Question 1

What is the best way to prevent the spread of infection?

Accepted Answer

Answer reason: This is the single most effective routine measure to reduce transmission of pathogens between people and surfaces. Soap and water physically remove dirt, organic material, and microorganisms, including those not reliably eliminated by brief glove use or masks alone. Gloves can have microtears and become contaminated, and they do not replace hand hygiene before and after use. Lotion supports skin integrity but does not provide antimicrobial removal by itself.
Category reason: This question tests a core nursing safety intervention to prevent healthcare-associated infections, which fits Infection Control under the NCLEX Safety and Infection Control category.

Question 2

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Immediate decontamination reduces the bioburden at the exposure site and is the first-line intervention after percutaneous exposure. This step should be performed promptly before administrative steps such as reporting or arranging source testing. After cleansing, the nurse should follow facility protocol for reporting, risk assessment, source evaluation, and timely consideration of postexposure prophylaxis based on exposure risk and source status.
Category reason: This is a workplace exposure scenario requiring a first-priority nursing action to prevent infection transmission, which fits Safety and Infection Control—Infection Control.

Question 3

Which of the following humidity levels are considered optimal environmental conditions for the operating room?

Accepted Answer

Answer reason: Operating rooms maintain controlled humidity to reduce static electricity (which increases when air is too dry) and to limit microbial growth and condensation (which increase when humidity is too high). A mid-range relative humidity supports equipment safety, sterile field integrity, and overall environmental infection-prevention practices. Standards commonly cite a target range around 20%–60% to balance these risks.
Category reason: This question tests knowledge of operating room environmental controls used to prevent contamination and maintain a safe sterile environment, which aligns with Infection Control under Safety and Infection Control.

Question 4

A nurse is preparing to administer a medication via intramuscular injection. Which action should the nurse take first?

Accepted Answer

Answer reason: Hand hygiene is the first step before any medication preparation or patient contact to reduce transmission of microorganisms and prevent healthcare-associated infections. It protects both the patient and the nurse during subsequent steps like handling supplies, drawing up medication, and performing the injection. While verifying the medication label is essential for medication safety, infection prevention measures should occur before touching medications, equipment, or the patient.
Category reason: This question tests the correct sequencing of a nursing intervention to prevent infection during an injection, which aligns with Safety and Infection Control.

Question 5

The Best method to dry hands after hand wash is?

Accepted Answer

Answer reason: Disposable paper towels are preferred because they reduce the risk of cross-contamination compared with reusable towels and avoid dispersing microorganisms into the environment. Friction from towel drying also helps remove residual transient organisms and moisture, and wet hands transmit pathogens more easily. Air dryers can aerosolize water droplets and potentially spread microbes, especially in busy clinical areas.
Category reason: This tests infection-control practice related to hand hygiene technique in a clinical setting, which aligns with NCLEX Safety and Infection Control.

Question 6

A nurse is teaching a patient about hand hygiene at 12:58 PM on June 23, 2025. Which step is most important?

Accepted Answer

Answer reason: Adequate duration with friction is the key determinant of removing transient microorganisms and reducing pathogen load on the hands. Water temperature (warm vs cold) is far less important than thorough rubbing of all hand surfaces for sufficient time. Using a dirty towel can recontaminate hands and undermines infection prevention. Therefore, the time spent washing is the most important step among the choices.
Category reason: This question tests a nursing infection-prevention practice (hand hygiene technique) that directly impacts transmission of microorganisms in patient care, which fits Safety and Infection Control—Infection Control.

Question 7

A nurse is teaching a client about infection prevention. Which instruction should the nurse include?

Accepted Answer

Answer reason: Hand hygiene is the single most effective measure to reduce transmission of pathogens and prevent infection, especially before food handling or eating when organisms can be ingested. The other options increase infection risk: improper food storage promotes bacterial growth, single-use supplies must not be reused due to contamination risk, and covering sneezes reduces droplet spread. Teaching handwashing supports both personal and community infection prevention.
Category reason: This question tests a nursing teaching intervention to prevent transmission of infection, which aligns with Infection Control under Safety and Infection Control.

Question 8

The nurse is caring for a client with pneumococcal pneumonia. Which of the following statements by the client would require follow-up?

Accepted Answer

Answer reason: Older adults have higher risk for severe illness and complications from respiratory infections, so the nurse should assess the client’s ability to prevent transmission at home. Follow-up includes teaching about hand hygiene, cough etiquette, cleaning high-touch surfaces, and limiting close contact until clinically improving and on appropriate antibiotics. The nurse should also evaluate whether the mother has symptoms, vaccination status (pneumococcal/influenza), and need for medical evaluation if exposed.
Category reason: This question tests nursing judgment about preventing spread of infection and protecting a high-risk household contact, which aligns with Infection Control within Safety and Infection Control.

Question 9

What is the first step in wound care?

Accepted Answer

Answer reason: Reducing transmission of microorganisms is the priority before any contact with an open wound or sterile supplies. Performing hand hygiene first lowers the risk of introducing pathogens and causing a wound infection or delayed healing. Other steps like irrigation or dressing changes are important but should only occur after basic infection-prevention measures are completed.
Category reason: This question tests the safest nursing action to prevent infection during wound care, which falls under Safety and Infection Control—Infection Control.

Question 10

A client who is receiving chemotherapy for breast cancer develops myelosuppression. Which of the following instructions should the nurse NOT include in the client’s discharge teaching plan?

Accepted Answer

Answer reason: Myelosuppression can cause neutropenia, which increases infection risk, so clients are typically taught neutropenic precautions. Raw or unwashed produce may carry bacteria, fungi, or spores and is commonly restricted in neutropenic diets to reduce exposure to foodborne pathogens. The other instructions focus on reducing bleeding risk (thrombocytopenia) and decreasing exposure to infectious organisms through hygiene and avoiding crowds.
Category reason: This item tests nursing discharge teaching to prevent infection/complications in an immunocompromised chemotherapy client, which falls under infection control and safety-focused patient care decision-making.

Question 11

When caring for a client with a femoral venous catheter, it is essential for the nurse to?

Accepted Answer

Answer reason: Central venous catheters provide direct access to the bloodstream, so contamination during access (connection changes, flushing, dressing care) is a major cause of catheter-related bloodstream infection. Strict aseptic technique (hand hygiene, sterile supplies, scrub-the-hub, sterile dressing changes) is the primary, universal nursing priority for all central lines regardless of insertion site. Routine irrigation “to maintain patency” is not an essential standing action and should follow specific orders and facility protocol (often using heparin/saline per type/valve). While monitoring for bleeding and limiting limb movement may be relevant immediately post-insertion, they are situational and secondary to infection prevention during ongoing care.
Category reason: This item tests a nursing safety intervention—preventing catheter-related infection through sterile handling of a central venous catheter—so it fits NCLEX Safety and Infection Control (Infection Control).

Question 12

Which is the best method to prevent nosocomial infection?

Accepted Answer

Answer reason: It is the single most effective measure to reduce healthcare-associated transmission by removing transient microorganisms before and after patient/environment contact. It prevents spread via the most common route (hands of healthcare workers), including contact with contaminated surfaces and patients. PPE and isolation are important but are situation-specific barriers, whereas this applies universally across all patient encounters. Antibiotics do not prevent transmission and can worsen resistance and alter normal flora.
Category reason: This question asks for the best nursing practice to prevent hospital-acquired infections, which falls under safety and infection control measures in patient care.

Question 13

What primary health teaching would you gi mike?

Accepted Answer

Answer reason: The stem asks for the primary health teaching, which in many nursing contexts prioritizes reducing exposure to infectious agents when the client may be vulnerable (e.g., immunocompromised) or at high risk for complications. Teaching on hand hygiene, avoiding sick contacts/crowds, food safety, and when to seek care directly reduces morbidity and is broadly applicable as a first-line education focus. The other options are beneficial general wellness measures, but they are not as immediately safety-critical as infection-prevention teaching in at-risk clients.
Category reason: This question is about client teaching focused on preventing infection and promoting safety measures, which aligns with nursing responsibilities in Safety and Infection Control rather than foundational biomedical science.

Question 14

A case of meningomyelocele was posted for surgery. Till the patient is waiting for surgery, the covering of the sac will be protected by a gauze soaked in?

Accepted Answer

Answer reason: An exposed meningomyelocele sac must be kept moist and protected to reduce the risk of rupture and infection while awaiting surgical repair. Sterile normal saline–soaked gauze maintains hydration of delicate neural tissues without causing chemical injury. Antiseptics such as iodine, methylene blue, or mercurochrome are irritating/cytotoxic and can damage exposed meninges/neural tissue and increase complications. Using a moist sterile dressing also helps provide a barrier against contamination until definitive closure.
Category reason: This question tests a nursing intervention to protect an exposed neural tube defect sac and prevent infection/complications while awaiting surgery, which is primarily a patient-safety and infection-control care decision.

Question 15

Which intervention is essential after birth for open NTDs?

Accepted Answer

Answer reason: An open neural tube defect exposes CNS tissue to contamination and drying, creating high risk for infection and additional tissue injury. The immediate priority after birth is to protect the exposed area by keeping it covered with a sterile (typically moist, nonadherent) dressing and maintaining strict asepsis. Routine oral antibiotics are not the first essential step, and surgery is important but follows stabilization and protection of the lesion. Early breastfeeding is beneficial overall but does not address the urgent risk to exposed neural tissue.
Category reason: This question tests immediate newborn nursing actions to prevent infection and injury from an exposed lesion, which fits Safety and Infection Control (Infection Control).

Question 16

Scenario: A nurse instructs a female client on clean-catch urine collection. What instruction is most accurate?

Accepted Answer

Answer reason: Discarding the initial urine flushes urethral contaminants so the specimen better reflects bladder urine, reducing false-positive culture results. Midstream collection helps avoid contamination from periurethral flora and skin. Starting collection immediately or holding the cup under the stream from the beginning increases contamination risk. Cleansing should be front to back, not back to front, to avoid bringing rectal bacteria toward the urethra.
Category reason: This question tests correct nursing instruction for obtaining a sterile/clean specimen and preventing contamination, which is primarily an infection-control practice in patient care.

Question 17

Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation. Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do?

Accepted Answer

Answer reason: Using utensils to handle ready-to-eat food is an effective infection-control measure that reduces hand-to-food contamination, especially when hands also contact money. This response is respectful and focuses on a practical behavior change rather than blaming, which increases the likelihood of cooperation. Option A shifts handling to the nurse (not sustainable and still risks contamination), and option D is confrontational and less therapeutic. Therefore, suggesting tongs/forceps is the safest and most appropriate public-health nursing intervention.
Category reason: This is a patient/public safety question about preventing foodborne transmission through hygienic handling practices, which aligns with Infection Control under Safety and Infection Control.

Question 18

Scenario: A patient receiving chemotherapy is neutropenic (ANC < 500). Which action should the nurse take?

Accepted Answer

Answer reason: With severe neutropenia (ANC < 500), the priority is preventing infection by minimizing exposure to potential sources of pathogens, including raw produce and plant material that can harbor bacteria and fungi. Negative-pressure rooms are used for airborne isolation to protect others from an infected patient, not to protect an immunocompromised patient. Droplet precautions are only indicated for specific droplet-spread infections, not for neutropenia alone. Live vaccines are contraindicated in significantly immunocompromised patients due to risk of vaccine-derived infection.
Category reason: This is a nursing infection-prevention decision for an immunocompromised (neutropenic) patient, focusing on protective measures and contraindicated practices, which fits Infection Control under Safety and Infection Control.

Question 19

What is the most effective method for preventing the spread of infection?

Accepted Answer

Answer reason: It is the single most effective measure to reduce transmission of pathogens because hands are the primary vector for cross-contamination between patients, surfaces, and the nurse’s own mucous membranes. Proper technique and timing (before/after patient contact, after glove removal, after contact with bodily fluids or contaminated surfaces) significantly lowers healthcare-associated infections. Masks, gloves, and environmental cleaning are important adjuncts, but they do not replace consistent hand hygiene and can fail if used incorrectly or if hands are contaminated during donning/doffing.
Category reason: This item tests infection-prevention practice and the safest intervention to limit transmission in patient care settings, aligning with NCLEX Safety and Infection Control.

Question 20

What is the primary purpose of hand hygiene in healthcare?

Accepted Answer

Answer reason: A) To prevent infection Hand hygiene is the most effective routine measure to reduce transmission of microorganisms between patients, healthcare workers, and the environment. By decreasing the microbial load on hands before and after patient contact, it interrupts the chain of infection and lowers rates of healthcare-associated infections. While it can also remove visible soil, its primary clinical purpose is preventing cross-contamination and infection.
Category reason: This question targets a core patient-safety intervention used to reduce healthcare-associated infections, which falls under Safety and Infection Control—Infection Control.

Question 21

Scenario: A patient has an intraventricular catheter (EVD) to monitor intracranial pressure (ICP). Which finding requires immediate action?

Accepted Answer

Answer reason: This suggests a CSF leak and/or a compromised EVD system, which greatly increases the risk of ventriculitis/meningitis and can indicate dislodgement or loss of a closed sterile circuit. Any leakage around the insertion site requires urgent assessment of the dressing and connections, maintaining sterility, and prompt notification of the provider per protocol. By contrast, an ICP of 12 mmHg and a present waveform are expected findings, and a small amount of drainage can be normal depending on ordered drainage parameters and leveling.
Category reason: This question tests nursing recognition of a high-risk complication and immediate safety response for an invasive intracranial monitoring device, aligning with infection prevention and maintaining a closed sterile system.

Question 22

Scenario: A nurse prepares to change the dressing of a central venous catheter. Q. What indicates a breach of sterile technique?

Accepted Answer

Answer reason: After sterile gloves are applied, contact with nonsterile surfaces (such as the outside of the gown) contaminates the gloves and breaks sterile technique. This increases the risk of introducing microorganisms into the central line site during the dressing change. The other actions describe standard sterile-field practices that help maintain sterility (opening away from the body, keeping hands above waist, and using the sterile drape as the sterile field).
Category reason: This item tests maintenance of aseptic technique during a central line dressing change, which is a nursing safety practice focused on preventing healthcare-associated infection.

Question 23

Scenario: A nurse is about to insert a Foley catheter in a female patient with a urinary retention issue. Q. Which step is most critical in preventing catheter-associated urinary tract infection (CAUTI)?

Accepted Answer

Answer reason: Maintaining sterile technique during catheter insertion is the most critical measure to prevent introducing microorganisms into the urinary tract, which is a primary driver of CAUTI. Sterile gloves are a key element of aseptic technique that protects the sterile catheter and insertion field from contamination by the nurse’s hands. While perineal cleansing reduces surface bioburden, it does not replace sterile technique during insertion. Lubricant and correct balloon inflation support comfort and device function but do not primarily prevent infection.
Category reason: This question centers on preventing a healthcare-associated infection during a nursing procedure, which is best categorized under Safety and Infection Control—Infection Control.

Question 24

A patient on mechanical ventilation begins to show signs of ventilator-associated pneumonia (VAP). What position helps reduce the risk?

Accepted Answer

Answer reason: C. Head of bed 30–45° Elevating the head of the bed to 30–45° reduces aspiration of oropharyngeal and gastric contents, a key mechanism in VAP development in intubated patients. Supine positioning increases aspiration risk and is associated with higher VAP rates. High Fowler’s can be used if tolerated, but the evidence-based ventilator bundle recommendation is specifically 30–45° as the target range to balance aspiration prevention with hemodynamic and pressure-injury concerns. Lateral positioning alone does not reliably reduce microaspiration risk compared with semi-recumbent elevation.
Category reason: This item tests an infection-prevention nursing intervention (patient positioning) to reduce ventilator-associated pneumonia risk, which aligns with Safety and Infection Control.

Question 25

Scenario: During a sterile dressing change, a nurse accidentally touches the inside of the dressing package with bare fingers. Q. What is the most appropriate action?

Accepted Answer

Answer reason: Touching the inside of the package with bare fingers contaminates the sterile field, making the dressing non-sterile and unsafe to use. Maintaining aseptic technique requires replacing any item whose sterility is compromised to reduce the risk of introducing pathogens into the wound. Continuing to use it or trying to “compensate” with antibiotic ointment does not restore sterility and increases infection risk. Reporting to the charge nurse may be appropriate per policy, but the immediate priority is preventing contamination by obtaining a new sterile dressing.
Category reason: This is a nursing practice question focused on maintaining sterile technique and preventing infection during a procedure, which aligns with Safety and Infection Control—Infection Control.

Question 26

Infectious non sharp waste is collected in?

Accepted Answer

Answer reason: Infectious (soiled) non-sharp waste requires segregation into a designated biohazard stream to prevent exposure and cross-contamination. The yellow bag is the standard container color used for infectious, non-sharp clinical waste in many biomedical waste segregation systems. This choice aligns with infection prevention principles by ensuring appropriate handling, transport, and downstream treatment (e.g., incineration/autoclaving) based on infectious risk. A common distractor is the red bag, which is often reserved for specific recyclable contaminated plastics rather than general infectious non-sharp waste. Proper color-coded segregation reduces needlestick/handling risks and supports regulatory compliance in waste management.

Question 27

The nurse has placed an indwelling urinary catheter via sterile technique. The nurse recognizes that it is how long before bacterial colonization begins?

Accepted Answer

Answer reason: Indwelling urinary catheters rapidly become colonized because they bypass normal urethral defenses and allow biofilm formation on catheter surfaces. Even when inserted with sterile technique, organisms can ascend extraluminally or intraluminally from the drainage system over time. Clinically, colonization and bacteriuria commonly begin within about 48 hours, which is why minimizing catheter duration is a key CAUTI-prevention strategy. Options like 12 or 24 hours are typically too early for predictable colonization, while 72 hours delays the recognized early window when colonization often starts.

Question 28

The most effective method to prevent infection in the newborn is?

Accepted Answer

Answer reason: Hand hygiene is the single most effective measure to reduce transmission of pathogens and prevent healthcare-associated infections, especially in newborns with immature immune defenses. Cleaning hands before and after contact interrupts contact spread, which is the predominant route for many neonatal infections. Disposable items and visitor restriction can reduce exposure but do not reliably prevent transmission if hands are contaminated. Routine prophylactic antibiotics are not indicated for general infection prevention and can promote resistance and disrupt normal flora.

Question 29

Most important complication of peritoneal dialysis?

Accepted Answer

Answer reason: Peritonitis can rapidly progress to sepsis, technique failure, and hospitalization, so it is prioritized over less immediately dangerous issues. Typical clues include abdominal pain, fever, and cloudy effluent, and prevention hinges on strict aseptic technique during exchanges. DVT, diarrhea, and hypertension may occur in some patients but are not the hallmark, high-risk complication most strongly associated with peritoneal dialysis.

Question 30

Tubes & Catheters are disinfectant with ?

Accepted Answer

Answer reason: Glutaraldehyde 2% is a standard high-level disinfectant used for heat-sensitive equipment that contacts mucous membranes and does not tolerate steam sterilization. Sodium hypochlorite solutions are primarily used for environmental surface decontamination and can be corrosive/damaging to many instruments. Formalin is not routinely used for disinfecting patient-care tubing due to toxicity and handling concerns, making it a poor choice for this purpose.

Question 31

How many moments of hand hygiene have been laid down by WHO?

Accepted Answer

Answer reason: These moments address both protecting the patient (before touching a patient, before clean/aseptic procedure) and protecting the healthcare worker and environment (after body fluid exposure/risk, after touching a patient, after touching patient surroundings). This framework is used internationally for auditing compliance and reducing healthcare-associated infections. Options listing higher or lower numbers do not match the WHO-defined core set of hand-hygiene indications.

Question 32

Infection acquired during the stay of pt. in the hospital is called?

Accepted Answer

Answer reason: This definition directly matches the term used for infections acquired in a hospital setting. “Secondary infection” refers to a new infection occurring during or after treatment for a primary infection, not specifically tied to hospitalization. “Reinfection” implies a repeat infection after recovery, and “localized infection” describes extent rather than source.

Question 33

Which of the following chain of infection is in the correct order....?

Accepted Answer

Answer reason: Placing the reservoir/source first is essential because without a site where the organism lives and multiplies, there is nothing to transmit. The mode of transmission is the linkage that carries the organism from the source to the next person (e.g., contact, droplet, airborne, vehicle, vector). Options starting with the host invert the causal sequence and imply exposure occurs before a transmissible source exists, which is not consistent with infection-control principles. This ordering also aligns with common prevention strategies: control the source, interrupt transmission, and protect the host.

Question 34

Best prevention of septic shock:

Accepted Answer

Answer reason: Preventing that progression hinges on rapid identification and immediate source control (e.g., appropriate cultures, early broad-spectrum antibiotics, drainage/removal of infected devices). This directly interrupts the path from sepsis to shock by reducing pathogen burden and inflammatory drive early. Pain control, nutrition, and exercise can support recovery but do not prevent the hemodynamic collapse that results from ongoing infection.

Question 35

Which of the following actions of the nurse is most appropriate to reduce the risk of infection during the post-operative period?

Accepted Answer

Answer reason: Early catheter removal eliminates a common portal of entry for bacteria and is a high-impact, evidence-based postoperative nursing intervention to prevent CAUTI. Removing it when the client can ambulate balances infection prevention with safety by reducing urinary retention and promoting normal bladder function. By contrast, heparin flushing addresses line patency (and carries bleeding risk) rather than targeting a common postoperative infection source, and analgesics or diet are supportive but less directly preventive than eliminating an unnecessary device.

Question 36

Antibiotic resistant organism are a major infection control problem. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients?

Accepted Answer

Answer reason: Colds and influenza are viral illnesses, so antibiotics provide no benefit and unnecessarily expose normal flora and potential bacterial pathogens to antibiotic pressure. Teaching clients to avoid antibiotics for viral infections directly prevents inappropriate use, a leading cause of resistance. A common harmful misconception is stopping antibiotics early when symptoms improve, which can leave partially treated bacteria to survive and adapt. Using broad-spectrum “newest” agents or vancomycin without indication further accelerates resistance and increases risk of adverse effects.

Question 37

To maintain the cleanliness of the bag and its contents, which of the following must the nurse do?

Accepted Answer

Answer reason: Infection control during bag technique focuses on preventing microorganisms from being carried back into the bag and transferred to other homes. Folding the barrier so the contaminated surface is contained and not in contact with the bag or clean items reduces cross-contamination risk between visits. Hand hygiene is essential but alone does not address contamination of the bag’s exterior and reusable items if the barrier is handled incorrectly. Keeping the contaminated side exposed would allow it to contact the bag or supplies, increasing the chance of contaminating the contents.

Question 38

The PHN bag is an important tool on providing nursing care during a home visit. The most important principle of bag technique states that it?

Accepted Answer

Answer reason:  Bag technique is fundamentally an infection-control practice aimed at preventing cross-contamination between the nurse, the client, and the home environment. Proper placement of the bag, use of barriers, hand hygiene, and sequencing of clean-to-dirty tasks are designed to interrupt transmission of microorganisms. While efficiency and adaptability matter, they are secondary to maintaining asepsis and preventing the nurse’s equipment from becoming a vector. The best choice is the one that directly states infection prevention as the primary principle.

Question 39

Which of the following is an epidemiologic function of the nurse during an epidemic?

Accepted Answer

Answer reason: During an epidemic, the nurse’s epidemiologic role includes case finding, contact tracing support, data collection, and participation in outbreak investigations that pinpoint the origin and mode of spread. This directly aligns with helping determine the source of the epidemic, which is a core outbreak-control function. Teaching preventive measures is important public health education, but it is broader health promotion rather than the defining investigative function of epidemiology. Monitoring individual cases is clinical surveillance/care management and does not primarily address source identification.

Question 40

Which is an example of the school nurse’s health care provider functions?

Accepted Answer

Answer reason: During a measles outbreak, screening/surveillance in classrooms helps identify symptomatic students early, supports isolation/referral, and limits transmission through timely public health measures. This is a clinical infection-control activity aligned with protecting students’ health during an epidemic. By contrast, requesting vaccines is largely program coordination/resource procurement, and addressing playground hazards is primarily environmental safety management rather than providing health care services.

Question 41

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 WBC of 3,000 is leukopenia and commonly correlates with neutropenia in immunocompromised patients, prompting protective measures (e.g., strict hand hygiene, avoiding sick contacts, no fresh flowers/raw foods per policy). The other values are within or above typical adult WBC reference ranges and do not reflect neutropenic-level immunosuppression. Because AIDS and its therapies can suppress bone marrow, using a low WBC threshold to trigger infection-prevention interventions is the safest nursing action.

Question 42

Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?

Accepted Answer

Answer reason: difficile diarrhea is most strongly associated with recent antibiotic exposure that disrupts normal gut flora, particularly in hospitalized patients. Clindamycin is a classic high-risk antibiotic for triggering C. difficile overgrowth and toxin-mediated colitis. Inpatient settings also increase exposure risk and facilitate transmission via spores, making monitoring for new-onset watery diarrhea especially important. By comparison, an aminoglycoside more typically causes nephrotoxicity/ototoxicity rather than antibiotic-associated colitis, and acne regimens or prednisone alone are less directly linked than high-risk broad-spectrum antibiotics.

Question 43

The nursing care plan for a client with decreased adrenal function should include?

Accepted Answer

Answer reason: Protecting the client from exposure to pathogens is a key nursing priority, especially during illness, hospitalization, or adrenal crisis risk. Reverse isolation focuses on shielding an immunocompromised client by limiting exposure and using protective techniques. By contrast, routine encouragement of activity or constipation prevention may be supportive care but does not address the most immediate safety risk of infection for this condition.

Question 44

The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time?

Accepted Answer

Answer reason: At 2 hours postpartum, the most immediate preventable complication tied directly to a 36-hour rupture is maternal infection (e.g., endometritis), so nursing care should prioritize early detection and prevention measures. This diagnosis guides focused assessment for fever, uterine tenderness, foul-smelling lochia, and tachycardia, and supports timely cultures/antibiotics per protocol. Hemorrhage and fluid volume deficit are critical postpartum concerns, but they are not specifically increased by the history of prolonged membrane rupture in the way infection risk is.

Question 45

A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Pediculicides (e.g., permethrin 1% or pyrethrins where appropriate) are the standard first-line treatment recommended in school/community health guidance when used per product instructions and repeated if indicated. Cutting hair may reduce combing burden but is not necessary and does not reliably eliminate infestation. Bleach is not recommended for laundering because hot water/high heat drying is sufficient for items in contact with the head and bleach adds unnecessary chemical exposure risk.

Question 46

When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse?

Accepted Answer

Answer reason: Using strict sterile/aseptic technique during dressing changes directly reduces microbial entry at the insertion site and protects the bloodstream. While intake and output monitoring is important for fluid balance, it does not prevent the most immediate high-risk complication of the central line itself. Cardiac arrhythmia monitoring is not a primary routine focus of TPN care unless specific electrolyte disturbances or cardiac risk factors are present.

Question 47

Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?

Accepted Answer

Answer reason: Reporting triggers immediate case investigation, contact tracing, and initiation of airborne precautions to prevent community spread, which makes it the priority within 24 hours. In contrast, Pneumocystis pneumonia is typically an opportunistic infection indicating immunosuppression and is not generally a condition that mandates urgent public health notification for transmission control. While Shigella and varicella can be reportable depending on locale, the combination of airborne spread risk and public health urgency makes suspected active TB the most time-critical report.

Question 48

A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?

Accepted Answer

Answer reason: Assessing that every lesion is crusted indicates there are no active, fluid-filled lesions left to shed virus. Fever can resolve earlier and does not reliably mark the end of infectivity. Persistent vesicles specifically indicate ongoing communicability and a continued need for exclusion and infection-control precautions.

Question 49

Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the health care provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Therefore, exclusion from school or isolation based solely on the rash is typically unnecessary, and the nurse should provide reassurance and accurate infection-control guidance. Bringing the child back for evaluation is not indicated if the diagnosis was already made and no red-flag symptoms are described (e.g., immunocompromise, hemolytic anemia, pregnancy exposure concerns). Antibiotics are ineffective for a viral exanthem and implying their use promotes inappropriate treatment expectations.

Question 50

A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a “feeling of being hot all the time.” The nurse should assign the client to share a room with a client with the diagnosis of?

Accepted Answer

Answer reason: Therefore, the roommate should not have any airborne or contact-transmissible infection that could spread to an immunocompromised patient or be spread by the suspected TB patient. Herpes zoster on the trunk can require airborne/contact precautions (especially if disseminated or in immunocompromised hosts), and C. difficile requires contact precautions due to spore transmission, making either an unsafe match. A noninfectious condition such as inflammatory polyarthritis is the safest roommate choice while isolation needs are clarified and implemented.

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