Question 1

The nurse assessed the client and noted shortness of breath and a recent trip to China. The client is strongly suspected of having Severe Acute Respiratory Syndrome (SARS). Which of these prescribed actions will the nurse take first?

Accepted Answer

Answer reason: Suspected SARS represents a high-risk, potentially transmissible respiratory infection, so immediate transmission-based precautions are the priority to prevent spread to staff and other patients. Instituting airborne and contact precautions promptly addresses the most urgent safety threat before initiating nonurgent treatments or diagnostics. Starting IV fluids or administering high-dose steroids does not reduce immediate contagion risk and could be harmful if given before adequate evaluation. Cultures and other diagnostic sampling can be performed after isolation is in place to limit exposure during specimen collection and transport.

Question 2

The nurse is admitting a 72 year-old patient hospitalized for a medical diagnosis of Mycoplasma pneumonia. Which tier two transmission-based precautions are needed?

Accepted Answer

Answer reason: Droplet precautions require a surgical mask for close contact (commonly within 3 feet/1 meter per many nursing exam conventions) to block large-particle respiratory transmission. Negative-pressure rooms and HEPA-filtered air are airborne-precaution measures used for pathogens like tuberculosis or measles, not typical Mycoplasma. Gloves are part of standard precautions when contact with secretions is anticipated, but they are not the defining tier-two requirement for droplet transmission in this scenario.

Question 3

A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?

Accepted Answer

Answer reason: Bacterial meningitis can be transmitted via respiratory droplets, so the priority is preventing spread using transmission-based precautions in an appropriate isolation room. A single isolation room supports droplet precautions and limits exposure to other patients and staff, which is the central safety goal at admission. Cohorting with someone who had viral meningitis or a history of bacterial meningitis is unsafe because it risks cross-infection with different organisms and does not meet required isolation practices. Proximity to the nurses’ station is not the primary determinant; isolation requirements outweigh convenience for monitoring.

Question 4

What precaution should a nurse initiate when caring for a patient with hepatitis B?

Accepted Answer

Answer reason: Using routine hand hygiene, gloves when contacting blood/body fluids, and appropriate PPE for splash risk appropriately addresses this transmission route. Airborne/respiratory measures target pathogens spread by droplets or aerosols rather than bloodborne viruses. Enteric precautions focus on fecal-oral transmission, which is not the dominant route for hepatitis B in healthcare settings.

Question 5

Patient with bronchiolitis what's standard precautions use except?

Accepted Answer

Answer reason: Bronchiolitis (commonly RSV) primarily requires contact precautions (and sometimes droplet precautions depending on policy), but a mask is not a routine component of standard precautions by itself. Gloves and gown are often used to prevent contact transmission from respiratory secretions, and meticulous hand washing is central to preventing spread. Therefore the item that is not typically listed as a standard precaution measure in this context is the mask.

Question 6

A client has been diagnosed with cutaneous anthrax in a cut on the right hand. What should the nurse do for self protection while caring for this client?

Accepted Answer

Answer reason: Cutaneous anthrax is primarily spread through direct contact with infected lesions or contaminated materials, so barrier protection and hand hygiene are the key safety measures. Standard (universal) precautions address this risk by using gloves and appropriate PPE when contact with blood/body fluids or non-intact skin is possible. A mask alone does not protect against the main transmission route for cutaneous disease. Avoiding the client is not an infection-control strategy; appropriate precautions allow safe care while preventing transmission.

Question 7

The nurse reviews the transmission of rubella to a client contemplating pregnancy. Which client statement about the route of transmission indicates that teaching as been effective?

Accepted Answer

Answer reason: Droplet transmission explains why avoiding close contact with infected individuals and using appropriate masking/isolation measures reduces risk. This route is especially important for a client contemplating pregnancy due to the severe fetal risks of congenital rubella syndrome. Foodborne and bloodborne routes are not typical mechanisms for rubella, making them unsafe misconceptions. Direct contact can occur with secretions, but the tested standard category for rubella is droplet precautions.

Question 8

The full form of PPE is?

Accepted Answer

Answer reason: This expansion precisely matches the widely used clinical abbreviation in infection prevention and occupational safety. The other options incorrectly reorder or replace key words and do not represent any standard healthcare term. Correct understanding supports appropriate selection and use of gloves, gowns, masks/respirators, and eye protection to prevent transmission.

Question 9

Which one of the following statements is correct? Standard precautions should be implemented?

Accepted Answer

Answer reason: Standard precautions are applied universally because any patient may have unrecognized infection or colonization, and blood/body fluid exposure can occur unpredictably. They include core measures such as hand hygiene, appropriate PPE based on anticipated exposure, respiratory hygiene/cough etiquette, and safe injection practices. This approach reduces transmission risk regardless of diagnosis, setting, or known infectious status. Options limiting use to known infection or isolation are unsafe because they miss asymptomatic or undiagnosed cases.

Question 10

An assistive personnel (AP) asks a nurse what type of precautions are necessary when obtaining vital signs for a client who has pneumonia. Which of the following is an appropriate response by the nurse?

Accepted Answer

Answer reason: " Pneumonia is commonly transmitted via respiratory droplets, so droplet precautions are used in addition to standard precautions. A surgical mask upon room entry helps prevent exposure to cough-generated droplets during close contact such as taking vital signs. Hand hygiene alone does not replace appropriate PPE when droplet transmission is possible, making the “no gloves if you wash hands” idea unsafe reasoning. Gloves are used when contact with secretions or contaminated items is anticipated (e.g., soiled linens), but that guidance does not address the key droplet risk during routine entry.

Question 11

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi’s sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Accepted Answer

Answer reason: Open, draining Kaposi’s sarcoma lesions create a risk of exposure to potentially infectious body fluids and contamination of the nurse’s clothing during close contact bathing. Gloves protect hands from direct contact with drainage, and a gown protects uniform/skin from soiling during prolonged contact care. A mask is not indicated unless splashing or aerosol-generating exposure is expected.

Question 12

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?

Accepted Answer

Answer reason: A negative-pressure private room reduces airborne particle dispersion to protect other patients and staff. Contact precautions are required because the virus can transmit via direct contact with vesicular fluid and contaminated surfaces. Droplet precautions alone are insufficient for disseminated disease, and a positive-pressure room is used to protect immunocompromised patients rather than contain an infectious source.

Question 13

The nurse is reinforcing home care instructions to the client diagnosed with severe acute respiratory syndrome (SARS). Which statement, if made by the client, indicates a need for further instruction?

Accepted Answer

Answer reason: " SARS is a contagious respiratory infection, so home care teaching emphasizes strict infection-control practices to prevent droplet/contact spread to others. Sharing utensils can transmit respiratory secretions via contaminated hands and fomites and is not considered safe based on an arbitrary time period. Clients should continue to avoid sharing personal items and maintain careful hygiene until they are clearly no longer infectious per public health/clinical guidance. The other statements reflect appropriate understanding of expected symptoms and key transmission-reduction behaviors (hand hygiene and limiting visitors).

Question 14

When a patient is admitted with acute influenza, what type of isolation is MOST appropriate?

Accepted Answer

Answer reason: Droplet-type measures (masking, patient placement, and minimizing unprotected close contact) are best captured by respiratory-focused isolation among the choices provided. Contact precautions alone are incomplete because they do not directly address droplet exposure to mucous membranes. Reverse isolation is intended to protect an immunocompromised patient from others, not to contain a contagious respiratory virus.

Question 15

A construction worker is admitted to the hospital for treatment of active tuberculosis (TB). The nurse teaches the client about TB. Which of the following statements by the client indicates to the nurse that further teaching is necessary?

Accepted Answer

Answer reason: " Airborne isolation for active pulmonary TB is based on infectiousness and response to therapy, not a fixed number of weeks. Isolation can typically be discontinued when the client has been on effective therapy, is clinically improving, and has consecutive negative sputum smears per facility/public health guidance. Stating a mandatory 6-week isolation period reflects a misunderstanding of transmission-based precautions and monitoring criteria. By contrast, cough etiquette and the need for prolonged multidrug therapy are appropriate teaching points for preventing spread and achieving cure.

Question 16

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room?

Accepted Answer

Answer reason: The client should wear a surgical mask when leaving the negative-pressure room to contain respiratory secretions and reduce environmental contamination. An N95 respirator is required for healthcare workers providing care in close contact during transport, not for the patient. Gown, gloves, and goggles are not routinely required unless there is anticipated contact with secretions or splash risk.

Question 17

During the height of the flu season, the nurse notes that several family members accompanying clients in the outpatient clinic are coughing and have runny noses. Which action will the nurse take first?

Accepted Answer

Answer reason: Respiratory hygiene/cough etiquette aims to immediately reduce droplet spread from symptomatic individuals in shared waiting areas. Separating those who are coughing from others creates an immediate barrier to transmission and is a rapid, actionable intervention the nurse can implement at the point of care. Posting signage and providing tissues support infection control but do not reduce exposure as quickly as physical distancing once symptomatic people are already present. Advising family members to stay home is appropriate teaching, but it does not address the current exposure risk in the clinic right now.

Question 18

You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?

Accepted Answer

Answer reason: Using only standard precautions implies non-sterile handling of the inner cannula during removal/cleaning, increasing the risk of introducing pathogens into the trachea and causing lower respiratory infection. Suctioning before care is appropriate when secretions are present to maintain airway patency and reduce coughing during the procedure. Removing soiled dressings/secretions and then replacing the inner cannula while cleaning the stoma are expected steps when performed with appropriate sterile technique and clean-to-dirty principles.

Question 19

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 severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first?

Accepted Answer

Answer reason: Suspected SARS represents a high-risk transmissible respiratory infection, so the immediate priority is preventing exposure to staff and other patients using appropriate transmission-based precautions. Airborne plus contact precautions (with appropriate PPE and isolation) should be initiated immediately upon suspicion, before any further diagnostic or therapeutic steps. Cultures and other specimens can be obtained after isolation is in place to avoid contaminating the environment and increasing transmission risk. Starting IV fluids or administering high-dose corticosteroids does not address the urgent public health/safety hazard and may be inappropriate before diagnosis and stabilization.

Question 20

The nurse is caring for a client with active pulmonary tuberculosis (TB). Which of the following should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: A surgical mask on the client during transport reduces dissemination of infectious particles into the hallway and other departments. Staff caring for the patient should use a fit-tested N95 respirator (or higher), not a simple surgical mask, and the room should have negative pressure with the door closed. Labeling precautions as “droplet” is incorrect for TB because the required transmission-based precaution is airborne, making that option unsafe/incomplete.

Question 21

The client with cellulitis containing methicillin-resistant Staphylococcus aureus (MRSA) has a neutrophil level of 82%. What intervention does the nurse perform for the client?

Accepted Answer

Answer reason: A key nursing priority with MRSA cellulitis is preventing transmission using appropriate infection-control measures. A neutrophil percentage of 82% reflects an expected neutrophilia with bacterial infection and is not, by itself, an emergency requiring immediate provider notification. Obtaining stat blood cultures is typically ordered when bacteremia/sepsis is suspected (e.g., fever, hypotension, altered mental status), not solely for an elevated neutrophil fraction. Implementing appropriate PPE during care addresses the immediate safety risk to staff and other patients and is within nursing scope without needing a new order.

Question 22

A nurse cares for a group of clients in the emergency department. Which client is placed on transmission-based precautions first?

Accepted Answer

Answer reason: Varicella is managed with airborne plus contact precautions, and a new vesicular rash with exposure is highly suggestive and should be treated as contagious until proven otherwise. Pertussis requires droplet precautions (less stringent than airborne), and C. difficile requires contact/enteric precautions, which are important but typically lower immediate airborne risk to others in the waiting area. A history of TB exposure without current symptoms like cough/hemoptysis is less urgent for airborne isolation than a probable active, highly contagious varicella presentation.

Question 23

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client?

Accepted Answer

Answer reason: Using contact protection (gown and gloves) plus airborne-level respiratory protection (N95) provides a higher safety margin than a simple surgical mask when the pathogen is severe and procedures may aerosolize particles. Eye protection is added because mucous membranes are a portal of entry for droplets/splashes during coughing, suctioning, or other care. Options that omit the respirator or eye protection leave the nurse vulnerable to inhalation or mucous membrane exposure.

Question 24

Your pediatric client has rubeola. What kind of infection control measure should you, as the nurse, initiate?

Accepted Answer

Answer reason: Rubeola (measles) is transmitted via airborne particles that can remain suspended and travel over distances, so airborne isolation is required to prevent nosocomial spread. This includes placing the child in an AIIR (negative-pressure room) when available and using a fit-tested N95 (or higher) respirator for staff. Droplet precautions are insufficient for measles because they mainly target larger respiratory droplets that fall quickly and do not address true airborne spread. Rapid institution of airborne precautions is especially important due to measles’ very high contagiousness and risk to unvaccinated or immunocompromised contacts.

Question 25

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?

Accepted Answer

Answer reason: Droplet precautions should be started at once (masking/appropriate room placement) while diagnostic workup and treatment proceed. Assessment steps like vital signs and neurologic checks are important but do not prevent rapid nosocomial spread if isolation is delayed. Seizure precautions are supportive and may be needed, but they are not the first action unless the child is actively seizing or unstable.

Question 26

You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection?

Accepted Answer

Answer reason: A child with a new pruritic rash suspicious for chickenpox should be placed immediately in an airborne infection isolation room and managed with airborne and contact precautions, with staff using appropriate respiratory protection. By contrast, a past history of MRSA warrants contact precautions, but it is not as efficiently transmitted through the air to bystanders in a waiting area. TB exposure without current symptoms primarily calls for screening/testing and does not pose the same immediate transmission risk as suspected active airborne disease.

Question 27

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?

Accepted Answer

Answer reason: PPE is removed in a sequence that minimizes self-contamination by taking off the most contaminated items first and keeping respiratory protection on until exiting the exposure area. Gloves are typically the most heavily contaminated after suctioning and contact care, so they should be removed first to reduce transfer of organisms to other PPE and surfaces. After glove removal, the gown is removed, then eye protection, and the respirator is removed last after leaving the room because it protects against airborne particles. Hand hygiene is performed immediately after PPE removal to eliminate any contamination acquired during doffing.

Question 28

In the emergency room, the nurse assesses a 4-year-old child suspected of having measles. Which of the following kinds of precautions should the nurse initiate?

Accepted Answer

Answer reason: The nurse should place the child in an airborne infection isolation room (negative pressure) and use appropriate respiratory protection to prevent exposure. Droplet precautions are insufficient because they target larger respiratory droplets that do not stay airborne and typically require only a surgical mask within close range. Reverse isolation is used to protect immunocompromised patients from pathogens and does not address preventing spread from a contagious child.

Question 29

The nurse is caring for a group of clients. What nursing infection control intervention must be implemented?

Accepted Answer

Answer reason: They include hand hygiene and appropriate PPE based on anticipated exposure to blood, body fluids, nonintact skin, and mucous membranes, which is always relevant when caring for a group of clients. “Needle precautions only” is incomplete because infection prevention extends beyond sharps safety to routine hand hygiene and barrier protection. Contact precautions are added only when a specific organism or condition warrants them, but they are not universally required for every client.

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