The other options describe narrower or unclear practices, while standard precautions encompass hand hygiene and glove use as part of a comprehensive approach.
Category reason: This question asks about the most important infection-control procedure to use while caring for a patient, which is a nursing safety decision under Safety and Infection Control.

Question 44

Scenario: A patient is admitted with suspected pulmonary tuberculosis (TB). Which PPE is essential before entering the room?

Accepted Answer

Answer reason: Suspected pulmonary TB requires airborne precautions because infectious droplet nuclei can remain suspended in air and be inhaled. A fit-tested particulate respirator is needed to filter airborne particles when entering the room, whereas a surgical mask primarily protects others from the wearer’s droplets and does not provide reliable airborne filtration. Additional PPE (e.g., gloves/gown) may be used based on anticipated contact with body fluids, but respiratory protection is the essential requirement for entry.
Category reason: This question tests nursing infection-control actions and appropriate PPE selection for airborne isolation, which falls under Transmission-Based Precautions.

Question 45

Scenario: A patient is diagnosed with influenza and placed under droplet precautions. What nursing action is appropriate?

Accepted Answer

Answer reason: Influenza is transmitted primarily via respiratory droplets that typically travel short distances, so droplet precautions require a surgical mask when within close range of the patient. An N95 respirator is reserved for airborne precautions (e.g., tuberculosis, measles) or when performing aerosol-generating procedures per facility policy. Keeping the door open/closed is not a key control for droplet transmission, and routine double-gloving is not indicated unless contact with blood/body fluids is anticipated.
Category reason: This question tests the nurse’s selection of appropriate transmission-based precautions and PPE to prevent spread of infection in patient care, which falls under Safety and Infection Control.

Question 46

Scenario: A nurse is changing the dressing of a central line. What is the most important infection control practice?

Accepted Answer

Answer reason: Central line dressing changes require strict aseptic technique because the catheter provides direct access to the bloodstream, making contamination high-risk for CLABSI. Barrier protection with sterile gloves and a mask reduces transmission of skin and respiratory flora during the procedure. Antiseptic solutions and dressing type are important, but they are secondary to maintaining a sterile field and minimizing microbial shedding from the caregiver.
Category reason: This question tests nursing infection-control actions during a central line dressing change, which is a patient-care safety intervention under Safety and Infection Control.

Question 47

Which statement below best describes universal precaution?

Accepted Answer

Answer reason: C. Assuming all patients present a potential for transmission of infectious disease and adopting the same protective techniques with every patient Standard (universal) precautions are applied to all patients regardless of known diagnosis because blood and certain body fluids can be infectious even when risk is not apparent. This approach prevents missed exposures when infections are undiagnosed or asymptomatic. Option B is too narrow because it limits precautions to known infectious cases, and option D describes examples of PPE but not the core principle of applying precautions universally.
Category reason: This question tests infection prevention practices (standard/universal precautions) used in routine patient care to protect patients and healthcare workers, which is an NCLEX Safety and Infection Control topic.

Question 48

A patient is admitted to the ward with symptoms of acute diarrhea. What should your initial management be?

Accepted Answer

Answer reason: Acute diarrhea may be infectious, so the priority is preventing transmission while evaluating severity (hydration status, vital signs, stool characteristics, exposure/travel/antibiotic history). Source isolation (e.g., contact precautions as indicated) limits spread from the symptomatic patient, whereas protective isolation is for immunocompromised patients. Empiric antibiotics and antimotility agents are not universal initial steps and can be inappropriate (e.g., suspected C. difficile or invasive dysentery), so they should follow assessment and likely etiology.
Category reason: This is primarily about initial nursing actions to prevent infection transmission in a hospitalized patient, which falls under Safety and Infection Control and the use of standard/transmission-based precautions.

Question 49

A nurse is caring for a patient diagnosed with meningococcal meningitis. Which of the following isolation precautions should the nurse initiate?

Accepted Answer

Answer reason: Neisseria meningitidis is transmitted primarily via respiratory droplets during close contact, so droplet precautions are required to prevent spread. This includes wearing a surgical mask when within close range of the patient and using standard precautions for all care. Airborne precautions are reserved for organisms that remain suspended and spread over longer distances (e.g., TB, measles), which does not match meningococcal transmission. Contact or enteric precautions target pathogens spread by direct touch or fecal-oral routes, which is not the primary mode here; droplet precautions should be maintained (typically for at least the first 24 hours of effective antibiotics).

Question 50

A mask prevent the spread of microbes from

Accepted Answer

Answer reason: By covering the nose and mouth, they limit dispersion of saliva and respiratory secretions into the environment and onto nearby people or surfaces. Microbes from the GI tract are mainly spread via the fecal–oral route, which is prevented by hand hygiene and contact precautions rather than masking. Microbes from intact skin are more effectively controlled with hand hygiene, gloves, and proper skin antisepsis, not a face mask.

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