Question 1

Precautions used when caring for a rubella patient is ?

Accepted Answer

Answer reason: Droplet precautions include wearing a surgical mask when within close range of the patient and using appropriate patient placement to reduce exposure to others. Standard (universal) precautions and hand hygiene are still required for all patients but are not the specific additional isolation category indicated for this diagnosis. Contact precautions are reserved for pathogens spread mainly by direct touch or contaminated surfaces rather than respiratory droplets.

Question 2

A pregnant nurse is working in the ward. Which patient should be assigned to her?

Accepted Answer

Answer reason: Rubella can cause severe congenital infection, and measles is highly contagious via airborne transmission with significant maternal morbidity in pregnancy. C. diff requires contact precautions and carries a high risk of spore transmission, making assignment less ideal when safer alternatives exist. Pneumonia (in general, without a specified high-risk pathogen) is typically managed with standard/droplet precautions and does not uniquely threaten the fetus the way rubella or measles do.

Question 3

A nurse is irrigating a patient's wound. Which pieces of PPE should the nurse wear in order to perform this task?

Accepted Answer

Answer reason: Wound irrigation commonly generates spray/aerosolized droplets that can contaminate mucous membranes and clothing, so both eye/face protection and a gown are indicated along with gloves. Using only gloves (or gloves with a gown) leaves the nurse’s eyes/nose/mouth unprotected from splash. A mask plus goggles without a gown also fails to protect uniform/skin from contamination during high-splash procedures.

Question 4

You are providing teaching to the nursing staff on your unit. Based on your knowledge, you tell them that which of the following patient patients would not be able to be taken to the playroom because of their physical condition?

Accepted Answer

Answer reason: Playrooms are communal spaces with frequent hand-to-surface contact, making transmission risk high even with routine cleaning. In contrast, children with orthopedic injury, new-onset diabetes, or uncomplicated postoperative status may participate if pain is controlled, mobility needs are accommodated, and they are medically stable. The key issue is infection-control isolation status rather than mobility limitation alone.

Question 5

Which precaution must a nurse take when checking the blood pressure of an HIV-positive client?

Accepted Answer

Answer reason: Checking blood pressure is a noninvasive task with no expected contact with blood or body fluids, so additional PPE is not required solely due to HIV status. Gloves are indicated only if there is anticipated contact with blood/body fluids, non-intact skin, or mucous membranes, which is not inherent to taking a BP. Contact precautions and gowns are reserved for organisms spread by contact (e.g., certain multidrug-resistant bacteria) or when splashing/soiling is expected, not for HIV in routine vital-sign measurement.

Question 6

The nurse provides care for a client who tested positive for Neisseria meningitidis. Which action does the nurse take first?

Accepted Answer

Answer reason: Neisseria meningitidis is transmitted via respiratory droplets, so immediate transmission-based isolation is the priority to protect staff and other clients. Implementing droplet precautions (masking, private room/cohorting, appropriate PPE) is a time-sensitive safety action that should occur before non-urgent assessments. While neurologic assessment (LOC) and checking for meningeal signs support ongoing evaluation, they do not reduce immediate risk of spread. Seizure precautions may be appropriate depending on the client’s condition, but infection control comes first once the diagnosis is known/confirmed.

Question 7

Which disease does NOT require airborne precautions?

Accepted Answer

Answer reason: Airborne precautions are used for pathogens that remain suspended in air and can be inhaled over distances, requiring a fit-tested N95 (or higher) and negative-pressure room. Measles, varicella, and pulmonary tuberculosis are classic airborne infections. Pertussis is primarily spread via large respiratory droplets and close contact, so droplet precautions (mask within close range) are indicated rather than airborne. Confusing droplet infections with airborne ones is a common test trap; the key is whether true aerosols persist and travel.

Question 8

What are the precautions that need to be taken to protect from the Corona virus?

Accepted Answer

Answer reason: Covering the mouth and nose during sneezing helps contain infectious secretions and protects nearby individuals and surfaces. By contrast, antibiotics do not treat viral infections and inappropriate use promotes resistance and adverse effects. Dietary garlic is not an evidence-based primary prevention measure, and a rigid “every hour” handwashing schedule is less accurate than washing when hands are soiled and after high-risk contacts.

Question 9

A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these?

Accepted Answer

Answer reason: Airborne precautions include placing the client in an airborne infection isolation room (negative pressure) and using a fit-tested N95 or higher-level respirator when entering, which provides comprehensive protection beyond a single equipment choice. Negative-pressure ventilation alone is incomplete without appropriate respiratory PPE. A face mask with shield primarily protects against splashes and large droplets, which does not adequately address airborne spread.

Question 10

A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?

Accepted Answer

Answer reason: Postmortem care still involves exposure to potentially infectious body fluids and contaminated linens, making gloves and gown with strict hand hygiene the key additional measures beyond standard precautions. Airborne and droplet precautions target respiratory spread and are not the routine route for MRSA transmission in this context. Maintaining contact precautions during handling, bagging, and environmental cleanup reduces the risk of staff contamination and cross-transmission.

Question 11

In addition to standard precautions, a nurse should implement contact precautions for which client?

Accepted Answer

Answer reason: Contact precautions are indicated for infections where transmission occurs via direct contact with infectious skin lesions or contaminated surfaces. Herpes simplex can involve active vesicular lesions with high viral shedding, making direct-contact spread a key risk, so adding contact precautions (e.g., gloves/gown when touching the client or their environment) is appropriate. Mononucleosis is primarily spread via saliva, which aligns with standard precautions rather than routine contact isolation. Many pneumonias and scarlet fever (Group A strep) are typically managed with droplet precautions when indicated, not contact, unless there are additional factors like copious uncontrolled secretions or draining wounds.

Question 12

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

Accepted Answer

Answer reason: MRSA is primarily transmitted via direct contact with contaminated hands, surfaces, and client-care equipment, so transmission-based contact precautions are required in addition to standard precautions. This includes gown and gloves upon room entry and dedicated or properly disinfected equipment to reduce cross-transmission. Airborne isolation is reserved for pathogens spread via droplet nuclei (e.g., TB, measles), which is not the typical route for MRSA. Reverse isolation is used to protect severely immunocompromised clients rather than to prevent spread from colonized/infected clients.

Question 13

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to handwashing, to be implemented is which of these?

Accepted Answer

Answer reason: Gloves create a direct barrier during high-risk tasks like emptying or cleaning bedpans, which is when contamination is most likely. This aligns with standard precautions emphasizing protection when anticipating contact with potentially infectious body substances. A mask/face shield is only needed for splash risk and does not address the primary transmission route, and signage is not itself a protective barrier.

Question 14

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

Accepted Answer

Answer reason: Droplet/respiratory-secretion precautions should be initiated promptly on arrival before other routine assessments and interventions. Seizure precautions and frequent neurologic checks are important for safety and monitoring of increased ICP/neurologic decline, but they do not address the immediate risk of spreading infection. Antibiotics are time-sensitive and should follow quickly, yet initiating isolation first is the most immediate, system-level safety action upon admission.

Question 15

A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client?

Accepted Answer

Answer reason: HAV is primarily transmitted via the fecal–oral route, so the priority early nursing action is to prevent spread through strict hand hygiene and contact precautions when there is potential exposure to stool or contaminated surfaces. Gown and gloves with patient contact reduce the risk of contaminating hands/clothing and transmitting the virus to other patients or the environment. Mask/eye shield is only necessary when splashes to mucous membranes are anticipated and is not routinely the highest priority for HAV. Disposable utensils are not required because HAV is not typically spread by sharing dishes when standard cleaning is used, and diet changes are supportive but do not address immediate infection-control risk.

Question 16

The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement?

Accepted Answer

Answer reason: The highest-priority action is immediate isolation in a negative-pressure private room to contain airborne particles and protect others. Visitors and staff should use appropriate respiratory protection (e.g., fit-tested N95 or equivalent); cough etiquette and hand hygiene are helpful but do not adequately control airborne spread without isolation. Implementing airborne precautions first addresses the greatest safety risk and meets infection-control standards for suspected or confirmed active TB.

Question 17

The nurse supervises the staff caring for clients in the medical/surgical unit. The nurse observes the student nurse enter wearing a gown, gloves, and a facemask. The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients??

Accepted Answer

Answer reason: Influenza is primarily spread via respiratory droplets, so droplet precautions are indicated in addition to standard precautions. A surgical mask protects the nurse’s mucous membranes from droplets; gloves are used for anticipated contact with secretions, and a gown is appropriate when close contact may lead to soiling of clothing. RSV is typically managed with contact precautions (often plus eye protection), hepatitis A with contact precautions due to fecal-oral transmission, and toxic shock syndrome does not require transmission-based isolation beyond standard precautions. Therefore, gown, gloves, and a facemask best match droplet-based isolation for influenza.

Question 18

Sputum positive TB patient on chemotherapy should be isolated at least for?

Accepted Answer

Answer reason: With drug-susceptible TB, infectiousness usually drops substantially after about 2 weeks of appropriate treatment along with clinical improvement and reduced cough. This minimum time frame is commonly tested as the earliest point at which transmission risk is markedly decreased, whereas longer durations are not routinely required for all patients if they are responding to therapy. In practice, facilities often also require additional criteria (e.g., improving symptoms and negative sputum smears), but among the time-only choices, this is the best answer.

Question 19

What is the correct order for a nursing assistant for putting on the protective equipment when caring for a client in isolation?

Accepted Answer

Answer reason: Hand hygiene is performed first because it removes transient organisms before touching any PPE and prevents contaminating the equipment during donning. Mask with eye protection is applied before the gown so facial protection is secure and not disrupted by pulling a gown over the head/neck area. Gloves go on last because they are the most likely to become contaminated and should cover the gown cuffs to create a continuous protective barrier; options that place handwashing after donning PPE break standard infection-control technique.

Question 20

Which of the following infectious control methods should be used when caring for a patient with bacterial pneumonia?

Accepted Answer

Answer reason: A surgical mask protects the nurse’s mucous membranes from droplets when within close range, which is common while obtaining vital signs. Restricting flowers and requiring disposable utensils are more relevant to neutropenic or enteric precautions rather than routine pneumonia care. Visitors are not categorically prohibited; instead they should follow droplet/hand-hygiene guidance and be restricted only if symptomatic or per facility policy.

Question 21

The nurse prepares to perform the initial assessment on a school-age client. The client has an open wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which precaution will the nurse take?

Accepted Answer

Answer reason: MRSA in an open wound requires contact precautions because the organism is primarily transmitted by direct contact with infected drainage or contaminated surfaces. A gown and gloves reduce the risk of contaminating the nurse’s hands, clothing, and the environment during close assessment and possible contact with wound exudate. A mask is not routinely required for wound MRSA unless there is risk of splash/spray or concurrent respiratory infection requiring additional precautions. Gloves alone is incomplete because clothing can readily become contaminated during bedside care.

Question 22

A nurse is caring for a client who is being admitted for bacterial meningitis. Which of the following actions should the nurse do first?

Accepted Answer

Answer reason: Droplet isolation is a time-critical safety step that can be implemented immediately on arrival, before any medications are prepared or administered. Antibiotics are urgent, but starting them does not prevent near-term exposure risk to others during triage and initial assessment. Comfort measures like analgesia and environmental control are appropriate after safety measures and initial stabilization steps are in place.

Question 23

A 1-year-old child is admitted to the pediatric unit with a diagnosis of pertussis. Which type of transmission-based precautions should the nurse institute?

Accepted Answer

Answer reason: Droplet precautions require a surgical mask for close contact and placing the child in a private room or cohorting when appropriate. Airborne precautions are reserved for organisms that remain suspended over long distances (e.g., TB, measles, varicella), which is not the typical transmission pattern for pertussis. Standard precautions are used for all clients but are not sufficient alone when a known droplet-spread infection is present.

Question 24

The nurse is planning care for a 3-year-old client being admitted with pertussis (whooping cough). Which of the following interventions should the nurse include in the client’s plan of care?

Accepted Answer

Answer reason: Pertussis is transmitted via respiratory droplets, so preventing spread to staff and other patients is a core priority during assessment and close contact. Droplet precautions include wearing a surgical mask and using other standard/droplet measures (e.g., hand hygiene, limiting exposure) to reduce transmission risk. Antitussives such as dextromethorphan are generally not helpful for the paroxysmal cough and can mask symptoms or create false reassurance; treatment focuses on antibiotics and supportive care. Encouraging frequent ambulation and using a fan do not address the primary immediate nursing priority of infection containment and may worsen coughing spells if the child becomes over-stimulated.

Question 25

In the presurgical holding area, a nurse is caring for a client who has a white blood cell count (WBC) of 2.8 K/µL. Which nurse action is most important for the nurse to plan prior to initiating an IV?

Accepted Answer

Answer reason: A WBC of 2.8 K/µL indicates leukopenia, increasing susceptibility to infection, so minimizing microbial transmission from the nurse’s hands is the highest-priority prevention step. Skin cleansing at the site is also important, but it does not replace the need for proper hand hygiene and typically follows after preparing to perform the procedure. Prophylactic antibiotics require a provider order and are not routinely indicated solely for IV initiation, and respiratory isolation is not appropriate for leukopenia (protective/neutropenic precautions would be considered instead).

Question 26

Universal precutions are used to prevent transmission of?

Accepted Answer

Answer reason: They specifically target prevention of transmission of viruses like HIV and hepatitis B and C through practices such as hand hygiene, appropriate PPE, sharps safety, and safe handling of potentially contaminated materials. Airborne infections like TB require additional airborne precautions (e.g., N95 respirator and negative-pressure room), which goes beyond standard precautions alone. Influenza typically requires droplet precautions, and malaria is vector-borne, so neither is the primary focus of universal precautions.

Question 27

You are caring for a patient under droplet precautions. Which piece of equipment will you use to prevent the droplets from entering your airway passages?

Accepted Answer

Answer reason: Droplet precautions are used for pathogens spread by large respiratory droplets that typically travel short distances, so barrier protection over the nose and mouth is the standard to prevent inhalation/exposure of mucous membranes. A surgical mask is specifically recommended for routine care of patients on droplet precautions. An N95 respirator and a PAPR hood are reserved for airborne precautions or aerosol-generating procedures where smaller particles remain suspended. A cloth mask is not appropriate PPE for healthcare transmission-based precautions due to inconsistent filtration and fit.

Question 28

The nurse is caring for a child admitted with varicella (chickenpox). Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Varicella requires airborne and contact precautions to prevent transmitting virus on hands, clothing, and equipment to other patients and staff. Doffing gloves and gown and discarding them appropriately upon leaving the room is a key step that prevents environmental contamination and cross-transmission. This action directly addresses the highest-risk mechanism of spread (contaminated PPE) during routine care. A dedicated BP cuff can be helpful but is not as universally critical as correct PPE removal, and cleaning with only warm soapy water may be insufficient compared with facility-approved disinfectants.

Question 29

The nurse needs to put on personal protective equipment (PPE) now that the client is in isolation. In which order will the nurse don PPE?

Accepted Answer

Answer reason: The gown goes on first to cover clothing and provide a base barrier before touching the mask or eyewear. The mask is applied next, then eye protection, because both require adjustment and proper positioning to prevent exposure to droplets/splashes. Gloves are donned last so they can extend over the gown cuffs and remain the “dirtiest” layer during patient care, reducing self-contamination risk.

Question 30

The nurse learns that the hospitalized client has a history of chronic hepatitis C. Which precaution should the nurse plan to implement?

Accepted Answer

Answer reason: Standard precautions are used for all clients and specifically cover bloodborne pathogen protection through hand hygiene, gloves when anticipating contact with blood/body fluids, and safe sharps handling. Transmission-based (airborne, droplet, contact) precautions are added only when an organism spreads by those routes, which is not the case for chronic hepatitis C in routine care. A key safety focus is preventing needle-stick injuries and using appropriate PPE when exposure to blood is possible.

Question 31

The nurse is instructing a client regarding transmission of human immunodeficiency virus (HIV). The nurse instructs the client that the most likely route of virus transmission is?

Accepted Answer

Answer reason: HIV is transmitted through exposure to infected blood and certain other body fluids that contain sufficient viral load, primarily via percutaneous exposure (e.g., needle sharing/needlestick) or mucous membrane contact. Among the listed choices, blood is the established high-risk vehicle for transmission and is the key focus of standard precautions in health care settings. Feces, urine, and saliva are not typical routes of transmission unless visibly contaminated with blood, because they generally contain little to no infectious virus. Teaching should emphasize blood-borne precautions and safer sex/needle practices to reduce exposure risk.

Question 32

The NA is preparing to provide care for four clients. The nurse should direct the NA to utilize contact precautions for which client?

Accepted Answer

Answer reason: A draining abscess can shed organisms onto skin, linens, and equipment, creating high risk of transmission via hands and fomites, so gown and gloves are indicated. Influenza and mumps are primarily managed with droplet precautions due to respiratory secretions. Gonorrhea is typically not spread by casual contact in routine care and is managed with standard precautions unless there are other draining/soiling body fluids requiring additional measures.

Question 33

Which type of precautions should the nurse implement for the client diagnosed with aseptic meningitis?

Accepted Answer

Answer reason: Aseptic meningitis is most commonly viral and is not the classic contagious meningococcal form that requires routine transmission-based isolation in addition to standard measures. Standard precautions (hand hygiene, gloves with potential body-fluid exposure, and appropriate PPE based on anticipated exposure) are the baseline approach to prevent healthcare-associated spread. Droplet precautions are specifically indicated when bacterial meningitis due to Neisseria meningitidis is suspected/confirmed, particularly early in therapy, because respiratory secretions can transmit infection. Airborne precautions apply to pathogens like tuberculosis or measles, and contact precautions are reserved for organisms primarily spread by direct contact (e.g., some multidrug-resistant organisms), which is not the primary concern in typical aseptic meningitis.

Question 34

The nurse should implement which precautions for a client who has scabies?

Accepted Answer

Answer reason: Scabies is primarily transmitted via direct skin-to-skin contact and can also spread through contaminated linens or clothing, so transmission-based contact precautions are indicated. Standard precautions still apply to all clients because they cover routine protection against exposure to body fluids and contaminated surfaces. Adding contact precautions ensures gown and gloves and appropriate handling of bedding and clothing to prevent facility spread. Options that omit contact precautions underestimate the high transmissibility of mites in close-contact care settings.

Question 35

A nursing student is assigned an HIV-positive client. The student asks the staff nurse what precautions are necessary when taking the clients blood pressure. The nurse instructs the student to?

Accepted Answer

Answer reason: Hand hygiene is the single most effective measure to prevent transmission of microorganisms and is required before and after any patient contact, including noninvasive tasks like measuring blood pressure. HIV is transmitted via blood and certain body fluids, not through intact skin contact during routine vital signs, so additional isolation measures are not indicated. Gloves are used when anticipating contact with blood/body fluids or nonintact skin, which is not expected when applying a blood pressure cuff to intact skin. Gowns and contact precautions are reserved for situations with likely contamination or pathogens spread by contact, not for HIV status alone.

Question 36

The pediatric nurse cares for a client diagnosed with cytomegalovirus (CMV). The nurse should take which precaution?

Accepted Answer

Answer reason: CMV is transmitted through direct contact with infected body fluids (especially urine and saliva in young children), so transmission-based measures focus on preventing contamination of hands, clothing, and environmental surfaces. Using gloves and gown as indicated, plus meticulous hand hygiene, best interrupts the typical route of spread in pediatric care. Droplet precautions are used for pathogens spread primarily by respiratory droplets, which is not the main mechanism for CMV. Standard precautions apply to all patients, but CMV requires additional contact-focused measures when there is risk of exposure to secretions/excretions (e.g., diapers, oral secretions).

Question 37

In which order should the nurse remove personal protective equipment (PPE)?

Accepted Answer

Answer reason: PPE is removed in a sequence that minimizes self-contamination by taking off the most contaminated items first while keeping respiratory protection on until the end. Gloves are typically the dirtiest and should come off first to reduce transfer of organisms to the face or other surfaces. Eye protection is removed next, followed by the gown, which may have extensive contamination on the sleeves and front. The mask is removed last because it protects mucous membranes during the earlier steps when aerosolization or inadvertent contact may still occur.

Question 38

A nurse is teaching a client with tuberculosis about the disease process and the importance of medication compliance. The client asks the nurse how long he is considered to be infectious after the medication is started. What is the best response by the nurse?

Accepted Answer

Answer reason: Clinical teaching commonly uses about 2 weeks of appropriate therapy (with improving symptoms and decreasing cough) as the typical timeframe when infectiousness drops substantially. Shorter intervals like 72 hours or 1 week are not reliably sufficient to reduce transmission risk. Longer blanket durations such as 4 weeks are usually unnecessary as a standard teaching point when therapy is effective and adherence is maintained.

Question 39

The nurse is performing mouth care on a client with acquired immunodeficiency syndrome (AIDS). The most appropriate nursing intervention is?

Accepted Answer

Answer reason: Standard precautions apply to all clients and require barrier protection when contact with mucous membranes or body fluids is anticipated. Mouth care involves direct contact with oral mucosa and saliva, so gloves protect the nurse and reduce cross-contamination between clients and the environment. HIV/AIDS does not require reverse isolation or routine private-room placement; those measures are reserved for specific high-risk situations (eg, profound neutropenia or uncontrolled secretions). Mask and gown are not routinely indicated for simple oral care unless there is a risk of splash/spray or other organism-specific transmission precautions are present.

Question 40

The nurse asks the UAP to help admit the client diagnosed with bacterial meningitis. Which nursing task is priority?

Accepted Answer

Answer reason: Bacterial meningitis (especially suspected/confirmed meningococcal disease) requires immediate droplet precautions to prevent rapid transmission to staff and other clients during the admission process. Infection-control actions are time-critical and should be implemented before or at the moment of first contact, whereas vital signs, height/weight, and comfort measures can follow once containment is in place. Assigning the UAP to set up the isolation room is appropriate delegation because it is a noninvasive, protocol-driven task. A common distractor is vital signs, but they do not reduce the immediate public health risk posed by an infectious respiratory-spread organism.

Question 41

A client with acquired immunodeficiency syndrome (AIDS) requires assistance with oral care. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Oral care can involve exposure to saliva mixed with blood from gingival irritation, creating a realistic risk of mucous membrane splash to the nurse’s eyes, nose, or mouth. Standard Precautions require gloves for potential contact with blood/body fluids and add mask plus eye protection when splash or spray is anticipated. A gown is not routinely required unless clothing contamination is likely, so it is less targeted than adding eye protection. Gloves alone do not adequately protect mucous membranes during a task with potential splatter.

Question 42

The nurse is planning care for the adolescent client being admitted with newly diagnosed active TB secondary to AIDS. Which intervention is most important for the nurse to plan?

Accepted Answer

Answer reason: Active pulmonary TB is transmitted via airborne droplet nuclei, so immediate transmission-based isolation is the top priority to protect staff and other patients. Admission planning should include prompt placement in an airborne infection isolation room and use of a fit-tested N95/respirator per policy. While HIV-related immune status labs (e.g., CD4/T-cell counts) help guide ongoing management, they do not prevent immediate facility exposure. Bleeding monitoring and skin-care teaching may be appropriate for selected complications but are not as urgent as containing an airborne pathogen.

Question 43

A client has been diagnosed with active tuberculosis (TB) and asks the nurse if he will be admitted to the hospital. The nurse responds that hospitalization would be most likely to occur?

Accepted Answer

Answer reason: Active pulmonary TB is an airborne infection, and the priority is protecting others from transmission through rapid isolation and infection-control measures. Hospitalization is most likely when the client cannot safely maintain airborne precautions or adhere to treatment at home, creating a higher public health risk. Airborne isolation in a controlled setting helps reduce exposure until the patient is improving and is no longer considered highly infectious (e.g., on effective therapy with clinical response and improving sputum results per policy). Evaluation and deciding on antibiotics can usually be done outpatient and do not alone justify admission, whereas preventing transmission is the key safety driver.

Question 44

The HCP is about to examine the client on contact precautions for MRSA without donning PPE. Which is the best action by the nurse?

Accepted Answer

Answer reason: The nurse’s safest and most immediate action is to intervene at the point of care by facilitating proper PPE use before the exam begins, thereby reducing risk to the client, staff, and other patients. Remaining silent permits a preventable breach of infection control and violates the nurse’s duty to advocate for safety. Escalating to management may be appropriate if noncompliance persists, but it is not the best first action when an immediate corrective step can stop exposure now.

Question 45

A student nurse asks the nurse if any precautions are needed when caring for a 2-month-old infant with respiratory syncytial virus (RSV) to prevent the spread of infection. What is the best response by the nurse?

Accepted Answer

Answer reason: Using contact precautions (gown and gloves) reduces spread from clothing and hands during handling of infants and their equipment. A mask is appropriate with close contact because respiratory secretions can be generated with coughing, suctioning, or other care, adding protection against droplet exposure in the immediate vicinity. Hand hygiene is essential but is not sufficient alone when contact precautions are indicated, and claiming RSV is not contagious is unsafe and incorrect.

Question 46

The client who has airborne precautions asks the nurse not to shut his door. Which response by the nurse is most appropriate?

Accepted Answer

Answer reason:  Airborne precautions require engineering controls that prevent infectious particles from escaping the room, including maintaining negative-pressure airflow with the door closed. Keeping the door shut protects staff and other clients by containing droplet nuclei in the isolation environment. Offering an alternative to meet the client’s comfort request (opening curtains for light/less confinement) is therapeutic while still maintaining infection-control standards. The mask-focused response is misleading because the priority is containment via airflow/door closure, not making the client mask continuously, and leaving the door open (even partially) undermines airborne isolation.

Question 47

The client is placed on contact precautions. When should the nurse caring for the client plan to put on disposable examination gloves?

Accepted Answer

Answer reason: The key principle is to create a barrier before touching anything in the patient environment and to remove gloves before leaving the room to prevent spread to other areas. Limiting glove use only to anticipated wound contact is too narrow and misses environmental contamination. The 3-foot rule applies to droplet precautions, not contact precautions.

Question 48

The nurse assists a physician in draining a client’s large abscess at the bedside. The nurse holds the client to prevent the client from jerking during the procedure. The nurse should wear which personal protective equipment?

Accepted Answer

Answer reason: Draining a large abscess creates a high risk of splash and spray of purulent material, so Standard Precautions require protection of skin/clothing and all mucous membranes (eyes, nose, mouth). Because the nurse is physically close while restraining the client, exposure risk is increased and a gown plus gloves are needed to prevent contamination of hands and uniform. A mask with a face shield provides combined nose/mouth and eye protection from droplets and splatter. Options that omit eye protection or a mask leave a key mucous membrane unprotected during a procedure likely to generate splashes.

Question 49

The nurse cares for a client diagnosed with HIV whose chest x-ray results are abnormal. The nurse suspects tuberculosis (TB). Which precautions should the nurse implement when caring for this client?

Accepted Answer

Answer reason: TB is transmitted via airborne droplet nuclei that remain suspended, so suspected pulmonary TB requires airborne isolation to prevent inhalational spread. This means placing the client in a negative-pressure room and using a fit-tested N95 (or PAPR) for staff, while also maintaining standard precautions for potential blood/body fluid exposure. Droplet precautions are insufficient because they target larger, short-range respiratory droplets rather than true airborne particles. Contact precautions alone do not address the primary route of TB transmission and would leave staff and other clients at risk.

Question 50

A nurse is instructing a nursing assistant on the procedure of changing bed linens. The nursing assistant asks the nurse what to do if the linens are soiledwith drainage from a pressure ulcer. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: " Standard Precautions require gloves whenever there is potential contact with blood, body fluids, secretions, excretions, or non-intact skin. Drainage from a pressure ulcer can contaminate hands during linen removal and handling, so gloves are needed to prevent cross-contamination to the caregiver and environment. Sterile gloves are reserved for sterile procedures such as wound care or invasive tasks, not routine linen changes. A mask or shoe covers are not routinely indicated unless there is anticipated splashing/spraying or an isolation/OR-type requirement.

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