Question 1

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection?

Accepted Answer

Answer reason: Prepackaged CHG cloths also standardize technique and avoid contamination risks associated with reusable basins that can harbor pathogens and spread them between patients. Showering with “antibacterial soap” is less reliable and may not provide the sustained antimicrobial effect of CHG. Waiting for antibiotics delays hygiene and does not address contact spread from skin colonization, which is a key infection-control target.

Question 2

A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplants. Which of the following instructions should the nurse manager include in the teaching?

Accepted Answer

Answer reason: Protective (reverse) isolation is the key principle after stem cell transplant because profound neutropenia makes the client highly susceptible to airborne and environmental pathogens. Positive-pressure rooms reduce entry of unfiltered corridor air and help prevent exposure to organisms such as fungal spores. Rectal temperatures should be avoided due to risk of mucosal injury and bacteremia in immunocompromised clients. Routine N95 use is not required unless the client is on airborne precautions for a specific infection; the priority is environmental protection and strict infection-control measures.

Question 3

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?

Accepted Answer

Answer reason: Maintaining sterility of the IV administration set is a core infection-control principle because any contamination of the spike can directly introduce microorganisms into the IV fluid pathway and bloodstream. Once the spike touches a nonsterile surface, it is considered contaminated and cannot be reliably re-sterilized at the bedside with wipes or swabs. Replacing the tubing removes the contaminated component and restores a sterile infusion setup. Replacing the IV bag is unnecessary because the bag has not been breached, and antiseptics on the spike risk incomplete decontamination and introducing chemical residue into the system.

Question 4

A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

Accepted Answer

Answer reason: A culture showing minimal bacteria indicates no significant local colonization progressing toward invasive infection. The other findings suggest infection: cloudy, foul-smelling urine points to a UTI, a WBC of 14,000 indicates leukocytosis, and a temperature of 101°F indicates fever and possible systemic involvement. Therefore, the culture result is the assessment most consistent with the expected outcome.

Question 5

The nurse plans to collect a urine specimen from a client with an indwelling urinary catheter. Which action does the nurse take?

Accepted Answer

Answer reason: Urine specimens from an indwelling catheter should be collected from the designated sampling (aspiration) port using aseptic technique to minimize CAUTI risk and to avoid contaminating the closed drainage system. Clamping the tubing distal to the sampling port allows fresh urine to pool in the tubing/bladder segment so an adequate, current sample can be withdrawn. Disconnecting the catheter from the drainage tubing breaks the closed system and increases infection risk. Inserting a needle into the tubing can create leaks and introduces contamination, and irrigating before collection dilutes the sample and can alter culture/urinalysis results unless specifically prescribed.

Question 6

A client 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: The core priority with suspected avian influenza is immediate transmission prevention because it is a potentially severe respiratory infection with risk of spread in a healthcare setting. Implementing appropriate isolation is a time-critical nursing action that protects other patients and staff before additional assessments or procedures increase exposure. Diagnostic cultures can be obtained after precautions are in place to reduce aerosol/droplet generation risk during specimen collection. A fluid bolus is only first if there is evidence of hemodynamic instability, which is not provided in the stem.

Question 7

The home health nurse teaches a client how to procure a clean-catch urine specimen. Which statement indicates that the client understands the nurse’s instructions?

Accepted Answer

Answer reason:  A clean-catch (midstream) urine specimen is collected by voiding the initial urine stream to flush urethral contaminants, then collecting the midstream portion in a clean container to reduce false contamination. This statement correctly describes discarding the first small amount and then collecting the remaining midstream sample. Keeping a bottle on ice is not part of the collection technique being taught and relates more to specimen preservation after collection. Using sterile gloves/iodine and calling it a sterile specimen describes a sterile collection (or an overly sterile technique) rather than the standard clean-catch method taught to most clients at home.

Question 8

A home health nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: A fully cooked poultry dish fits this principle because heat reduces bacterial load and makes the food safer. Soft-boiled eggs are often undercooked and can harbor Salmonella, and raw vegetables/leafy salads can carry pathogens that are difficult to eliminate even with washing. Therefore, the safest choice among the options is the fully cooked entrée.

Question 9

A mother has heard that several children have been diagnosed with mononucleosis. She asks the nurse what precautions should be taken to prevent this from occurring in her child. The nurse should instruct the mother to?

Accepted Answer

Answer reason: Infectious mononucleosis (typically EBV) is primarily transmitted through saliva with close personal contact, and it is not effectively prevented by routine household sterilization or special laundry practices. Standard hygiene (handwashing, avoiding sharing drinks/utensils when someone is ill) is reasonable, but there are no specific isolation-type precautions recommended for healthy children in the community to prevent acquisition. Sterilizing utensils and separating linens suggest fomite or contact-spread control measures that are not central to EBV transmission. Mask use is aimed at droplet/airborne pathogens and is not indicated for typical mono exposure in the home/community setting.

Question 10

The color of bag in which the infectious solids wastes are disposed?

Accepted Answer

Answer reason: Infectious solid waste (soiled items contaminated with blood/body fluids) is placed in designated biohazard bags intended for contaminated solids, which are commonly red. This directs staff to apply appropriate precautions and ensures correct downstream treatment (e.g., disinfection/incineration) for infectious material. Black is generally reserved for non-infectious/general waste, while blue and yellow are typically used for other specific waste streams depending on local policy, making them less appropriate for infectious solids here.

Question 11

A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials?

Accepted Answer

Answer reason: Fever in a client on PN raises concern for catheter-related bloodstream infection or contaminated PN solution, so potential sources should be cultured to guide targeted therapy. Sending the discontinued solution and tubing for culture preserves evidence of contamination and supports appropriate antimicrobial selection and infection-control actions. Discarding them removes the opportunity to identify the organism and source. Returning to pharmacy/manufacturer does not address the immediate clinical need to evaluate infection risk and manage the patient safely.

Question 12

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?

Accepted Answer

Answer reason: 2000 mm3 (2.0 × 10^9/L) Neutropenic precautions are implemented when the patient’s infection risk is high due to markedly reduced leukocyte/particularly neutrophil availability, most commonly reflected by very low WBC/ANC in oncology patients. A WBC of 2000/mm3 indicates significant leukopenia and strongly suggests a potentially dangerously low absolute neutrophil count, warranting protective measures (strict hand hygiene, avoiding sick contacts, limiting raw foods/flowers per policy, monitoring for fever). Values like 5800/mm3 and 8400/mm3 are within typical adult reference ranges and do not indicate neutropenia by themselves. Although 11,500/mm3 may indicate inflammation or stress leukocytosis, it does not signal immunosuppression requiring neutropenic precautions.

Question 13

The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?

Accepted Answer

Answer reason: Gentle rinsing with sterile water after feeds helps keep the incision clean without applying friction or pressure that could disrupt the repair. Waiting to clean until drainage appears is reactive and allows residue to remain in place, increasing risk of crusting and infection. Direct rubbing with a swab can traumatize the delicate suture line and precipitate bleeding or dehiscence. Keeping the Logan bar in place is important, but the key appropriate routine incision-care action immediately after feeds is cleansing/rinsing to remove contaminants.

Question 14

Anurag is put on a femoral venous catheter in a hospital. What should a nurse to while caring for Anurag-?

Accepted Answer

Answer reason: Using sterile technique for hub access, dressing changes, and line manipulation reduces contamination and subsequent sepsis risk. Routine irrigation/flushes are not universally indicated unless prescribed and can introduce organisms or cause complications if done improperly. While monitoring for bleeding and limiting hip flexion/movement can be helpful with femoral sites, infection prevention remains the highest-priority, always-applicable intervention.

Question 15

A nurse is providing care for a client who had kidney transplant surgery. The nurse should advise the client that taking immunosuppressive medications can result in which of the following?

Accepted Answer

Answer reason: This makes opportunistic and common infections more likely and often more severe, so teaching emphasizes early symptom reporting and infection-prevention behaviors. Increased urinary output reflects graft function and fluid status rather than a direct expected consequence of immune suppression. Autoimmune disorders are not an expected result because these medications dampen, rather than stimulate, immune responses.

Question 16

A student nurse performs the morning assessment and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is in contact precautions. The registered nurse intervenes when the student performs which action?

Accepted Answer

Answer reason: Using a 2% chlorhexidine solution is not the standard method for disinfecting a stethoscope and can be inconsistent with recommended environmental disinfection practices, so the RN should stop and correct this. The other actions reflect correct infection-control technique: transporting the specimen in a sealed leak-proof bag, disinfecting the sampling port before access, and performing hand hygiene after glove removal. The priority is preventing cross-contamination with correct, approved disinfection procedures.

Question 17

The nurse admits several clients during the day shift. Which room assignment is most appropriate for the nurse to make?

Accepted Answer

Answer reason: Room assignments should minimize cross-transmission risk by avoiding pairing clients with contagious infections or highly vulnerable immune status with potentially infectious roommates. A postoperative orthopedic client and a pancreatitis client are not inherently infectious, so cohorting them does not add specific transmission-based precaution conflicts. In contrast, pairing two clients with different bacterial pneumonias risks exposure to different organisms and may require different isolation measures. Also, a neutropenic client should not room with someone with a gastrointestinal illness due to heightened risk of acquiring infection.

Question 18

The nurse teaches a pregnant client diagnosed with human immunodeficiency virus (HIV) about measures to prevent opportunistic infections. Which client statement indicates that the teaching has been effective?

Accepted Answer

Answer reason: " Immunocompromised clients are at increased risk for opportunistic infections from environmental exposures, including pathogens found in aquarium water and animal waste. Avoiding or delegating tasks like cleaning fish tanks reduces exposure to waterborne organisms that can cause serious infection. In contrast, simply attending a large gathering increases exposure to contagious illnesses and is not a preventive measure. Delivery method decisions relate primarily to vertical transmission risk management and depend on viral load and treatment, not on preventing opportunistic infections.

Question 19

The nurse is caring for a patient with AIDS. The nurse should implement neutropenic precautions when the patient's white blood cell count is?

Accepted Answer

Answer reason: A total WBC of 3,000 cells/mm² strongly suggests clinically meaningful immunosuppression and likely neutropenia, warranting protective measures to reduce exposure to pathogens. By contrast, 11,500 and 15,000 cells/mm² are elevated counts typically associated with inflammation/infection rather than neutropenia. A WBC of 4,900 cells/mm² is near the lower end of normal for many labs and is less consistent with severe immunosuppression requiring strict neutropenic precautions without additional ANC data.

Question 20

The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time?

Accepted Answer

Answer reason: Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter." When a female urinary catheter is inadvertently placed in the vagina, urine will not return; removing it eliminates the key landmark and increases the risk of repeating the error. Leaving the catheter in place allows it to serve as a guide while a new sterile catheter is obtained and inserted correctly into the urethra, reducing contamination and trauma. Coaching quietly preserves the client’s dignity and supports the student without alarming the client. Publicly announcing the likely misplacement or interrogating the student delays correction and can breach therapeutic communication while not addressing infection-control needs.

Question 21

The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client's temperature is 100.2. Which of the following is the most appropriate nursing action?

Accepted Answer

Answer reason: The priority nursing action is focused assessment of the dialysis access (shunt/AV fistula or graft) for local signs such as warmth, erythema, tenderness, swelling, drainage, and changes in bruit/thrill. Prompt identification supports rapid escalation (cultures/antibiotics) if findings suggest infection. Encouraging fluids is inappropriate in chronic renal failure due to fluid restrictions, and simply continuing routine vital signs is less targeted than assessing the most likely source.

Question 22

The most effective way to break the chain of infection is?

Accepted Answer

Answer reason: Consistent hand cleansing before and after patient contact reduces cross-contamination regardless of whether gloves are used or what room type the patient is in. Gloves can develop microtears and become contaminated during removal, so they do not replace proper hand cleansing. Isolation and private rooms are useful for specific pathogens and situations but are less universally effective than hand cleansing across all contacts.

Question 23

The nurse in the long-term care facility provides care for clients during an outbreak of Legionnaire disease. The nurse recognizes that which client is most at risk to develop the disease?

Accepted Answer

Answer reason: Legionnaires’ disease (Legionella pneumonia) disproportionately affects people with impaired immune defenses and chronic systemic illness, leading to higher susceptibility and more severe infection. End-stage kidney disease is associated with immune dysfunction and often frequent healthcare exposures, both of which increase risk during an institutional outbreak. Advanced age alone raises risk, but the hip fracture, CVA, and Alzheimer diagnoses do not inherently create the same level of immunocompromise as ESRD. Therefore, the client with ESRD is the most vulnerable in this set.

Question 24

A client with acute leukemia develops a low white blood cell count. In addition to isolation, the nurse should?

Accepted Answer

Answer reason: Sealed, single-serving packages reduce handling and the chance of contamination compared with shared containers or unsealed items, aligning with neutropenic dietary precautions when ordered by the facility/provider. Having the client wear a mask for visitors is not the key control measure; instead, visitors with illness should be restricted and staff/visitors should perform meticulous hand hygiene and use PPE as indicated. “Mild soap and water and alcohol” is not appropriate skin antisepsis for IV insertion compared with recommended antiseptics (e.g., chlorhexidine), and disposable utensils do not meaningfully reduce infection risk compared with ensuring proper food preparation and limiting exposure sources.

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Infection Control Practice Test 10

Infection Control NCLEX Practice Test

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