Question 1

What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?

Accepted Answer

Answer reason: This principle drives nursing care toward strict infection prevention measures, early recognition of fever/respiratory or GI symptoms, and timely evaluation for sepsis. In-utero infection is associated with more rapid disease progression in infants, not a longer incubation or slower course, making option A incorrect. Normal growth and development cannot be assumed because chronic infection and recurrent illness can cause failure to thrive and developmental delays, eliminating option C. Renal monitoring is not the central HIV-specific planning principle unless a particular nephrotoxic therapy or renal disease is present, so option D is less appropriate.

Question 2

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that?

Accepted Answer

Answer reason: Visitors may come, but they should clean their hands before and after any contact with the client or the client’s environment to reduce the risk of spreading pathogens. Routine masking is not required for contact precautions unless there is concern for droplet/airborne spread or splashing of secretions. Gloves may be appropriate if touching the wound/dressings or contaminated items, but hand hygiene remains essential and applies to all visitors regardless of whether gloves are used.

Question 3

Chain Of Infection Which element in the circular chain of infection can be eliminated by preserving skin integrity?

Accepted Answer

Answer reason: Intact skin is a primary physical barrier that prevents microorganisms from entering sterile tissues and the bloodstream. Preserving skin integrity (preventing cuts, pressure injuries, or breakdown) removes or blocks a key access point for pathogens, thereby breaking the chain at the entry step. In contrast, a reservoir (where organisms live) may still exist in the environment or on the client, but cannot readily cause infection without an entry route. This is why wound care, pressure-injury prevention, and maintaining mucous membrane/skin integrity are core infection-prevention measures.

Question 4

The charge nurse is observing a staff nurse perform a sterile dressing change for a client with a sacral wound. Which action by the staff nurse while wearing sterile gloves would require the charge nurse to intervene?

Accepted Answer

Answer reason: Sterile gloves must only contact sterile supplies and the prepared sterile field; touching nonsterile linens breaks aseptic technique. A clean bed sheet is not sterile and is commonly contaminated from the environment and patient contact, so manipulating it with sterile gloves contaminates the gloves. Once contaminated, the nurse can transfer microorganisms directly to the wound and increase infection risk. The other actions describe handling sterile or sterile-prepared items used appropriately for wound cleansing/packing, which is consistent with sterile technique when performed within the sterile field.

Question 5

The nurse is caring for an infant postoperatively who had a placement of a silo for gastroschisis. The nurse is knowledgeable that which of the following interventions is a priority?

Accepted Answer

Answer reason: Immediate prevention and treatment of infection is a safety priority before advancing enteral nutrition, especially while bowel edema and dysmotility are common. IV antibiotics are routinely used perioperatively in gastroschisis to reduce infectious complications related to exposed viscera and surgical handling. Enteral feeding (oral or gavage) is typically delayed until bowel function returns and the silo reduction/closure is stable, so feeding-focused options are not the first priority.

Question 6

MASK IS DISPOSED IN......?

Accepted Answer

Answer reason: In standard biomedical waste segregation, contaminated disposable items like masks and gloves go into the infectious waste stream for appropriate treatment (e.g., incineration/autoclaving). Yellow bags are commonly designated for infectious/soiled waste, while red is for certain contaminated recyclable plastics and white is for sharps. Placing masks in the infectious waste category supports consistent infection prevention and regulatory compliance.

Question 7

Which of the following are appropriate nursing interventions for a client with neutropenia?

Accepted Answer

Answer reason: Neutropenia greatly increases infection risk because the body’s first-line cellular defense is impaired, so preventing transmission is the priority. Hand hygiene is the single most effective, evidence-based intervention to reduce healthcare-associated infection from staff and visitors. Other measures can be used selectively (e.g., restricting sick visitors, avoiding potential microbial reservoirs, and using safe-food practices), but they are adjuncts and vary by institutional policy. Live vaccines are generally avoided in immunocompromised patients because they can cause disease. Therefore, emphasizing meticulous hand hygiene best matches the most universally appropriate nursing intervention.

Question 8

The nurse in the emergency department (ED) is triaging a client who reports recent international travel to West Africa and has signs and symptoms of conjunctival injection, fever, rash, vomiting, and blood in their stool. The nurse is concerned that this client may have?

Accepted Answer

Answer reason: This presentation emphasizes a high-consequence viral hemorrhagic fever risk based on recent travel to West Africa plus fever, conjunctival injection, rash, vomiting, and gastrointestinal bleeding. Ebola commonly causes systemic symptoms with prominent GI involvement and can progress to hemorrhage, making it a critical triage and isolation concern. Pulmonary tuberculosis typically presents with chronic cough, weight loss, and night sweats rather than acute vomiting and bloody stool. Inhalation anthrax is primarily a severe respiratory illness (mediastinal widening, dyspnea), and encephalitis would be driven by neurologic findings (altered mental status, seizures), neither of which best matches the stem.

Question 9

A client receiving chemotherapy is at risk for neutropenia. What should the nurse emphasize to this client to prevent infection?

Accepted Answer

Answer reason: Neutropenia reduces the body’s first-line defense against bacterial and fungal infections, so prevention relies heavily on minimizing pathogen exposure. Consistent hand hygiene is the most effective, evidence-based measure to reduce transmission in both healthcare and home settings. Avoiding all social contact is unnecessarily restrictive and not required; instead, the client should avoid sick contacts and crowded areas when counts are low. A diet high in raw produce can increase exposure to microbes, and aspirin can mask fever and increase bleeding risk, delaying recognition of infection.

Question 10

A 10 year-old client is admitted to the oncology unit with a diagnosis of acute leukemia. Which of the following actions by the parents requires further education in the care of their child?

Accepted Answer

Answer reason: Raw/unwashed fruits can carry pathogens and are commonly restricted during neutropenia unless thoroughly washed/peeled and allowed by the oncology team’s neutropenic-diet guidance. The other actions focus appropriately on reducing exposure to potential sources of infection (public play areas, extra visitors) while still supporting development with low-risk activities. A common misconception is that certain foods meaningfully improve immune function in this setting; the priority is infection prevention and safe food handling.

Question 11

Which action by the nurse in charge is essential when cleaning the area around a Jackson - Pratt wound drain..?

Accepted Answer

Answer reason: The core principle is to clean from the least contaminated area to the most contaminated area to minimize introducing microorganisms into the insertion/incision site. For a JP drain site, the skin immediately adjacent to the drain/exit site is treated as the “clean” starting point after hand hygiene and sterile/clean technique per policy, and cleansing moves outward so organisms on surrounding skin are not dragged toward the site. A circular outward motion also helps ensure systematic coverage without repeatedly crossing back over the cleaned insertion area. Options that move from the periphery toward the center increase contamination risk by carrying skin flora toward the drain tract. Brisk back-and-forth wiping is not recommended because it is less controlled and can irritate tissue and disrupt healing.

Question 12

The doors of each ot should ideally be?

Accepted Answer

Answer reason: Doors that open by sliding reduce the need for door swing space, lowering the risk of accidental contact with sterile fields and facilitating smoother transfer of stretchers and equipment. Wood is porous and difficult to disinfect reliably, making it unsuitable for high-level aseptic environments. Hinged doors can create more air disturbance and increase collision risk during frequent entry/exit, which can compromise sterile workflow.

Question 13

The nurse has taught a client with herpes zoster. Which of the following client statements indicate that teaching was effective?

Accepted Answer

Answer reason: " Herpes zoster lesions can transmit varicella-zoster virus to susceptible individuals via direct contact with vesicular fluid, so preventing exposure is a key safety teaching point. Avoiding close contact until the lesions have crusted/healed reduces risk of spreading infection to pregnant people, immunocompromised patients, and those without prior varicella immunity. A common misconception is that heat application is appropriate; however, heating pads can worsen discomfort and increase risk for skin injury, and cool/wet compresses are typically preferred. Another misconception is delaying antivirals; treatment is most effective when started early (ideally within 72 hours) to reduce duration and severity and lower complication risk such as postherpetic neuralgia.

Question 14

A nurse is teaching a client about the incentive spirometer. Which of the following statements should the nurse include in the teaching?

Accepted Answer

Answer reason: Teaching should focus on deep, sustained inhalation with appropriate frequency and technique rather than unrelated preventive services or chronic disease management tasks. Among the provided options, the only one that aligns with preventing or managing respiratory complications associated with infection risk is addressing treatment for infection. The other options (immunizations, glucose screening, cancer medication regimen) are not connected to using an incentive spirometer and would not be included in that device-specific teaching.

Question 15

The charge nurse in the medical unit is responsible for reporting all healthcare associated infections. Which of the ff client condition needs to be reported?

Accepted Answer

Answer reason: Healthcare-associated infections are infections that develop during the course of receiving healthcare and were not present or incubating at admission, and C. difficile is a classic example tied to antibiotic exposure. New-onset C. difficile while hospitalized and on antibiotics indicates a likely facility-acquired infection that requires reporting and immediate infection-control actions (enteric/contact precautions and surveillance). A wound MRSA that is documented on admission is community- or pre-existing colonization/infection rather than healthcare-associated in that facility. Diarrhea from ulcerative colitis is an inflammatory disease flare, and a low-grade temperature 2 days post-op does not by itself establish a reportable infection without additional evidence.

Question 16

Which hand hygiene method is best at killing bacteria?

Accepted Answer

Answer reason: They work faster than soap-and-water and are more consistently effective when hands are not visibly soiled. Antimicrobial soap and water can reduce organisms but is generally slower and more technique-dependent, and soap/water is preferred mainly when hands are visibly dirty or for certain pathogens (e.g., spores). Hot running water alone does not provide adequate antimicrobial action and can increase skin irritation, which may worsen colonization risk over time.

Question 17

The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?

Accepted Answer

Answer reason: Bell’s palsy causes unilateral facial nerve (CN VII) dysfunction, leading to incomplete eyelid closure and reduced blink reflex, which can expose and dry the cornea. Loss of the normal protective barrier and tear distribution increases the risk of corneal irritation, keratitis, and secondary infection, making protection of the eye the most time-sensitive priority. The other options describe potential psychosocial or sensory issues, but they do not typically pose the same immediate threat to tissue integrity and function. Prioritizing prevention of infection aligns with preventing complications from exposure-related breakdown and contamination.

Question 18

A nurse is caring for a client diagnosed with bacterial pneumonia. Which action should a nurse prioritize when caring for this client to prevent the transmission of infection?

Accepted Answer

Answer reason: Hand hygiene is the single most effective measure to prevent healthcare-associated transmission because hands are the most common vehicle for spreading respiratory pathogens via contact with contaminated secretions and surfaces. Consistent hand cleaning before and after patient contact, after removing gloves, and after contact with respiratory equipment interrupts the chain of infection across multiple routes. Mask use can reduce droplet exposure, but it does not address indirect contact spread and is less globally protective than proper hand hygiene. Deep breathing exercises support ventilation and secretion clearance but are not an infection-control intervention.

Question 19

Urine sample for culture is collected from?

Accepted Answer

Answer reason: The clean-catch midstream technique flushes initial contaminants with the first part of the stream, then captures urine that better reflects organisms in the bladder. “First urine” is more likely to contain urethral contaminants and can yield false-positive growth. Collecting a properly obtained midstream sample supports correct organism identification and targeted antibiotic selection.

Question 20

After iv cannulation within how many days should be change the cannula?

Accepted Answer

Answer reason: A 72–96 hour replacement interval is the commonly taught window in many nursing exam resources and older institutional protocols, balancing complication risk with unnecessary re-sites. Replacing at 24 hours is unnecessarily frequent for routine peripheral access and increases trauma and infection opportunities from repeated insertions. A fixed 72 hours is narrower than the standard window and does not reflect the typical guideline range used in practice questions.

Question 21

What is the single most effective way to break the chain of corona infection?

Accepted Answer

Answer reason: Consistent hand hygiene (soap and water or alcohol-based rub when appropriate) reduces viral load and prevents self-inoculation of mucous membranes after touching contaminated objects. PPE helps when correctly selected and donned/doffed, but it does not replace hand hygiene and can fail if hands contaminate the face during removal. Sterilization is limited to critical instruments and is not feasible for routine community or general contact transmission, while disinfection is important but secondary to interrupting hand-mediated spread.

Question 22

A nurse is advising a patient with Chronic Fatigue Syndrome on infection control procedures. Which of the following statements indicates that the patient understands the advice?

Accepted Answer

Answer reason: Infection control teaching emphasizes reducing exposure to contagious respiratory pathogens through avoidance of sick contacts and consistent hygiene practices. This statement directly reflects an actionable behavior that lowers the patient’s risk of acquiring an infection. Attending a basketball game or large-crowd functions increases exposure opportunities, so those choices do not best demonstrate understanding of infection prevention. A blood test is not an infection-control measure and does not reduce transmission risk.

Question 23

The nurse is preparing to insert a nasogastric tube (NGT). Which action should the nurse take?

Accepted Answer

Answer reason: Cleaning hands immediately before NGT insertion reduces the risk of introducing pathogens into the patient’s nares, oropharynx, and gastrointestinal tract. Sterile gloves are not required for routine NGT insertion (clean gloves are typically used), so that option overstates aseptic requirements. Verifying tube placement is critical, but CT is not the standard verification method; radiography is used when imaging is required, and this does not replace proper preparation.

Question 24

The nurse is instructing a female client who is neutropenic. It would be appropriate for the nurse to recommend that she?

Accepted Answer

Answer reason: Neutropenia increases the risk for infection, so teaching focuses on minimizing mucosal trauma and avoiding introduction of microorganisms into the body. Tampons can cause microabrasions and increase the risk of vaginal infection or toxic shock, especially when immune defenses are reduced. Using sanitary pads is a safer hygiene measure during menses for an immunocompromised client. Brushing teeth every other day is inadequate oral hygiene, a face shield is not standard protective guidance for community outings, and hot water alone is not a reliable disinfection method compared with appropriate cleaning agents.

Question 25

The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that?

Accepted Answer

Answer reason: Norovirus spreads primarily via the fecal-oral route and is highly contagious, with significant transmission from contaminated hands and environmental surfaces. An effective outbreak control measure is rigorous cleaning and disinfection of high-touch surfaces using chlorine bleach, which reliably inactivates norovirus compared with many routine disinfectants. Respiratory PPE like surgical masks or face shields is not the core control strategy unless there is anticipated splash from vomitus, and it does not address the dominant contact/environmental route. Using disposable dishware is not necessary when standard dishwashing/sanitization is performed and is less impactful than targeted environmental disinfection and hand hygiene.

Question 26

A client with leukemia has developed neutropenia. The nurse informs the client to avoid which food?

Accepted Answer

Answer reason: Undercooked meats can harbor bacteria such as Salmonella, Campylobacter, and E. coli, making them unsafe for immunocompromised clients. A medium-rare steak is not reliably cooked to temperatures that kill pathogens throughout the meat. In contrast, cooked foods like bread and stewed fruit are generally low risk, and raw produce may be restricted depending on facility policy but is typically less clearly hazardous than undercooked meat in standard exam framing.

Question 27

Which nursing action demonstrates the principle of medical asepsis?

Accepted Answer

Answer reason: Medical asepsis (clean technique) focuses on reducing the number and spread of microorganisms through routine disinfection and cleanliness measures. Disinfecting shared or reusable client-care equipment with an alcohol-based agent directly interrupts transmission via contaminated fomites. Returning unused linen to the supply cart risks contaminating clean stock, which violates infection control practices rather than demonstrating proper asepsis. Keeping the environment generally clean is important but is less specific to the key medical asepsis action of disinfecting contaminated equipment between uses.

Question 28

What is the initial action of a nurse when preparing to insert a nasogastric (NG) tube?

Accepted Answer

Answer reason: Hand hygiene is the first step for any invasive or potentially contaminating bedside procedure because it most effectively reduces transmission of microorganisms. NG tube insertion is performed using clean technique, so sterile gloves are not required as an initial preparation step unless facility policy or specific patient factors dictate. Mask and gown are not routine unless there is a risk of splash or the patient is on indicated transmission-based precautions. Gathering and opening equipment occurs after hand hygiene to avoid contaminating supplies and the patient environment.

Question 29

A client complains of small, red, pruritic dots between his fingers and toes. Based on the assessment data, the nurse recognizes that the client most likely has which condition?

Accepted Answer

Answer reason: This distribution pattern is more specific than a generalized rash and should prompt consideration of a contagious ectoparasite requiring contact precautions and treatment of close contacts. Herpes zoster typically presents as a unilateral, dermatomal vesicular eruption with burning pain rather than scattered interdigital papules. Varicella usually causes a diffuse, generalized vesicular rash in various stages, not isolated lesions between digits. A contusion is a traumatic bruise and would not present as pruritic red dots between fingers and toes.

Question 30

The client has sustained the initial phase of a burn injury. The nurse anticipates that the primary focus of the client’s care is?

Accepted Answer

Answer reason: Loss of the skin barrier after a burn creates a major portal of entry for microorganisms and rapidly increases risk for local wound infection and progression to sepsis. Early nursing priorities include strict aseptic technique with wound care, protective isolation as indicated, and careful monitoring for infection while supporting fluid resuscitation. Psychosocial needs such as anxiety and self-esteem are important but are not the immediate primary focus when a life-threatening complication like infection is highly likely. Hygiene supports comfort and infection prevention, but infection prevention is the broader, priority safety outcome driving care in the acute burn phase.

Question 31

The medical resident admits the 4-year-old with complications related to chicken pox. Which prescribed medication is most important for the nurse to question?

Accepted Answer

Answer reason: Varicella (chickenpox) is a classic viral trigger, so this order requires immediate clarification before administration. Antipyresis and pain control can be achieved more safely with acetaminophen in this age group. Antivirals like acyclovir may be appropriate in complicated or high-risk varicella when started promptly, whereas the key safety issue here is avoiding salicylates.

Question 32

A client has been treated for compartment syndrome by undergoing a fasciotomy. Which nursing diagnosis has the highest priority for this client?

Accepted Answer

Answer reason: Compartment syndrome threatens limb perfusion, but the question states the client has already been treated, shifting priority to preventing post-op complications that can rapidly worsen outcomes (cellulitis, osteomyelitis, sepsis, delayed healing). Pain is expected after surgery but is not the top threat to life/limb compared with a high-risk open wound. Impaired gas exchange and decreased cardiac output are not the most likely priority problems directly driven by fasciotomy care unless additional assessment data indicate respiratory or hemodynamic compromise.

Question 33

The nurse prepares to insert a peripheral intravascular catheter in a client requiring fluids. Which antiseptic is preferred for prepping the skin prior to insertion of the catheter?

Accepted Answer

Answer reason: Reducing catheter-related bloodstream infection risk requires an antiseptic with strong, persistent activity against skin flora. Chlorhexidine-based skin prep is preferred for peripheral IV insertion because it has broad antimicrobial coverage and continues working after application, lowering colonization at the insertion site. Alcohol alone lacks sustained residual effect, and iodophors generally have less persistent activity and can be affected by organic material or require longer contact time. Acetone is not an appropriate antiseptic for skin preparation and can be irritating and unsafe for this purpose.

Question 34

The nurse is collecting information and preparing to assess the toddler with eczema. Which component is most important for the nurse to assess?

Accepted Answer

Answer reason: Assessing hygiene routines, handwashing, nail care, and measures used to prevent skin breakdown directly targets the most immediate preventable complication. This assessment also guides anticipatory teaching to reduce impetigo/cellulitis risk and to recognize early signs of infection that require prompt treatment. While severity descriptors of lesions can help characterize disease, preventing infection is the higher safety priority in the nursing assessment.

Question 35

The nurse is working in the newborn nursery when the Environmental Services Department states they would like to evaluate a new disinfectant on the unit. Which disinfectant should the nurse not recommend for the newborn nursery?

Accepted Answer

Answer reason: Phenolic disinfectants are avoided in nurseries because neonates have immature hepatic and renal clearance and can absorb chemicals through thin skin, increasing risk of systemic toxicity (e.g., hyperbilirubinemia and neurotoxicity). The safest selection focuses on minimizing chemical exposure while still achieving appropriate environmental disinfection. Bleach (diluted sodium hypochlorite) and alcohol are commonly used in healthcare with appropriate dilution, contact time, and ventilation, and iodophors are used for skin/environmental antisepsis when appropriate. Therefore the product that should not be recommended in a newborn nursery is the phenolic class.

Question 36

Before using a bronchoscope from one client to the next, the bronchoscope must be cleaned. The nurse knows that minimal cleaning of the bronchoscope includes?

Accepted Answer

Answer reason: Bronchoscopes contact mucous membranes and respiratory secretions, making them semi-critical devices under Spaulding classification. Semi-critical items require at least high-level disinfection between patients to prevent transmission of organisms such as mycobacteria and respiratory viruses. Sterilization is not the minimum standard for this category and is not required in routine use when high-level disinfection is performed properly. Low-level disinfection or simple washing removes soil but does not reliably eliminate all pathogenic microorganisms needed for safe reuse between clients.

Question 37

The nurse observes the NA preparing a food tray for the 4-year-old who recently underwent a bone marrow transplant. Which food item should the nurse remove from the child's tray?

Accepted Answer

Answer reason: Undercooked or runny eggs can harbor pathogens such as Salmonella, making them unsafe for this child. Fully cooked, commercially prepared foods are preferred because they minimize bacterial exposure. The other items listed are generally acceptable when prepared hygienically and served appropriately, whereas an incompletely cooked egg is a high-risk food.

Question 38

The clinic nurse is assessing the 17-year-old male and observes multiple lesions on both upper arms- Some of these lesions are covered with a honey- colored crust. Based on this assessment, which skin condition should the nurse consider?

Accepted Answer

Answer reason: The description of multiple lesions on exposed areas (upper arms) fits a highly contagious superficial bacterial skin infection often spread by direct contact or autoinoculation. Herpes zoster typically presents with grouped vesicles on an erythematous base in a dermatomal distribution with pain, not diffuse honey-crusted lesions. Cellulitis causes diffuse warmth, tenderness, and swelling without crusted superficial lesions, and ringworm presents as annular, scaly plaques with central clearing rather than crusting.

Question 39

A parent calls the school nurse to ask when her child who developed chickenpox can return to school. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Once every vesicle has dried/crusted, the risk of transmission is markedly reduced and standard school exclusion criteria are met. Being afebrile does not reliably indicate noninfectiousness because viral shedding continues while new lesions are forming. Waiting until lesions are completely gone is unnecessarily restrictive, since crusted lesions can persist after the contagious period ends.

Question 40

The HCP documents that the client has a generalized infection. Which specific assessment finding should the nurse expect?

Accepted Answer

Answer reason: This option reflects systemic involvement rather than a localized process. Redness, warmth, swelling, and pain “at the site” are classic localized inflammation findings and would be more consistent with a localized infection. Hypertension with bradycardia is not a typical hallmark of systemic infection and may suggest other physiologic disturbances rather than infection.

Question 41

A nurse who works on an oncology unit notices a respiratory technician (RT) carrying a baby down the hallway. The nurse should?

Accepted Answer

Answer reason: Immunocompromised oncology patients are at high risk for acquiring infections from community exposures, including infants who may carry contagious viral illnesses with minimal symptoms. Removing the infant from the oncology environment promptly is the safest immediate action, and the nursery is the appropriate service to receive and secure the baby. Notifying a manager or asking a director to educate staff addresses the system issue but delays the urgent infection-control response. Doing nothing fails to mitigate a preventable exposure risk on a high-risk unit.

Question 42

Which condition indicates to a nurse that a sterile field has been contaminated?

Accepted Answer

Answer reason: Moisture allows capillary action (strike-through), which can wick microorganisms from a nonsterile surface into the sterile field and is treated as contamination. A sterile field must remain dry and above the level of the waist/table edge to maintain sterility. Holding sterile objects above waist level and opening the first flap away are correct sterile-technique actions and do not indicate contamination. Although the outer 1 inch of a sterile drape is considered nonsterile, the key contamination cue here is wetness on the sterile barrier over a nonsterile surface.

Question 43

Which nursing action is the most effective infection control measure for preventing the transmission of microorganisms?

Accepted Answer

Answer reason: Hand hygiene is the single most effective measure to break the chain of infection because hands are the primary vector for transferring organisms between patients and the environment. Cleaning hands both before and after contact reduces introduction of pathogens to a vulnerable client and prevents carrying organisms to other clients or surfaces. Gloves and masks are important components of standard/transmission-based precautions, but they are situation-specific and do not replace hand hygiene (and can fail with improper removal). Changing linens helps reduce bioburden but is less impactful than consistent hand hygiene on direct transmission prevention.

Question 44

The nurse is aware that the highest risk for developing a postoperative wound infection exists with a client who has experienced which of the following?

Accepted Answer

Answer reason: The perineal approach is adjacent to the anus and perineal skin, increasing contamination risk from gastrointestinal flora compared with suprapubic or retropubic approaches. TURP is performed through the urethra with no external surgical incision, so it is less associated with a postoperative wound infection at an incision site. Therefore, the perineal approach carries the greatest postoperative wound infection risk among these choices.

Question 45

The nurse is teaching a parent skin care for the child diagnosed with impetigo. Which instruction is best?

Accepted Answer

Answer reason: Impetigo is a highly contagious superficial bacterial skin infection, and hygiene measures that reduce bacterial load and remove crusts help limit spread and promote healing. Gentle daily cleansing softens and loosens crusts so prescribed topical therapy can contact the affected skin effectively. Avoiding bathing increases colonization and transmission risk to other body sites and household contacts. Sharp or aggressive debridement is unnecessary and can traumatize skin, increase pain, and worsen infection risk. Teaching routine cleansing aligns with infection-control principles and safe home care.

Question 46

A 40-year-old paraplegic client must perform intermittent catheterization of the bladder. Which instruction should be given?

Accepted Answer

Answer reason: Intermittent self-catheterization teaching prioritizes reducing urinary tract infection risk through proper perineal hygiene and clean technique. Washing the urinary meatus with soap and water before catheter insertion decreases bacterial load at the entry site and is appropriate home instruction. Cleaning “from back to front” moves bacteria from the anus toward the urethra and increases contamination risk. Measuring urine output can be useful in select monitoring situations but is not the key safety instruction for routine self-catheterization technique.

Question 47

The student nurse asks if any precaution is necessary when caring for children with respiratory infections such as croup. What is the best information for the nurse to provide?

Accepted Answer

Answer reason: Respiratory infections like croup are commonly spread via droplets and contaminated hands/fomites, so meticulous hand hygiene is the most universal and consistently effective prevention measure. It is required with every patient interaction regardless of whether additional transmission-based precautions are ordered. Isolation may be appropriate in some situations, but it depends on the specific organism, symptoms, and facility policy and therefore is not the single best general precaution to teach. Teaching tissue use supports respiratory hygiene, but it is less reliable than staff/visitor hand hygiene and does not replace it; keeping siblings together increases transmission risk.

Question 48

A client tells a nurse he boils his urinary catheters to keep them sterile. What is the most appropriate question for the nurse to ask the client?

Accepted Answer

Answer reason: ” Preventing catheter-associated UTI depends most on maintaining aseptic/clean technique during insertion and handling, because contamination at the time of catheterization is a common source of infection. Asking about the technique assesses the client’s actual practice (hand hygiene, sterile supplies, avoiding touching the catheter, cleansing, and maintaining a closed system) and identifies teachable gaps that directly reduce infection risk. Focusing on boiling temperature is less clinically useful because home boiling does not reliably ensure sterility and does not address handling contamination. Storage/drying is important, but it is secondary to insertion and handling technique in preventing introduction of organisms into the urinary tract.

Question 49

Which nursing intervention would best help prevent bladder infections for a client with an indwelling urinary catheter?

Accepted Answer

Answer reason: The core principle is minimizing introduction of microorganisms into the urinary tract and keeping the catheter/perineal area clean while maintaining a closed drainage system. Showers reduce prolonged exposure of the perineum and catheter to bath water that can become contaminated and promote ascending infection. In contrast, opening the drainage system to obtain a specimen breaks the closed system and is a major infection risk; specimens should be obtained via the sampling port using aseptic technique. Limiting fluids concentrates urine and decreases flushing of bacteria, and routine irrigation increases manipulation/trauma and is not performed unless specifically ordered for obstruction management.

Question 50

The clinic nurse is assessing the 12-year-old who has multiple scaly—ringed lesions on the face, neck, and arms. Which is the most important question that the nurse should ask?

Accepted Answer

Answer reason: Scaly, annular (ringed) lesions are most consistent with tinea corporis (ringworm), a contagious fungal infection frequently acquired from infected pets (especially cats and dogs). Identifying an animal exposure helps pinpoint the source, guides teaching about preventing reinfection (vet evaluation/treatment, hygiene, avoiding shared linens), and supports appropriate infection-control counseling. Asking about onset is useful but does not direct source control as effectively as identifying a common zoonotic reservoir. Picking at sores is less aligned with the classic ringed, scaly appearance and is lower priority than determining transmissible exposure.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Infection Control NCLEX Practice Test

Continue Learning