Question 1

A nurse is watching a patient wash their hands. Which of the following actions would the nurse correct?

Accepted Answer

Answer reason: Ten seconds is too short and is a common technique error that reduces decontamination effectiveness, increasing the risk of healthcare-associated infection transmission. Cleaning under the fingernails is appropriate because organisms commonly collect there. Drying with a towel is expected after rinsing; while vigorous “scrubbing” can irritate skin, the clearly incorrect step being tested here is inadequate washing time.

Question 2

A nurse reviews telephone messages in a pediatric clinic. Which message should be returned first?

Accepted Answer

Answer reason: Redness and moisture at the base of the umbilical cord stump may indicate infection (omphalitis), which can rapidly become serious in newborns. The other findings are normal neonatal variations, including the Moro reflex, expected circumcision healing, and typical stool patterns.

Question 3

Which of the following is the first priority in preventing infections when providing care for a client?

Accepted Answer

Answer reason: It is required before and after client contact and before donning and after removing gloves because gloves do not fully prevent contamination and can spread organisms during removal. PPE such as gowns, goggles, and gloves is important but is used based on anticipated exposure and does not replace routine hand hygiene. Environmental barriers (e.g., under a nurse’s bag) reduce fomite spread but are secondary to the universal priority of cleaning hands.

Question 4

Which part of the chain of infection is where the infectious organism lives and grows?

Accepted Answer

Answer reason:  In the chain of infection, the reservoir is the site where microorganisms normally live, survive, and multiply (e.g., humans, animals, water, soil, equipment). This directly matches the stem’s description of where the organism “lives and grows.” The agent is the pathogen itself rather than its habitat, while portals of exit/entry describe how the organism leaves one host and enters another. Infection control measures like cleaning/disinfection and hand hygiene primarily target reducing reservoirs and breaking transmission.

Question 5

Prior to setting up a sterile field, what action should the nurse take?

Accepted Answer

Answer reason: Inspecting for tears, moisture, punctures, or broken seals is a required pre-step before opening any sterile item onto the field. Clean surfaces should be dry (moisture wicks microorganisms), so making the surface damp increases contamination risk. Sterile gloves are typically donned after opening the sterile field/supplies, and “3 feet tall” is not a sterility standard (the sterile field must be kept above waist level and within view).

Question 6

A nurse is caring for a client who underwent a below knee amputation (BKA). Which of the following nursing interventions is the highest priority during the postoperative period?

Accepted Answer

Answer reason: Postoperative priorities emphasize early detection and prevention of complications that can rapidly threaten recovery and limb healing. A fresh amputation incision is high risk for wound infection, which can progress to systemic infection and impair tissue perfusion needed for stump healing and future prosthetic fitting. Monitoring the surgical site (and related vitals/drainage) enables prompt escalation for antibiotics, cultures, or surgical evaluation. Elevation on pillows may temporarily reduce edema but can also contribute to knee flexion contracture if used improperly and is not the most time-critical priority compared with infection surveillance. Teaching about phantom sensations and massage are appropriate later; massage is typically avoided early to protect the incision and prevent tissue trauma.

Question 7

Nurse Troy is aware that the most appropriate nursing diagnosis for a patient with Addison’s disease is which of the following?

Accepted Answer

Answer reason: With lower cortisol reserves, the client is more vulnerable to infection and may deteriorate quickly during intercurrent illness (risk for adrenal crisis). This makes surveillance for infection and prompt prevention/early treatment a priority nursing focus. In contrast, Addison’s disease typically causes sodium and water loss with hypotension (not excessive fluid volume), and urinary retention is not a characteristic problem. Hypothermia can occur but is not as central or consistently prioritized as infection risk in this condition.

Question 8

The primary complication of a central venous access device (CVAD) is?

Accepted Answer

Answer reason: Central lines provide direct access to the central circulation, so any breach in aseptic technique can quickly lead to catheter-related bloodstream infection, making it the most clinically significant and commonly emphasized complication. The insertion site and hub are frequent sources of microbial entry, and infection can progress to sepsis with high morbidity. While thrombosis and intraluminal occlusion do occur, they are typically secondary to mechanical factors or maintenance issues and are less prioritized than infection risk in standard nursing safety frameworks. Pain/discomfort is expected early and is not considered a primary CVAD complication compared with systemic infectious risk.

Question 9

The best method to prevent nosocomial infections is?

Accepted Answer

Answer reason: Hand cleansing before and after patient contact and after contact with bodily fluids or contaminated surfaces most directly reduces cross-contamination and is consistently the single most effective measure to prevent healthcare-associated infections. Isolation is important but applies to specific organisms and cannot replace routine interruption of contact transmission across all patients. Antibiotics treat infections and can increase resistance or C. difficile risk, and vaccination is preventive for selected diseases but does not broadly prevent most nosocomial transmission events.

Question 10

A neonate born 18 hours ago with meningomyelocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?

Accepted Answer

Answer reason: A meningomyelocele involves exposed neural tissue, which creates a direct pathway for pathogens and places the neonate at extremely high risk for life-threatening infections such as meningitis. Protecting the sac with sterile, moist dressings and strict aseptic technique is the highest priority over other supportive measures.

Question 11

The nurse prepares to insert an indwelling urinary catheter in a female client. Which action is most important to reduce risk of infection?

Accepted Answer

Answer reason: Preventing catheter-associated UTI hinges on maintaining strict aseptic technique throughout insertion because introducing microorganisms into the urethra/bladder is the key mechanism of infection. Donning sterile gloves at the correct time helps preserve the sterility of the field and equipment before any contact with the prepared perineal area and catheter occurs. Other steps like advancing the catheter appropriately and securing it reduce trauma and dislodgement but do not address the primary infection pathway as directly as asepsis. Lubrication is necessary, but petroleum-based products are not the infection-prevention priority and may be inappropriate depending on catheter material and facility policy. The highest-impact action is the one that best preserves sterility during insertion.

Question 12

The nurse is bathing a client who has an indwelling urinary catheter and is on contact precautions for Clostridioides difficile infection. Which action is the priority?

Accepted Answer

Answer reason: Difficile forms spores that are not reliably removed by alcohol-based hand rub, so soap-and-water handwashing is the most effective action to prevent transmission. After glove removal, hands are considered contaminated and immediate hand hygiene is the key break in the chain of infection. Catheter and perineal cleansing techniques reduce local infection risk, but they do not address the higher-priority, facility-wide risk of spore spread to other patients and surfaces. Using disposable wipes can help reduce environmental contamination, but it does not replace the essential spore-removing step of soap-and-water hand hygiene.

Question 13

You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?

Accepted Answer

Answer reason: Cat bites carry a high risk of infection (e.g., Pasteurella multocida). Preventing and monitoring for infection is the highest priority over existing skin injury or potential complications.

Question 14

A toddler with Kawasaki disease is being evaluated by a primary care clinic nurse 1 week following discharge. The nurse understands that it is a priority to instruct the parents to contact the clinic immediately if the child?

Accepted Answer

Answer reason: Children treated for Kawasaki disease typically receive IV immunoglobulin (IVIG), which can interfere with immunity and live-virus vaccine effectiveness and requires vigilance for exposure to contagious infections. Varicella exposure can be high-risk in a recently treated child and may warrant prompt evaluation for post-exposure prophylaxis and close monitoring. The other options describe common toddler behaviors or nonspecific symptoms that are not as immediately safety-critical. A low-grade fever can be monitored and reported, but infectious exposure with potential severe complications is the more urgent “call immediately” teaching point.

Question 15

The burned client’s family asks at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?

Accepted Answer

Answer reason:  Infection risk in burn patients is primarily driven by loss of the skin barrier and devitalized tissue that supports bacterial colonization and invasion. Once wounds are closed (via re-epithelialization or grafting), the protective barrier is restored and the major portal of entry is eliminated, so infection risk markedly decreases. Fluid remobilization and discontinuation of IV fluids reflect phases of burn shock/resuscitation and do not determine whether a portal for pathogens remains. Body weight normalization relates to nutrition/metabolic recovery, which supports healing but does not define when the barrier-related infection risk has resolved.

Question 16

A nurse cares for a client who had a thoracotomy two days previously. There is an indwelling urinary catheter in place. Which would be the best reason for the nurse to advocate for removing the catheter?

Accepted Answer

Answer reason: Indwelling urinary catheters should be removed as soon as they are no longer clinically indicated because they significantly increase the risk of catheter-associated urinary tract infection. After a thoracotomy, a catheter is commonly used short-term to closely monitor urine output for perfusion/renal status, but once output is adequate and can be measured without a catheter, ongoing use offers little benefit. Adequate, clear urine output indicates that strict hourly monitoring via catheter is not necessary, supporting removal to reduce infection risk. Impaired mobility or discomfort may be relevant, but the strongest safety-based rationale for early removal is elimination of an unnecessary invasive device that predisposes to infection.

Question 17

A 50-year-old male undergoing chemotherapy for non-Hodgkin’s lymphoma develops a temperature of 101.8°F (38.8°C). His absolute neutrophil count (ANC) is 250. Which nursing action has the highest priority?

Accepted Answer

Answer reason: Protective (reverse) isolation reduces transmission risk by controlling visitors, PPE use, and environmental exposure, which addresses the highest immediate safety threat. Giving an antipyretic may temporarily lower the temperature but can mask fever trends and does not reduce infection risk. Hydration and routine temperature checks are supportive measures but are not the first action when severe neutropenia with fever indicates a high-risk infection emergency.

Question 18

The nurse is teaching a 17-year old client and the client’s family about what to expect with high-dose chemotherapy and the effects of neutropenia. What should the nurse teach as the most reliable early indicator of infection in a neutropenic client?

Accepted Answer

Answer reason: A new elevation in temperature is often the earliest and most dependable clue of infection and may be the only initial sign of sepsis. Chills can occur but are less consistent and may be absent in severely immunocompromised patients. Tachycardia and dyspnea are later, nonspecific physiologic responses and can indicate clinical deterioration rather than an early, reliable trigger for prompt evaluation and empiric antibiotics.

Question 19

The nurse is caring for the mother of a newborn. The nurse recognizes that the mother needs more teaching regarding cord care because she?

Accepted Answer

Answer reason: Routine vigorous washing with water at every diaper change can keep the area moist and increase irritation, which can delay drying and raise the chance of bacterial growth. Standard teaching includes keeping the cord exposed to air and folding the diaper below the stump to prevent contamination. Parents should also monitor for signs of infection or abnormal bleeding/drainage, and practice hand hygiene before handling the infant or cord area.

Question 20

A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?

Accepted Answer

Answer reason: Neutropenia greatly increases infection risk, so the priority is preventing transmission of microorganisms via the nurse’s hands and contaminated PPE. Gloves become contaminated during patient care and must be removed and replaced promptly to prevent cross-contamination between tasks, surfaces, and patients, with hand hygiene performed after glove removal. Changing a disposable mask after use is less central here because neutropenic precautions focus on protecting the patient from pathogens carried on hands and equipment rather than on routine mask turnover for every interaction. Minimizing contact or conversation is unnecessary and can compromise assessment, care, and therapeutic communication without providing reliable infection prevention.

Question 21

The provider has ordered a urine specimen for urinalysis and urine culture for an incontinent elderly female who cannot ambulate. What is the best way for the nurse to obtain the specimen?

Accepted Answer

Answer reason: A urine culture requires a specimen with minimal contamination, ideally obtained via a sterile technique. In an incontinent, non-ambulatory patient, clean-catch collection is unreliable and easily contaminated by perineal flora. Intermittent (straight) catheterization provides a one-time, sterile specimen while avoiding the prolonged infection risk of an indwelling catheter. Collecting from a drainage bag or suction canister is not sterile and yields inaccurate culture results due to contamination and bacterial overgrowth.

Question 22

The home health nurse is monitoring a client who performs self-care of a central line. The nurse observes the client doing all of the following activities. Which activity indicates the need for further education?

Accepted Answer

Answer reason: Smaller syringes generate higher psi with the same applied force, so a 3-mL syringe increases risk of catheter rupture or line-related complications. Standard teaching is to use a 10-mL syringe (or larger per facility policy) and appropriate push-pause technique to reduce occlusion risk. The other observed actions reflect appropriate asepsis for preventing CLABSI during access and dressing changes.

Question 23

When explaining the disorder to a client with tinea corporis, the nurse should include which information about this skin disorder?

Accepted Answer

Answer reason: Tinea corporis (ringworm) is a contagious superficial dermatophyte (fungal) infection that spreads via direct skin-to-skin contact or contaminated items (fomites). Teaching should therefore emphasize transmissibility and hygiene measures to reduce spread (e.g., avoiding sharing towels/clothing, cleaning linens, keeping affected areas clean and dry). The statement that it requires no treatment is incorrect because antifungal therapy is typically needed to eradicate the organism and prevent transmission. It is not a malignant condition, and advising routine sunlight exposure is not a core or reliable treatment strategy compared with appropriate antifungals and infection-control practices.

Question 24

The nurse is caring for four clients receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infection?

Accepted Answer

Answer reason: Central venous catheters have higher bloodstream infection risk than peripheral devices because they terminate in large central veins and provide a direct route for organisms into the circulation. Non-tunneled lines have no subcutaneous tunnel or cuff barrier, making them more vulnerable to skin flora migration and contamination at the insertion site. The internal jugular location is also associated with higher infection risk than subclavian access due to proximity to oral/respiratory secretions and more frequent dressing disruption. In contrast, implanted ports are fully subcutaneous when not accessed and generally carry lower infection risk than non-tunneled central lines.

Question 25

The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?

Accepted Answer

Answer reason: Open burn wounds create a major break in the skin barrier, making strict infection prevention the highest immediate safety priority. Hand hygiene is the single most effective measure to reduce transmission of pathogens and prevent wound contamination during any contact or care activity. While administering a tetanus vaccine can be within LPN scope in many settings, it is not as universally critical and immediate as preventing exogenous infection. “Assessing” for infection is also important but is a focused assessment activity and does not prevent introducing organisms in the first place.

Question 26

When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by auto contamination?

Accepted Answer

Answer reason: Changing gloves between different wound sites interrupts cross-contamination during the same dressing change, especially when moving from more contaminated to cleaner areas. Hand hygiene is essential overall, but glove changes specifically target the within-patient site-to-site transmission the question asks about. Not sharing equipment addresses transmission between different clients (cross-contamination), not self-inoculation across the same client’s wounds.

Question 27

An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct?

Accepted Answer

Answer reason: Airway suctioning technique prioritizes minimizing mucosal trauma and hypoxemia while effectively clearing secretions. Suction should be applied only on withdrawal, not during insertion, to avoid pulling mucosa into the catheter and causing bleeding/edema. Intermittent suction with a rotating/withdrawing motion further reduces negative-pressure injury compared with sustained suction. Applying suction while advancing or using continuous suction increases airway trauma and can worsen oxygen desaturation and dysrhythmias in a ventilated patient.

Question 28

The clinic nurse provides instructions to a client receiving an antineoplastic medication. When implementing the plan, the nurse tells the client to?

Accepted Answer

Answer reason: Antineoplastic therapy commonly causes immunosuppression, increasing the risk of severe infection from live vaccines and reducing response to inactivated vaccines. Verifying immunization type and timing with the oncology team helps prevent vaccine-related complications and ensures appropriate prophylaxis. Aspirin is often avoided because chemotherapy-related thrombocytopenia can increase bleeding risk, and it can mask fever. Alcohol intake may worsen mucositis, nausea, dehydration, and hepatic stress during treatment, making it an unsafe routine recommendation.

Question 29

In conducting client teaching with a client who will undergo peritoneal dialysis at home, the nurse includes discussion of what common and significant complication of peritoneal dialysis?

Accepted Answer

Answer reason: This makes infection the most common and clinically serious complication that home patients must be taught to prevent, recognize, and report promptly (e.g., cloudy effluent, abdominal pain, fever). Hypotension is more characteristic of hemodialysis due to rapid intravascular fluid shifts, whereas peritoneal dialysis produces slower fluid removal. Dyspnea can occur from large dialysate volumes elevating the diaphragm, but it is not the key common, high-risk complication emphasized in home teaching.

Question 30

Nurse Adams is preparing the operating room for a surgical procedure. She ensures that the environment is free from contamination, the wound remains sterile, and the operative area is properly isolated. What technique is she using to maintain these conditions?

Accepted Answer

Answer reason: The core principle is that the operating room and an open surgical wound require sterile technique to prevent introduction of microorganisms into normally sterile tissue. This includes maintaining a sterile field, using sterile supplies, and isolating the operative site with sterile drapes to prevent contamination. Medical asepsis and handwashing reduce the number/spread of organisms but do not create or preserve a sterile field for invasive procedures. “Aseptic technique” is a broader term, but in the OR context the specific technique described is sterile (surgical) asepsis.

Question 31

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

Accepted Answer

Answer reason: Intermittent self-catheterization teaching prioritizes infection prevention by reducing periurethral bacterial load before catheter insertion. Routine cleansing of the urinary meatus with soap and water is an appropriate, practical home instruction that supports clean technique and helps lower UTI risk. Cleaning “from back to front” is incorrect because it can bring organisms from the anus toward the urethra. Measuring urine output may be useful in some care plans but does not address the key safety instruction for preventing catheter-associated infection.

Question 32

A nurse is educating a patient diagnosed with hepatitis A. What should the nurse instruct this patient to avoid sharing?

Accepted Answer

Answer reason: Teaching focuses on preventing spread via shared items that can carry fecal contamination to another person’s mouth, especially in shared meals or food preparation. Avoiding sharing food and emphasizing strict hand hygiene reduces transmission risk in households and community settings. Sharing needles is more characteristic of hepatitis B/C bloodborne transmission and is not the primary route for hepatitis A.

Question 33

Consider to be the WEAKEST Link in the chain of infection that nurses can manipulate to prevent spread of infection and diseases?

Accepted Answer

Answer reason: Nurses can reduce susceptibility by promoting vaccination, adequate nutrition and hydration, rest, glycemic control, skin integrity, and early recognition of infection in high-risk patients. While nurses can also interrupt transmission with hand hygiene and PPE, the “weakest link” concept traditionally emphasizes that the host is the most variable and modifiable factor in the chain. Focusing on host susceptibility directly reduces the likelihood that exposure will progress to disease.

Question 34

In pouring a plain NSS into a receptacle located in a sterile field; how high should the nurse hold the bottle above the receptacle?

Accepted Answer

Answer reason: Holding the bottle about 6 inches above the sterile receptacle allows controlled pouring without risking contact that would contaminate the sterile field. Holding it too close increases the chance of accidentally touching the sterile container or field with the bottle. Holding it too high increases splashing and aerosolization, which can contaminate the sterile field.

Question 35

The tip of the sterile forceps is considered sterile. It is used to manipulate the objects in the sterile field using the non sterile hands. How should the nurse hold a sterile forceps?

Accepted Answer

Answer reason: Keeping the tips down also minimizes the risk of the tips contacting clothing or other nonsterile surfaces while moving. If the tips are held above the handle, any moisture or contaminants can drip toward the sterile end, breaking sterile technique. This is a core aseptic practice to maintain the sterility of the instrument portion that touches the sterile field.

Question 36

Minimum scrubbing time for hand wash?

Accepted Answer

Answer reason: A 2-minute scrub is commonly cited as the minimum duration for an effective scrub-style hand wash in clinical settings when a timed scrub is required. Shorter durations risk inadequate coverage of all hand surfaces and reduced microbial removal. Longer times may be used for surgical scrubs or institutional protocols, but the question asks for the minimum.

Question 37

A nurse is reinforcing teaching with the parents of a preschooler who is being treated for pinworms. Which of the following instructions should the nurse include to prevent the spread of the infection?

Accepted Answer

Answer reason: Pinworm transmission commonly occurs via the fecal–oral route when eggs are transferred from the perianal area to the hands and then ingested. Short nails reduce the surface area where eggs can lodge and make effective hand hygiene easier, lowering the risk of autoinfection and spread to household contacts. A daily bath may help with hygiene but is less directly targeted than preventing egg trapping under nails, which is a frequent reinfection mechanism in children. Topical antibiotics are not indicated because this is a helminth infection, not a bacterial skin infection.

Question 38

The client with a traumatic compound fracture of the humerus should be assessed for which of the following?

Accepted Answer

Answer reason: Nursing assessment should therefore focus on local and systemic indicators such as increasing pain, erythema, warmth, swelling, purulent drainage, fever, and rising WBC count. Prompt recognition supports timely wound care, antibiotics, and surgical debridement, which are key to limb preservation and healing. Neurogenic shock is associated with spinal cord injury, CSF leak suggests skull/base-of-skull trauma, and crutch training is not an acute assessment priority for a humerus fracture.

Question 39

A client who is receiving chemotherapy for leukemia has developed neutropenia. Which of these foods should the client avoid?

Accepted Answer

Answer reason: Raw vegetables can harbor pathogens in crevices and are harder to disinfect reliably, making them unsafe for immunocompromised clients. Cooked foods (e.g., stewed potatoes) are generally safer because heat reduces microbial load. While undercooked meats are also typically avoided, the option that most directly reflects the classic “avoid raw fruits/vegetables” neutropenic diet teaching is the raw celery sticks.

Question 40

An RN observes the hand hygiene routine of a nursing assistant. Additional teaching will be needed if the RN observes that?

Accepted Answer

Answer reason: Effective handwashing requires sufficient friction time to mechanically remove transient microorganisms; standard teaching is to scrub all hand surfaces for about 15–20 seconds. Ten seconds is typically inadequate contact time and increases the risk of incomplete decontamination. Water temperature being lukewarm is acceptable because temperature does not meaningfully improve microbial removal and overly hot water can irritate skin. While thorough drying is important to reduce moisture-related transmission, the most clearly incorrect technique here is the too-short scrubbing duration.

Question 41

A mother overhears two nurses discussing the incubation period for a measles outbreak. The mother asks why it is important to know this. The nurse’s reply would include which statement about the incubation period?

Accepted Answer

Answer reason: Measles can be transmitted during the late incubation/prodromal phase and early rash period, so knowing this timeframe guides monitoring, exclusion from school/childcare, and appropriate isolation precautions. This also informs contact tracing and the window for post-exposure prophylaxis decisions, which are based on exposure timing rather than symptom onset alone. Severity is not determined by incubation length, and incubation is not primarily age-dependent in a way that drives outbreak control messaging.

Question 42

A client with an indwelling urinary catheter needs a urine specimen. To obtain a specimen from a Foley catheter, the nurse should first?

Accepted Answer

Answer reason: A sterile urine specimen from a Foley should be obtained from the sampling port after allowing fresh urine to collect in the tubing, while maintaining a closed drainage system to reduce CAUTI risk. Clamping the tubing below the aspiration port for a short period allows urine to pool at the port so the nurse can aspirate an uncontaminated sample using aseptic technique. Inserting a needle into the catheter shaft or disconnecting the system breaks the closed system and increases infection risk. Irrigation is not part of routine specimen collection and can alter results or introduce organisms unless specifically prescribed.

Question 43

The hospital census is running high and the nursing supervisor informs all charge nurses that patients need to be assigned roommates. Which client is the most suitable roommate for a patient with an aorto-bifemoral bypass?

Accepted Answer

Answer reason: Room assignment prioritizes minimizing infection transmission risk, especially for postoperative vascular surgery patients who are vulnerable to surgical site infection and graft complications. A closed ankle fracture is noninfectious and typically does not require isolation precautions, making it the safest pairing. A diabetic foot ulcer may involve open, colonized/infected wounds (often with resistant organisms) that increase cross-contamination risk. Sarcoidosis can involve immunosuppressive therapy and respiratory symptoms that complicate infection-control screening, while another postoperative vascular/arterial surgery patient (carotid endarterectomy) increases the chance of competing care needs and higher-acuity complications in one room.

Question 44

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item?

Accepted Answer

Answer reason: A history of reactions to foods like banana, avocado, kiwi, and chestnut increases suspicion for clinically significant latex sensitivity and potential peri-procedural reactions. Asking specifically about banana allergy helps identify this higher-risk subgroup and prompts stricter latex-avoidance precautions. Eggs, milk, and yogurt are common food allergens but are not classically linked to latex cross-reactivity.

Question 45

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection?

Accepted Answer

Answer reason: Emergent placement conditions (during/after arrest in the ED) often limit maximal sterile barrier adherence, further increasing infection risk. Lines should be removed promptly when no longer essential, and the femoral site is generally the least preferred for ongoing ICU access when infection prevention is the priority. In contrast, subclavian access is typically associated with lower infection rates, and mild localized redness alone does not outweigh the baseline higher infection risk of a femoral line in this comparison.

Question 46

A nurse provides which of the following instructions to a client diagnosed with scabies?

Accepted Answer

Answer reason: Scabies is a highly contagious skin infestation transmitted through close skin-to-skin contact, so effective management requires treating close contacts at the same time to prevent reinfestation. Household members can be asymptomatic during incubation yet still harbor mites, making contact treatment essential for outbreak control. Environmental measures focus on laundering/bagging items rather than chemical soaking of all clothing, so that instruction is not the key priority. Medications (e.g., permethrin) are typically applied to clean, dry skin as directed, not to moist skin, to ensure correct absorption and coverage.

Question 47

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

Accepted Answer

Answer reason: Neutropenic precautions are indicated when a patient’s infection-fighting capacity is significantly reduced, most commonly reflected by marked leukopenia/neutropenia. A WBC of 2000/mm³ is well below the typical adult reference range (~4500–11,000/mm³) and signals high infection risk in an immunosuppressed oncology client. In this context, protective measures (strict hand hygiene, avoiding sick contacts/raw foods, monitoring for subtle infection signs) become a priority because fever and local inflammation may be blunted. The other values listed fall within or above the normal range and do not, by themselves, suggest the same level of neutropenia-associated risk.

Question 48

A client has undergone repeated tests for HIV antibody and has been confirmed to be HIV infected and is asymptomatic. Which of these statements about the client's ability to transmit the virus is accurate?

Accepted Answer

Answer reason: Therefore, once confirmed HIV-positive, the client should be regarded as potentially able to transmit the virus indefinitely unless proven to have sustained viral suppression with effective antiretroviral therapy. The idea that the virus is “dormant” or that infectiousness requires symptoms is incorrect, since asymptomatic infection is still contagious. While viral load testing helps estimate transmission risk, it does not change the need to consider the client potentially infectious as a safety principle.

Question 49

A 32-year old primigravida who 35 weeks pregnant is admitted following a rupture of membranes and loss of mucous plug 9 hours earlier. An internal exam shows she is dilated 4 cm. Since she is at risk for infection, which action is most appropriate?

Accepted Answer

Answer reason: Frequent temperature monitoring is a direct, safety-focused nursing action to detect infection promptly so treatment (e.g., antibiotics and delivery planning) can be initiated without delay. Increasing vaginal examinations would raise infection risk by introducing organisms into the cervix/vagina. Universal precautions are baseline care for all patients and do not specifically address the heightened infection risk created by prolonged membrane rupture.

Question 50

A nurse receives information in a change of shift report. Which client is the priority?

Accepted Answer

Answer reason: Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites Pin-site erythema, localized pain, and fever in a client with an external fixator are classic for an evolving device-related infection that can rapidly progress to osteomyelitis or sepsis if not treated promptly. This situation requires immediate assessment of the site, neurovascular checks, notification of the provider, and likely cultures/antibiotic adjustment, making it highest priority. Blood-tinged sputum with pneumonia can occur from airway irritation and is concerning, but it is typically less immediately limb- and life-threatening than a suspected hardware infection with systemic signs. The levothyroxine symptoms suggest possible over-replacement and the pancreatitis symptoms reflect chronic malabsorption, both important but not as urgent as a potential invasive infection source.

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