Question 1

The client’s total WBC count is 20,000/mm3 two days after surgery. Which assessment finding should the nurse most associate with this laboratory result?

Accepted Answer

Answer reason: Postoperative respiratory complications such as pneumonia commonly present with abnormal breath sounds, including crackles, along with reduced air movement in affected areas. This finding best aligns with leukocytosis driven by infection compared with normal incision appearance, which suggests expected healing. Dark, concentrated urine is more consistent with dehydration or low fluid intake and does not specifically explain a WBC of 20,000/mm3.

Question 2

A clinic nurse is teaching parents with young children. About which most common sources of infectious disease transmission should the nurse teach the parents?

Accepted Answer

Answer reason: Teaching parents to focus on these body substances targets the highest-frequency routes for common childhood pathogens (e.g., viral gastroenteritis and upper respiratory infections). This framing also aligns with standard precautions and hand hygiene education, which are the most effective general prevention measures in households and child-care settings. Blood exposure is a much less common routine transmission source in typical pediatric family interactions, making it a lower-yield focus compared with stool and respiratory secretions.

Question 3

A client receives a bed bath and bed linen change. The nurse knows that soiled linen should be?

Accepted Answer

Answer reason: Infection-control principles require containing contaminated materials to prevent leakage and environmental contamination during handling and transport. Bagging soiled linens at the point of use in a leak-proof container reduces the risk of microorganisms spreading to surfaces, staff uniforms, and other patients. Holding linen close to the body increases the chance of contaminating clothing and dispersing organisms, even if gloves are worn. Leaving linen on a hallway cart creates unnecessary exposure and violates basic containment and standard precaution practices.

Question 4

A nurse must obtain the blood pressure of a client in airborne isolation. Which method is best to prevent transmission of infection to other clients by the equipment?

Accepted Answer

Answer reason: The key infection-control principle is to prevent fomite transmission by avoiding sharing noncritical equipment between patients when an isolation precaution is in place. Dedicating a blood pressure cuff and other reusable equipment to a single airborne-isolation client eliminates cross-contamination risk to other clients. Gloves reduce the nurse’s hand contamination but do not prevent the equipment itself from carrying organisms to another patient if it is moved. Disposing of equipment after each use is unnecessary and impractical for reusable BP equipment when dedicated-use or appropriate cleaning is the standard approach.

Question 5

A nurse is caring for a client on neutropenic precautions. At which point should the nurse remove the barrier protection when leaving the room?

Accepted Answer

Answer reason: The doorway is the transition point between the client’s room and the hallway, so removing and discarding PPE just inside the room limits environmental contamination. After removing PPE, hand hygiene is performed before touching door handles or equipment outside the room. Removing PPE in the hallway risks spreading pathogens beyond the room, and removing it at the bedside increases the chance of contaminating surfaces during egress.

Question 6

The nurse is performing a sterile dressing change. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Sterility is maintained only while the field remains dry and uncontaminated; moisture allows strike-through wicking of microorganisms from a nonsterile surface to the sterile field. A wet sterile field is therefore considered contaminated and must be replaced to prevent introducing pathogens into the wound. This action directly prevents infection, which is the highest priority during a sterile dressing change. Other options describe steps that may be done correctly or incorrectly, but none mitigate an immediate break in sterility as decisively as replacing a wet field.

Question 7

The adolescent client diagnosed with HIV has a CD4-positive T-lymphocyte count of 160 mcL. The nurse evaluates that interventions have been most effective when which outcome in the client's plan of care is achieved?

Accepted Answer

Answer reason: An effective plan of care should therefore be reflected by the absence of opportunistic infections, which directly measures protection from the most serious HIV-related complications at this CD4 level. Gastrointestinal regularity and weight trends can be affected by many noninfectious factors and are less specific indicators of immune protection. The skin option describes a problem state rather than a desired outcome, so it cannot represent effectiveness of interventions.

Question 8

Several children at a day care center have been infected with hepatitis A virus. What is the most important information the nurse can provide to reduce the risk of hepatitis A transmission?

Accepted Answer

Answer reason: Diaper changes create high-risk exposure to fecal material, so consistent handwashing with soap and water after each change directly reduces contamination of hands, surfaces, and shared items. Isolation is less effective because children can shed virus before symptoms and many cases are mild or asymptomatic. Masks target respiratory spread and utensil sterilization is unnecessary as routine cleaning is sufficient; the main prevention focus remains hand hygiene.

Question 9

Immediately after giving an injection, a nurse is accidentally stuck with the needle. The nurse is aware that testing for human immunodeficiency virus (HIV) antibodies should occur?

Accepted Answer

Answer reason: Post-exposure management after a needlestick requires baseline testing to document the exposed worker’s status at the time of exposure, followed by repeat testing after the window period. HIV antibody seroconversion may not be detectable immediately, so a follow-up test is needed to identify infection that becomes detectable later. A 3-month follow-up is a standard time point used to capture the vast majority of seroconversions with modern testing strategies and aligns with typical occupational exposure protocols. Waiting to start testing until 2 weeks delays baseline documentation and is not appropriate for an immediate occupational exposure evaluation.

Question 10

What is the most important information for the nurse to give the parents of a child with fifth disease?

Accepted Answer

Answer reason: Fifth disease (parvovirus B19) is usually mild in children but can cause severe fetal complications when a pregnant person becomes infected, including fetal anemia, hydrops fetalis, and pregnancy loss. The priority teaching is the high-risk exposure warning so parents can notify pregnant household members, caregivers, or school contacts promptly for medical evaluation and counseling. Statements about rash recurrence are lower priority comfort teaching, and contagiousness is greatest before the rash appears, so focusing on the rash phase can mislead families about transmission risk. Preventing harm to vulnerable contacts is the most critical safety message.

Question 11

The nurse is using chlorhexidine to cleanse a vein site prior to inserting an IV catheter. While pressing the activated applicator on the skin, what should the nurse do next?

Accepted Answer

Answer reason: Chlorhexidine skin antisepsis for IV insertion relies on mechanical friction plus adequate contact time to lower skin bioburden. Using a back-and-forth scrubbing motion for about 30 seconds provides the needed friction over the insertion area and surrounding skin to optimize antimicrobial effect. Shorter scrubs (e.g., 10 seconds) are typically insufficient for recommended prep technique. Visual cues like “wet enough” or color change are not reliable endpoints and can lead to inadequate antisepsis and higher catheter-related infection risk.

Question 12

A client preparing for discharge home is having difficulty urinating. The physician writes and an order for the client to receive instructions regarding intermittent urinary catheterization prior to being discharged home. The nurse knows that home intermittent catheterization is?

Accepted Answer

Answer reason: Intermittent self-catheterization performed at home is taught using clean (not sterile) technique because the goal is to reduce infection risk to an acceptable level in a non-acute environment. Clean technique emphasizes hand hygiene, cleaning the urethral meatus, and using clean equipment while avoiding contamination of the catheter tip. Sterile technique is typically reserved for acute care settings or invasive procedures where full asepsis is required, which is not practical or necessary for routine self-catheterization at home. Teaching clean intermittent catheterization supports safe bladder emptying and helps prevent complications such as urinary retention and catheter-associated infection. This aligns with evidence-based infection control principles for patient-performed procedures after discharge.

Question 13

During a staff in-service, the nurse describes the transmission process of hepatitis B and HIV. Which information by the nurse is most correct?

Accepted Answer

Answer reason: Transmission risk depends on pathogen concentration in blood and ability to survive and infect after exposure. HBV is highly infectious, and the occupational risk after a needlestick from an HBV-positive source is substantially higher than from an HIV-positive source, especially if the source has high viral load (e.g., HBeAg positive). Sexual contact is a transmission route for both HBV and HIV, making the statement that only HIV is sexually transmitted incorrect. Neither virus is spread via toilet seats in routine contact, and both can be transmitted through blood and certain body fluids, so denying body-fluid transmission is unsafe and inaccurate.

Question 14

Ultraviolet lights are placed in the waiting room of the emergency department. Care of the ultraviolet lights should include?

Accepted Answer

Answer reason: Ultraviolet germicidal irradiation is an adjunct infection-control measure that requires consistent operation to reduce airborne microbial load in high-traffic areas. UV exposure can injure eyes and skin and dust can reduce lamp effectiveness, so the unit should be powered down for cleaning and maintenance to prevent exposure and allow safe handling. Keeping them running when the area is occupied supports continuous disinfection benefit, whereas turning them off when the room is empty undermines their intended continuous-use role. Waiting until a bulb burns out is unsafe because UV output degrades over time even when visible light persists, so maintenance should not rely solely on burnout.

Question 15

A child with chronic renal failure is scheduled for hemodialysis with an external shunt three times per week. As part of the discharge planning, the nurse should tell the family to perform which step?

Accepted Answer

Answer reason: External shunts create a direct portal for pathogens, so early detection of local infection is a key home-care priority. Daily inspection for redness (often with warmth, swelling, tenderness, or drainage) helps the family identify complications early and seek prompt care before bacteremia or shunt loss occurs. Measuring blood pressure on the shunt arm is unsafe because compression can impair flow and promote clotting. Routine “washing” at the site can increase contamination risk, and dressings are typically managed per dialysis/vascular access instructions rather than being the primary universal teaching point compared with monitoring for infection.

Question 16

The nurse is teaching a client’s family the procedure for a dressing change they will do when the client is discharged. What is the most important action for the nurse to tell the client’s family that they should do first?

Accepted Answer

Answer reason: Hand hygiene is the single most effective measure to prevent transmission of microorganisms during wound care. It must occur before donning gloves because gloves can have microtears and hands can contaminate the glove surface during application. Performing hand hygiene first reduces the risk of introducing pathogens into the wound and protects both the client and caregiver. Actions like removing the dressing or assessing drainage are important, but they should only occur after infection-prevention steps are initiated.

Question 17

The client has a split-thickness skin graft taken from the thigh to cover a burn on the back. Which intervention should the nurse expect to implement to help reduce the risk of infection at the donor and graft site?

Accepted Answer

Answer reason: Clients with burns and newly grafted donor/graft sites are at high risk for infection because the skin barrier is disrupted and local defenses are reduced. Plants and flowers can harbor waterborne organisms and fungal spores that increase environmental bioburden, so removing them is a standard infection-control measure in higher-risk wound and burn care settings. Routine serial cultures are not preventive and are typically reserved for signs of infection or surveillance protocols, not as a primary risk-reduction intervention. “Clean technique” is insufficient for fresh graft and donor-site care where aseptic practices are needed, and continual low-dose IV antibiotics is not recommended due to resistance risk and lack of benefit without clear infection indications.

Question 18

The nurse is reviewing hospital admission orders for the client diagnosed with acute prostatitis- Which prescription should the nurse verify with the HCP?

Accepted Answer

Answer reason: Acute prostatitis causes a swollen, tender prostate that can obstruct the urethra and makes urethral instrumentation high risk for worsening infection and precipitating bacteremia/sepsis. Routine placement of a urethral indwelling catheter should be questioned because it can traumatize inflamed tissue and increase bacterial spread. If urinary retention requires drainage, the safer approach is typically suprapubic catheterization or urology-guided management rather than blind urethral catheter insertion. Supportive measures (hydration/voiding) and pain control are reasonable, and antimicrobial therapy is expected, but the immediate safety concern is avoiding urethral catheterization in this condition.

Question 19

An outbreak of hepatitis has occurred at a local factory. Ten factory workers ages 16 to 18 years developed symptoms of hepatitis within 2 days of each other. The source of the illness is determined to be contaminated cafeteria food. The factory occupational health nurse should notify the CDC that which type of hepatitis outbreak likely occurred?

Accepted Answer

Answer reason: Hepatitis A has this transmission route and can produce clustered cases in a shared cafeteria exposure, consistent with multiple workers becoming ill in a tight time window. Hepatitis B and C are primarily spread through blood and body fluids (e.g., sexual contact, needles), making a cafeteria source unlikely. Hepatitis D requires coinfection with hepatitis B and is not typically linked to food contamination outbreaks.

Question 20

The nurse is preparing to review the HCP’s written instructions with the parent of the pediatric client who has diarrhea caused by Escherichia coli (E. coli). Which instruction should the nurse question?

Accepted Answer

Answer reason: Children with infectious diarrhea are at high risk for dehydration and electrolyte imbalance, so fluids should be appropriate (e.g., oral rehydration solution) and avoid worsening osmotic diarrhea. Advising “any beverage” may lead to giving high-sugar juices, sodas, sports drinks, or caffeinated drinks, which can increase stool output and fail to replace needed electrolytes. Excluding the child from day care until diarrhea stops helps reduce transmission, which is appropriate for a communicable GI illness. Avoiding antidiarrheal medications in pediatric infectious diarrhea is generally recommended because they can mask symptoms and may increase risk of complications by slowing pathogen clearance.

Question 21

A child is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to chickenpox 1 week ago. The nurse is correct in her assessment of room assignment when she determines that?

Accepted Answer

Answer reason: Varicella (chickenpox) is highly contagious and is transmitted via airborne and contact routes, so hospitalized patients with possible incubating infection must be managed to prevent transmission to others. After an exposure, a susceptible person can become contagious shortly before any rash appears, and the exact onset cannot be predicted from history alone. Because the child is 1 week post-exposure (within the typical 10–21 day incubation window), the safest room-assignment decision is to place the child in appropriate isolation now rather than wait for a specific day threshold. Delaying isolation based on an arbitrary day count risks exposing other patients and staff, particularly pregnant or immunocompromised individuals.

Question 22

The school nurse is discussing giardiasis, a parasitic intestinal infection, with a group of parents. Many parents ask the nurse what group is most at risk for developing this infection. What is the most accurate response by the nurse?

Accepted Answer

Answer reason: Group day care and nursery school settings increase exposure because many children have inconsistent hand hygiene and there is frequent close contact with shared toys and bathrooms/diaper areas. This makes transmission more likely than settings like riding a bus or attending a sporting event where fecal-oral exposure is typically less direct. The nurse’s most accurate risk-group statement therefore points to congregate childcare as the highest-risk setting.

Question 23

The nurse is using contact precautions to change the soiled bed sheet of the client with Clostridium difficile. In the process, the nurse’s right glove and skin on a finger is torn. After removing the soiled gloves, which action is priority?

Accepted Answer

Answer reason: Clostridium difficile forms spores that are not reliably removed/killed by alcohol-based hand rub, so immediate handwashing with soap and water is the most effective first step after glove removal to reduce transmission. A torn glove with skin exposure increases contamination risk, making decontamination of hands the priority action in infection control. Bleach wipes are appropriate for environmental disinfection, not routine hand hygiene. Holding pressure may be needed if actively bleeding, but stopping potential spore spread to self/others takes precedence once gloves are off and exposure is suspected.

Question 24

The nurse observes that the NA enters the client room, provides direct care, and then exits without performing any band hygiene. Which is the appropriate initial action of the nurse?

Accepted Answer

Answer reason: Hand hygiene is the primary, immediate intervention to prevent transmission of microorganisms and protect the client and others. The nurse should address the unsafe practice at the point of care through direct, timely coaching/correction, which is the least punitive and most effective initial step within routine supervision. Escalating to the nurse manager is appropriate if the behavior continues or is part of a pattern, but it is not the first action when immediate correction can prevent harm. An incident/variance report is generally reserved for actual events causing harm or exposures and does not replace immediate risk reduction. Shifting responsibility to the client is inappropriate and undermines staff accountability and infection-control standards.

Question 25

The client is scheduled for a 3-hour surgery under general anesthesia. Which statement indicates that the client needs further teaching?

Accepted Answer

Answer reason:  Preoperative skin shaving by the patient increases infection risk because it can create microscopic cuts that promote bacterial colonization. If hair removal is required, it should be done immediately before surgery with electric clippers per facility protocol, not by shaving the night before. The other statements reflect common perioperative expectations for general anesthesia and postoperative pulmonary hygiene. For longer procedures, urinary catheterization may be used to monitor output and fluid status.

Question 26

A community health nurse prepares a presentation about decreasing the risk of spreading influenza in the community. The presentation most likely includes which information?

Accepted Answer

Answer reason: Influenza primarily spreads through respiratory droplets, so source control and respiratory hygiene are key community measures. Covering coughs/sneezes with the elbow or upper sleeve reduces droplet dispersal onto hands and nearby surfaces when a tissue is not available, lowering transmission risk. The vaccine does not transmit influenza in typical community use, and describing it as a transmission route is incorrect education. Antibiotics do not treat viral influenza and inappropriate use increases adverse effects and antimicrobial resistance.

Question 27

A nurse removes a small bandage from a client who received an injection. The nurse notices a speck of blood on the bandage. Where should the nurse dispose of the bandage?

Accepted Answer

Answer reason: Items contaminated with blood are regulated medical waste and must be discarded in a labeled biohazard waste receptacle to prevent exposure and comply with standard precautions. A small bandage with visible blood is not a sharp, so it does not require a puncture-resistant sharps container. Disposing it in regular trash increases risk of bloodborne pathogen exposure to staff and environmental services. Using the correctly lined biohazard container ensures proper containment and downstream handling per facility policy.

Question 28

During the middle of a surgical procedure, the technician informs the nurse that the biological indicator in the instrumentation pan does not indicate the instruments are sterilized. Which action should the nurse take first?

Accepted Answer

Answer reason: A failed sterilization indicator means the sterility of that set cannot be trusted, so the priority is to immediately prevent use of potentially contaminated instruments to reduce the risk of surgical site infection. Removing only the implicated tray and instruments is the fastest action that controls the source of contamination while allowing the team to obtain a verified sterile replacement. Tearing down the entire field is not the first step unless broader contamination is confirmed because it is more disruptive and may be unnecessary. An incident report and any investigation occur after the patient is protected and the procedure can continue safely.

Question 29

The critical care nurse performs active surveillance cultures on all client admissions. Which is an example of an active surveillance culture?

Accepted Answer

Answer reason: Active surveillance cultures are screening cultures obtained from patients (typically on admission) to detect colonization with epidemiologically important organisms so isolation and targeted precautions can be initiated early. Culturing the patient directly aligns with this purpose because MRSA and VRE commonly colonize skin/nares or other body sites without symptoms and can silently spread in critical care units. Room or equipment cultures are environmental sampling and are not the standard definition of admission active surveillance screening. This approach supports prompt implementation of transmission-based precautions and reduces healthcare-associated transmission.

Question 30

The nurse cares for a client who has undergone a bone marrow transplant. While the nurse assesses the client’s IV site, the client’s sister complains of a low-grade fever. The nurse should?

Accepted Answer

Answer reason: Immunosuppressed bone marrow transplant clients are at extremely high risk for severe infection, so preventing exposure is the priority. A visitor with any fever or infectious symptoms should not enter or remain in the protective environment, because even minor viral illnesses can be life-threatening to the client. Hand hygiene and masking reduce transmission risk but do not sufficiently mitigate the hazard posed by a symptomatic visitor. Advising the visitor to seek care may be appropriate, but the immediate nursing action is to remove the potential source of infection from the client’s room.

Question 31

The nurse is assessing the client's grafted wound following a skin graft. Which information provided during shift report should prompt the nurse to care-fully assess if the client has a wound infection?

Accepted Answer

Answer reason: This temperature is markedly elevated and warrants prompt focused wound assessment (appearance, increasing pain, erythema, warmth, purulence, odor) and evaluation for sepsis. The other findings are less specific: a WBC of 9900/microL is within normal range and serosanguineous drainage can be expected early after surgery. Low urine output may indicate hypovolemia or poor perfusion but does not specifically indicate wound infection without other infectious signs.

Question 32

A 2-year-old child is diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV). The child’s family also includes an 8-year-old child. Which statement is correct?

Accepted Answer

Answer reason: RSV is a highly contagious respiratory virus spread primarily by close contact with respiratory secretions and contaminated hands/surfaces, making household transmission common. Separating the infected toddler from siblings reduces exposure opportunities during the period of active symptoms and highest viral shedding. The infection can spread to older children and adults, even if illness may be milder, so assuming lack of communicability is unsafe. Hospital admission is based on clinical severity (eg, hypoxia, dehydration, respiratory distress), not simply for isolation in an otherwise stable child.

Question 33

The nurse is collecting a urine specimen from a client’s indwelling urinary catheter. Which action should the nurse take?

Accepted Answer

Answer reason: A urine culture or sterile specimen must be obtained without contaminating the closed drainage system to reduce catheter-associated UTI risk. Accessing the designated sampling port after disinfecting it preserves sterility and provides urine that reflects current bladder drainage. Collecting from the drainage bag risks contamination from stagnant urine and environmental exposure. Disconnecting the tubing or replacing the catheter unnecessarily breaks sterility and increases infection risk and trauma.

Question 34

A client has an indwelling urinary catheter, and urine is leaking from a hole in the collection bag. Which nursing intervention would be most appropriate?

Accepted Answer

Answer reason: Maintaining a closed, intact urinary drainage system is a key infection-prevention principle with indwelling catheters. A leaking collection bag indicates equipment failure and requires replacing the faulty component to restore a sealed drainage pathway and prevent contamination and skin breakdown. Taping a hole is not a reliable, aseptic repair and can worsen leakage and contamination. Changing the catheter is unnecessary when the problem is isolated to the drainage bag and would add avoidable urethral trauma and CAUTI risk.

Question 35

The client has diarrhea that has been cultured positive for Clostridium difficile (C. diff). In order to prevent the spread of infection, the nurse should perform which intervention?

Accepted Answer

Answer reason: C. difficile is a spore-forming organism, and spores are not reliably killed or removed by alcohol-based hand rubs. Soap-and-water handwashing with friction physically removes spores from the hands and is the key measure to prevent transmission after contact with the patient or environment. Gloves and gowns are required under contact precautions, but a routine mask is not necessary unless there is a splash risk. Negative-pressure rooms are used for airborne infections, not for enteric contact-spread organisms like C. difficile.

Question 36

The nurse is presenting information about conjunctivitis to parents of preschool children. Which statement from a parent indicates understanding of the most important point about bacterial conjunctivitis?

Accepted Answer

Answer reason: " Bacterial conjunctivitis is highly contagious and spreads easily through direct contact and fomites, so infection-control measures are the key teaching priority for families with young children. Using separate towels and washcloths reduces transmission to other household members and classmates. Claims that conjunctivitis is “almost always self-limiting without treatment” misses the safety focus and can delay evaluation when bacterial infection or complications are possible. The other statements are not the central preschool teaching point because they do not address the most common day-to-day route of spread in the home and childcare settings.

Question 37

The nurse is using contact precautions when eating for the client. When changing the client's IV solution bag, the nurse inadvertently touches the end of the exposed spike of the tubing. Which is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Touching the exposed spike is a break in aseptic technique, so the contaminated sterile item must be replaced to eliminate infection risk. Changing gloves does not correct contamination of the spike itself. Wiping the spike with alcohol is not a reliable method to re-establish sterility for a critical device component and can still leave contamination risk.

Question 38

A college student is hospitalized with meningococcal meningitis after being seen in the campus clinic. What is the nurse’s responsibility to the campus community regarding this diagnosis?

Accepted Answer

Answer reason: g., roommates, intimate contacts, those exposed to oral secretions). The key public health nursing action is rapid contact identification so exposed persons can be promptly notified and given appropriate post-exposure chemoprophylaxis and guidance. Mass quarantine or giving prophylaxis to the entire campus is not indicated and would be unnecessary and potentially harmful. Sharing infected students’ names broadly violates confidentiality; notifications should be coordinated through infection control/public health with minimum necessary disclosure.

Question 39

The nurse is instructing the client who is to have surgery. According to Medicare’s Surgical Care Improvement Project, what instruction is important for the client to receive prior to arrival at the hospital to prevent postoperative infection?

Accepted Answer

Answer reason: Preoperative infection prevention includes minimizing breaks in skin integrity that can increase bacterial colonization and microabrasions. Patient shaving at home is associated with higher rates of surgical site infection compared with leaving hair in place or using appropriate hospital hair removal methods (e.g., clippers only if needed). This instruction is specifically actionable before hospital arrival and aligns with evidence-based SSI prevention measures emphasized in perioperative quality initiatives. In contrast, timing of prophylactic antibiotics is primarily a facility process and is not reliably controlled by the client before arrival.

Question 40

A college student came to the university health clinic and was diagnosed with bacterial meningitis and admitted to a local hospital. Which intervention should the university health clinic nurse implement?

Accepted Answer

Answer reason: Close contacts of suspected meningococcal meningitis require prompt antibiotic prophylaxis to eradicate nasopharyngeal carriage and prevent secondary cases. Roommates in a dorm setting meet criteria for high-risk exposure due to prolonged close contact and shared airspace. Chemoprophylaxis (e.g., rifampin, ciprofloxacin, or ceftriaxone per protocol) is time-sensitive and is a direct, evidence-based infection-control intervention. Vaccination is preventive but does not provide immediate protection for exposed contacts, and broad isolation of an entire dorm or contacting all parents is not the prioritized, targeted public health action.

Question 41

Discharge instructions are written for a client admitted with cellulitis including a prescription for antibiotics. Which statement made by the nurse to the client is most accurate?

Accepted Answer

Answer reason: The principle is that antibiotics must be taken exactly as prescribed for the full duration to adequately eradicate bacteria and reduce recurrence and resistance. Completing the course helps ensure the cellulitis is fully treated even if symptoms improve early. Saving doses for later or stopping when feeling better risks relapse and selection of resistant organisms. Doubling doses (either routinely or after a missed dose) increases adverse-effect risk without improving outcomes; missed doses are generally managed by taking the next scheduled dose as directed (or taking it when remembered if close to the scheduled time per label guidance).

Question 42

The nurse is reviewing the proper technique in obtaining a urine specimen from an indwelling urinary catheter. When collecting the urine, which would be the most appropriate technique to use?

Accepted Answer

Answer reason: Cleaning the port with alcohol and aspirating fresh urine from the closed system yields a more accurate sample than urine that has been sitting in the bag. Collecting from the drainage bag risks bacterial overgrowth and contamination, leading to false results. Disconnecting the catheter system breaks the closed drainage system and increases catheter-associated UTI risk. Removing and re-catheterizing is unnecessary and adds trauma and infection risk.

Question 43

The experienced nurse is supervising the new nurse. The nurse should intervene if observing the new nurse performing which intervention?

Accepted Answer

Answer reason:  Teaching that implies noninfectious periods earlier in the outbreak can lead to unsafe sexual/skin-to-skin contact and inadequate precautions. The nurse should instead emphasize avoiding direct contact with lesions/secretions, strict hand hygiene, and barrier protection during outbreaks (and often even when asymptomatic, depending on counseling goals). The other actions are generally supportive/therapeutic skin care or patient education that do not create a comparable infection-control risk when performed appropriately.

Question 44

The 45-year-old diagnosed with HIV presents to the clinic requesting to receive herpes zoster vaccine live. Which statement by the nurse is accurate concerning administration of zoster vaccine live to this client?

Accepted Answer

Answer reason:  Live attenuated vaccines can cause disease in immunocompromised clients because their immune systems may not adequately control replication of the vaccine strain. HIV is associated with impaired cell-mediated immunity, which is particularly important for controlling varicella-zoster virus. Therefore, a live zoster vaccine requires careful evaluation of immune status (e.g., CD4 count) and may be contraindicated or deferred in significant immunosuppression. By contrast, statements implying it is routinely appropriate solely based on age or that it prevents primary varicella infection misrepresent the indication and risk profile of a live zoster vaccine.

Question 45

The nurse is caring for the 1-year-old who had surgery for a gastrostomy tube insertion. Which intervention should the nurse implement?

Accepted Answer

Answer reason: New gastrostomy sites require routine, gentle cleansing to reduce bacterial burden and prevent local skin breakdown while the stoma heals. Using normal saline with cotton-tipped applicators allows removal of crusting and drainage from the immediate peristomal area without excessive irritation. Thick/occlusive dressings can trap moisture and increase maceration and infection risk. Applying traction and initiating feedings immediately are unsafe because they can disrupt the new tract and increase the risk of leakage, dislodgement, and peritonitis if done before provider clearance.

Question 46

The nurse completes teaching an adolescent receiving treatment for an STI. Which statement indicates further teaching is needed?

Accepted Answer

Answer reason:  Effective STI prevention teaching focuses on correct condom use and material compatibility rather than claiming one condom type is inherently less likely to break. Breakage is more strongly related to proper sizing, correct application, avoiding oil-based lubricants with latex, and correct storage/handling. Nonlatex condoms (e.g., polyurethane/polyisoprene) can be effective alternatives, especially for latex allergy, and should not be presented as more prone to break simply due to being nonlatex. The other statements reflect appropriate teaching: abstaining during chlamydia treatment, correct topical timing for wart treatment as ordered, and understanding that herpes is managed (not cured) with antivirals and symptom relief.

Question 47

The nurse is catheterizing the female adolescent who has nephrosis. In performing this procedure, the nurse uses the nondominant hand to gently separate then pull up the labia minora to see the meatus. What should the nurse do next with the nondominant hand?

Accepted Answer

Answer reason: Maintaining aseptic technique during female urinary catheterization requires keeping the labia separated to prevent contamination of the cleansed urinary meatus and catheter from contact with surrounding skin. The nondominant hand becomes “contaminated” once it contacts the patient’s skin, so it should remain in place holding the labia apart and should not touch sterile supplies. The dominant (sterile) hand performs cleansing and then handles the sterile catheter. Releasing the labia or changing what the nondominant hand touches increases the risk of introducing microorganisms and causing a catheter-associated infection.

Question 48

A nurse is developing a care plan for a neutropenic client with lymphoma. Appropriate nursing interventions for this client would include?

Accepted Answer

Answer reason: Neutropenia greatly increases infection risk, so care priorities focus on reducing exposure to pathogens and preventing mucosal injury that can introduce bacteria. Avoiding raw produce is consistent with a neutropenic (low-microbial) diet, and meticulous hand hygiene is the single most effective infection-prevention measure. Avoiding enemas reduces rectal mucosal trauma and translocation of gut flora, which can lead to bacteremia in immunocompromised clients. Option A targets bleeding precautions more consistent with thrombocytopenia, and option B implies routine use of full PPE beyond standard/neutropenic precautions unless another indication exists (e.g., transmission-based isolation).

Question 49

A 4-year-old child is diagnosed as having acute lymphocytic leukemia. His white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents?

Accepted Answer

Answer reason: Neutropenia markedly increases the risk for serious bacterial and fungal infections, making infection prevention the highest safety priority. Teaching parents to implement protective measures (hand hygiene, avoiding crowds/sick contacts, monitoring for fever, and prompt reporting of infection signs) directly addresses the most life-threatening complication. Bleeding precautions are important when platelets are low, but the stem emphasizes low neutrophils rather than thrombocytopenia. Rest for anemia and constipation management are supportive concerns but are not as immediately critical as preventing and detecting infection early in a neutropenic child.

Question 50

The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?

Accepted Answer

Answer reason: Prompt reporting enables timely case management, identification and evaluation of exposed contacts, and coordination of community control measures to limit transmission. Releasing information to the media is inappropriate and risks violating confidentiality. Restricting care to staff with negative tuberculin tests is not an evidence-based control strategy; instead, appropriate airborne isolation and respiratory protection are used for staff safety, and transfer is not automatically required solely for diagnosis confirmation.

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