Question 1

The nurse is caring for the 4-year-old hospitalized with complications from chicken pox. Which type of precautions should the nurse plan?

Accepted Answer

Answer reason: A negative-pressure room is used to prevent contaminated air from flowing out of the patient’s room into hallways and other patient-care areas. Positive-pressure rooms are protective environments for immunocompromised patients and would increase the risk of pushing infectious particles outward. Options that omit airborne precautions or use only standard/reverse isolation do not adequately prevent varicella transmission in the hospital.

Question 2

The nurse is conducting a class for family members of clients diagnosed with tuberculosis (TB). The nurse determines that teaching is effective when the family member states?

Accepted Answer

Answer reason: TB is primarily an airborne infection spread when an infected person coughs, sneezes, speaks, or sings, generating droplet nuclei that can remain suspended and be inhaled by others. This statement shows the family understands the true route of transmission that drives prevention measures such as airborne isolation, N95 respirators, and adequate ventilation. Sexual contact and needle exposure are transmission routes for other infections (e.g., STIs, bloodborne pathogens) but not typical for TB. Sharing utensils is not a common transmission mechanism for pulmonary TB, so focusing on respiratory precautions is the key teaching point.

Question 3

A client with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). The most important intervention by the nurse would be?

Accepted Answer

Answer reason: Suspected active TB is an airborne-transmitted infection, so immediate transmission-based precautions are the priority to protect staff and other clients. Airborne isolation (e.g., negative-pressure room and appropriate respiratory protection) is instituted as soon as TB is suspected, before confirmatory testing. Diagnostic steps like tuberculin testing do not prevent exposure and are not the first safety action. Starting a single drug dose before discharge is unsafe and inadequate for active TB, which requires multi-drug therapy and public health follow-up.

Question 4

The client is admitted with a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which precaution should be implemented to prevent spreading the infection to health care workers and other clients?

Accepted Answer

Answer reason: A private room (or cohorting with another MRSA-positive client when private rooms are unavailable) limits shared environmental surfaces and decreases spread to other clients. Masks within 3 feet are aimed at droplet precautions, and N95 respirators are for airborne pathogens, neither of which is the primary transmission route for MRSA. Negative-pressure rooms are reserved for airborne isolation (e.g., tuberculosis, measles, varicella), not routine MRSA care.

Question 5

The nurse cares for a client who is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. It is important for the nurse to?

Accepted Answer

Answer reason: MRSA is commonly spread by direct contact, so preventing cross-contamination between patients is a key infection-control priority. Keeping dedicated, single-patient-use equipment in the room reduces organism transfer via shared items (fomites) and supports proper contact isolation practices. Droplet precautions are not the primary transmission-based precaution for typical MRSA colonization/infection; contact precautions are used. Hand hygiene is essential but is a general standard that applies to all patients and does not specifically address the additional environmental/equipment control needed for MRSA.

Question 6

A client has a past history of vancomycin resistant enterococcus (VRE). The nurse knows for isolation precautions to be discontinued for this client, which must occur?

Accepted Answer

Answer reason: Contact precautions for VRE are based on whether the organism is still being shed/colonizing the GI tract, not on symptom resolution. Because VRE commonly colonizes the bowel for prolonged periods, discontinuation typically requires documentation of clearance via serial negative surveillance cultures (often rectal/perirectal swabs) over time per facility policy. Headache complaints and chest x-ray findings are unrelated to VRE colonization status and do not determine transmissibility. The statement that VRE is always indefinite is overly absolute; clearance can occur, but must be proven with negative cultures before stopping isolation.

Question 7

The nurse cares for a client who is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation. The nurse needs to perform an assessment of the client’s wound and administer prescribed medications to the client. The nurse should wear which personal protective equipment (PPE)?

Accepted Answer

Answer reason: MRSA requires contact precautions to prevent transmission via direct contact and contaminated surfaces. When assessing a wound and administering medications in the room, the nurse will have close contact with the client and the immediate environment, so barrier protection for hands and clothing is needed. Gloves protect against hand contamination, and a gown prevents contamination of the nurse’s uniform that could spread organisms to other clients or areas. A mask is not routinely required for MRSA unless there is a risk of splashing or the client has a condition requiring droplet/airborne precautions, which is not indicated here.

Question 8

A client is placed on contact precautions. A dietary worker brings the client’s lunch using regular dishes. The nurse’s first reaction should be?

Accepted Answer

Answer reason: Contact precautions primarily require gown/glove use and dedicated equipment when appropriate; they do not require disposable meal trays or dishes in routine hospital practice. Regular dishes can be used if they are handled with standard precautions and sent for normal dishwashing/sanitization, which is sufficient to eliminate pathogens. The immediate priority is ensuring the client receives nutrition without unnecessary delays while maintaining appropriate staff PPE and hand hygiene. Sending the tray back or blocking it from the room adds delay without improving infection control, and escalating to the nurse manager is not the first-line response for a non-hazardous, correctable issue.

Question 9

The charge nurse is planning a room assignment for the client with meningococcal meningitis. Which room and precautions should the nurse plan for this client?

Accepted Answer

Answer reason: A single room is preferred to reduce exposure risk to other clients and staff, especially during the first 24 hours of effective antibiotic therapy when contagiousness is highest. Airborne precautions are reserved for true airborne pathogens (e.g., tuberculosis, measles), not typical bacterial meningitis. Contact precautions are not the primary isolation method for meningococcal disease because spread is not mainly via contaminated surfaces.

Question 10

Many persons with active tuberculosis (TB) often first present in ambulatory care settings. What is the first action that should be taken in caring for a client with symptoms of tuberculosis?

Accepted Answer

Answer reason: Airborne pathogens like suspected TB require immediate source control to reduce droplet nuclei dispersion in a clinic setting before room placement is arranged. Masking the client is the fastest, most reliable first step to protect others in the waiting/triage area while the nurse initiates further infection-control actions. Negative-pressure isolation is appropriate but may not be instantly available and therefore is not the first action in many ambulatory settings. Asking the client to cover coughs is helpful but less effective and more dependent on consistent technique than masking.

Question 11

A client is admitted to the hospital with influenza. Which action should the nurse take when caring for this client?

Accepted Answer

Answer reason: Influenza is primarily transmitted via respiratory droplets, so transmission-based droplet precautions are indicated in addition to standard precautions. This includes masking for close contact and appropriate patient placement to reduce spread during coughing, sneezing, and talking. Airborne precautions with negative-pressure rooms are reserved for true airborne pathogens (e.g., tuberculosis, measles, varicella), not routine influenza. An N95 respirator is not required for routine care of influenza unless performing aerosol-generating procedures, making it less appropriate as the best general action.

Question 12

The nurse and NA are caring for the client with hepatitis A. The nurse determines that the NA understands correct infectious precautions for this client when observing what action?

Accepted Answer

Answer reason: During incontinence care, gown and gloves appropriately reduce skin and clothing contamination and limit spread to the environment. A mask is not routinely required unless there is risk of splashing, so adding a mask for routine vital signs is unnecessary. Asking about snack options does not involve anticipated exposure to body fluids, so extra PPE beyond standard hand hygiene is not indicated.

Question 13

A client is diagnosed with hepatitis B. When the client reveals this information to family members, the family becomes frightened to go home with the client. Teaching the family to decrease their risk of exposure to hepatitis B includes which information?

Accepted Answer

Answer reason: Hepatitis B is transmitted through exposure to infected blood and certain body fluids, so prevention teaching focuses on avoiding blood-to-blood contact in the home. Items that can be contaminated with microscopic blood (e.g., razors, toothbrushes) are common household sources of exposure risk and should never be shared. Casual contact such as hugging or kissing does not transmit hepatitis B, so restricting normal social contact is unnecessary. Hepatitis B is not spread by shared bathrooms or by dishes when routine cleaning is used, making separate bathroom use or special dishwashing practices nonessential.

Question 14

The home health nurse administers directly observed therapy (DOT) to a client who was diagnosed with pulmonary Mycobacterium tuberculosis (MTB) nine days ago. At that time the client was started on TB chemotherapy regimen. Which personal protective equipment (PPE) should the nurse wear when making her first intake visit at the client’s home?

Accepted Answer

Answer reason: Airborne transmission requires a particulate respirator (e.g., N95 or higher) for anyone entering the room/area of a patient with suspected or confirmed pulmonary TB until the patient is no longer considered infectious. After only 9 days of therapy, many patients can still be contagious, and home visits lack engineered airborne controls like negative-pressure rooms, so respiratory protection remains essential. A surgical mask does not filter airborne droplet nuclei adequately to protect the nurse. Eye protection and gloves alone do not address the primary airborne route of MTB transmission.

Question 15

The nurse cares for a client who recently delivered a baby. The client has a 10-mm reaction to a tuberculin (TB) skin test as measured on her left arm. The client does not have any symptoms, and chest x-ray is negative. The baby develops respiratory distress and is placed in the neonatal intensive care unit. The nurse should?

Accepted Answer

Answer reason: A positive TB skin test with no symptoms and a negative chest x-ray indicates latent TB infection, which is not contagious because there is no active pulmonary disease and no airborne organisms being expelled. Airborne precautions are reserved for suspected or confirmed active pulmonary or laryngeal TB, especially when cough, systemic symptoms, or abnormal imaging are present. The infant’s respiratory distress in the NICU does not, by itself, imply TB exposure requiring airborne isolation without evidence of active maternal disease. Adding a mask or isolating either patient would be unnecessary and inconsistent with transmission-based precaution principles for latent TB.

Question 16

A 20-year-old college student who lives in a dormitory is admitted to the emergency department with complaints of headache, nausea, vomiting, stiff neck, and a rash. The nurse should perform which action based on the information given?

Accepted Answer

Answer reason: The constellation of fever-like symptoms with headache, stiff neck, and rash in a dorm resident is highly concerning for meningococcal meningitis, which spreads via respiratory droplets. Transmission-based precautions should be initiated immediately to reduce exposure to staff and other patients while diagnostic workup proceeds. Airborne isolation/negative-pressure is reserved for true airborne pathogens (e.g., TB, measles, varicella), not typical meningococcal disease. Standard precautions alone are insufficient because they do not address droplet spread during close contact (e.g., within 3–6 feet) or procedures that generate cough/sneeze droplets.

Question 17

While the nurse performs a hospital admission assessment, the client complains of night sweats, productive cough with blood-tinged sputum, fever, and weight loss. Chest x-ray shows an upper lobe infiltrate. The nurse should implement which precautions?

Accepted Answer

Answer reason: The symptom cluster of night sweats, weight loss, hemoptysis, fever, and an upper-lobe infiltrate strongly suggests pulmonary tuberculosis, which is transmitted via airborne droplet nuclei. Suspected TB requires immediate transmission-based airborne isolation in addition to standard precautions to protect staff and other patients. Airborne isolation includes placement in an airborne infection isolation room with negative pressure to prevent contaminated air from escaping into hallways. Droplet precautions are insufficient because they do not address the smaller aerosolized particles that remain suspended and travel farther than large droplets.

Question 18

A team leader would instruct team members to wear a mask and protective eyewear or a face shield in which situation?

Accepted Answer

Answer reason: A mask plus goggles/face shield is indicated when sprays or splashes are likely because these routes can transmit pathogens via droplets contacting conjunctiva or oropharyngeal mucosa. Fever alone does not determine the need for facial protection unless a specific respiratory transmission risk is present. Sharps use primarily calls for safe handling and appropriate gloves, not routine mask/eye protection unless splash risk exists.

Question 19

The new nurse is caring for the client with a VRE infection. Which statement to the client indicates the new nurse needs additional orientation when caring for clients with a VRE infection?

Accepted Answer

Answer reason: " VRE requires contact precautions and meticulous hand hygiene, but routine handwashing with soap and water is not the required method for all encounters. Alcohol-based hand rub is acceptable and commonly preferred when hands are not visibly soiled, with soap and water reserved when soiling is present or specific organisms (e.g., spores) are suspected. Stating that visitors “should use soap and water” as the expectation implies an incorrect, overly rigid requirement and reflects misunderstanding of standard hand-hygiene guidance. By contrast, emphasizing gown/gloves on room entry and private room placement aligns with contact transmission prevention.

Question 20

The nurse is supervising the NA caring for a group of clients with antibiotic-resistant organisms. Which observation of the NA’s performance should prompt the supervising nurse to intervene?

Accepted Answer

Answer reason: Alcohol-based hand rub is not appropriate when hands are visibly soiled or after exposure to certain organisms where soap-and-water is indicated; emptying a urinary drainage bag is a high-risk task for contamination and environmental spread. The safer, guideline-consistent action is to wash hands with soap and water after glove removal for this type of exposure. The other observations reflect appropriate baseline practices (hand hygiene before gloving, gloves during care, and promoting hand hygiene for visitors).

Question 21

The nurse is providing postmortem care for a client who was being treated for Staphylococcus aureus. Which transmission-based precautions are indicated?

Accepted Answer

Answer reason: During postmortem care, body fluids and any draining lesions can contaminate surfaces and the nurse’s hands/clothing, making gown and gloves with dedicated equipment appropriate. Airborne precautions are reserved for pathogens that remain suspended in air (e.g., TB), which is not the typical route for S. aureus. Standard precautions apply to all clients, but the question asks specifically for the indicated transmission-based category, which is contact.

Question 22

The nurse is observing a student nurse wash their hands with soap and water. Which observation requires follow-up? The student nurse?

Accepted Answer

Answer reason: Effective hand hygiene requires removing jewelry and keeping forearms free of items that can harbor microorganisms and prevent thorough friction over all skin surfaces. A wristwatch is a known reservoir for pathogens and interferes with proper cleansing of the wrist area, so it should be removed rather than simply pushed up. Using warm water, keeping fingers pointed downward to prevent contaminated water from running toward the forearms, and drying from wrists to fingers are consistent with recommended technique to reduce contamination. Leaving a watch in place increases the risk of incomplete handwashing and cross-transmission, so this finding warrants follow-up teaching.

Question 23

The client’s wife states she doesn’t like to wear a mask. The nurse’s response should be?

Accepted Answer

Answer reason: I understand it can be uncomfortable. This is to help protect your husband from catching any germs that we may carry. Effective infection control teaching combines empathy with a clear, patient-centered rationale to promote adherence to precautions. This response acknowledges the visitor’s discomfort and explains the safety purpose of masking—reducing transmission of microorganisms to a potentially vulnerable patient. It avoids judgment or fear-based language, which can increase resistance and decrease cooperation. In contrast, dismissing the requirement undermines standard precautions, and focusing on whether the visitor is “sick” can sound accusatory while missing the key goal of protecting the immunocompromised or infected client.

Question 24

The nurse in the emergency department is caring for a child with nuchal rigidity, fever, photophobia, and rash. The nurse should initially?

Accepted Answer

Answer reason:  The immediate nursing priority with suspected meningitis/meningococcemia (fever, nuchal rigidity, photophobia, rash) is preventing transmission to staff and other patients. Droplet precautions should be started promptly because Neisseria meningitidis spreads via respiratory droplets, and delays increase exposure risk. Diagnostic steps like lumbar puncture or CT may be necessary, but they do not come before instituting appropriate isolation. Comfort measures such as a tepid sponge bath can be supportive but are not the first action when a highly contagious, potentially life-threatening infection is suspected.

Question 25

A nurse is caring for a child presenting with a productive cough, with blood-tinged sputum and SPO2 of 95% on room air. Which of the following actions should the nurse prioritize?

Accepted Answer

Answer reason: The child is not in acute respiratory failure (SpO2 95% on room air), so oxygen is not the most time-critical first action. Diagnostics (e.g., chest X-ray) and treatment initiation are important but should occur after implementing infection-control measures to prevent exposure. Prioritizing isolation aligns with safety and infection control principles and reduces risk of facility-wide transmission.

Question 26

A nursing instructor is monitoring the care of a new graduate nurse on a med-surg unit. A client culture results come back positive for the flu. Which of the following actions by the new graduate nurse requires further education by the instructor?

Accepted Answer

Answer reason: Influenza spreads via respiratory droplets, so promptly implementing droplet precautions reduces transmission risk to staff and other patients. Hand hygiene on entry/exit is a core infection-control measure and is appropriate. Masking the patient during transport is also consistent with droplet precautions to contain respiratory secretions; nausea/vomiting may warrant antiemetics and hydration but does not justify making the patient NPO as an infection-control step.

Question 27

The charge nurse is observing a staff member caring for a client who has a methicillin-resistant Staphylococcus aureus infection of a sacral wound. Which of the following actions by the staff member would indicate to the charge nurse an understanding of the principles of infection control for this client?

Accepted Answer

Answer reason: Wound irrigation can aerosolize or splash contaminated fluid, so a gown and gloves protect skin and clothing and a face shield protects mucous membranes of the eyes, nose, and mouth. Posting a “soap and water only” sign is more consistent with suspected/confirmed C. difficile, not MRSA. Precautions should not be stopped based on an early negative culture result because cultures may take longer to grow and clinical risk of transmission remains.

Question 28

The nurse supervises wound care being performed by a family member for a patient with cellulitis to the arm. Which action implemented by the patient's family member requires correction by the nurse?

Accepted Answer

Answer reason: Cellulitis is typically managed with standard precautions because it is an infection of the deeper dermis/subcutaneous tissue and is not inherently spread by casual contact unless there is uncontrolled drainage. Contact precautions are reserved for pathogens or situations with significant risk of transmission via contact (e.g., MRSA with draining wounds, uncontrolled secretions/excretions). Using contact precautions when not indicated reflects incorrect infection-control practice and should be corrected to the appropriate precaution level. Marking and dating erythema helps track progression, limb positioning can support comfort and care, and warm moist compresses are commonly used as supportive therapy when ordered and safe.

Question 29

The nurse is planning care for a client with acute hepatitis A. Which of the following should be included in the plan of care for an infant with an acute hepatitis A virus (HAV) infection?

Accepted Answer

Answer reason: Gloves during diaper changes are a practical application of standard precautions to prevent spread to caregivers and other contacts. Droplet precautions are not indicated for HAV because it is not spread through respiratory droplets in routine care. There is an effective HAV vaccine, and vertical transmission during childbirth is not the typical transmission pathway for hepatitis A.

Question 30

The nurse should initiate which type of precautions for a child with Fifth’s disease?

Accepted Answer

Answer reason: Droplet precautions (mask within close contact, private room or cohorting, and standard hand hygiene) address this route of spread. Airborne precautions are reserved for organisms that remain suspended over long distances (e.g., measles, varicella, TB), which does not apply here. Contact precautions are not the primary requirement unless there are copious secretions or other indications, so droplet is the best single choice.

Question 31

The nurse is planning a staff education program about N95 respirators. Which of the following information should the nurse include?

Accepted Answer

Answer reason: Transmission-based precautions are selected based on how an organism spreads, and airborne pathogens require a fit-tested respirator to prevent inhalation of small aerosolized particles. Teaching should therefore emphasize which infections warrant N95 use rather than implying respirators can be casually substituted or used inconsistently. Fit testing is not a one-time event for an entire career; it must be repeated per policy and when facial/weight changes could affect seal. Removing a respirator should occur after leaving the room and closing the door (per facility protocol) to avoid contaminating clean areas and to maintain protection during exit.

Question 32

Which of the following is not a bloodborne pathogen that can be contracted with a needlestick injury?

Accepted Answer

Answer reason: Hepatitis B, hepatitis C, and HIV are classic bloodborne pathogens with documented occupational transmission risk after percutaneous injury. Hepatitis A is mainly transmitted by the fecal–oral route and is not typically acquired through blood exposure from a needlestick in routine clinical settings. This distinction underlies standard precautions and post-exposure protocols that focus on HBV, HCV, and HIV risk assessment and follow-up.

Question 33

The nurse suspects a child in the emergency department is suffering from rubella. Which isolation precautions should be implemented?

Accepted Answer

Answer reason: Droplet precautions require a surgical mask for caregivers within close contact and appropriate patient placement to reduce exposure to others in the ED. Airborne precautions are reserved for infections with true airborne spread (e.g., measles, varicella, TB), which is a common confusion with viral exanthems. Contact precautions are mainly for pathogens spread by direct touch or contaminated surfaces and are not the primary route for rubella.

Question 34

A nurse is utilizing PPE to decrease the risk of infection. Which part of the PPE should be removed first?

Accepted Answer

Answer reason: Gloves are considered the dirtiest because they have the most direct contact with patient secretions and contaminated surfaces. Removing them first allows immediate hand hygiene before touching other PPE ties/straps that could transfer organisms to the face or clothing. A common error is removing the mask or eye protection early, which increases risk of inoculating mucous membranes during removal.

Question 35

A patient is admitted with a diagnosis of varicella. Which type of transmission precaution would be appropriate for this patient?

Accepted Answer

Answer reason: Airborne precautions reduce inhalation exposure risk for susceptible staff and patients, which is the primary safety concern in inpatient settings. Contact precautions are also used in practice, but if only one category must be selected, airborne best captures the high-risk route. Droplet precautions are insufficient because they do not address smaller particle suspension in air, and standard precautions alone do not prevent transmission to non-immune individuals.

Question 36

The infection control nurse reviews guidelines with other nurses. Which of the following statements by the nurses would indicate a correct understanding of the teaching?

Accepted Answer

Answer reason: "Neisseria meningitidis is spread primarily by respiratory droplets, so droplet precautions are required in addition to standard precautions. Droplet precautions include wearing a surgical mask when within close range of the patient (commonly cited as within 3 feet) to prevent mucous membrane exposure. In contrast, active pulmonary TB requires airborne precautions with an N95 respirator (not a simple surgical mask) for staff, making that statement incorrect. Hepatitis B is transmitted via blood/body fluids and does not require special food/utensil disposal, and uncomplicated bacterial pneumonia typically calls for droplet precautions rather than routine gown use unless contact with secretions is anticipated.

Question 37

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 by direct contact with contaminated hands, equipment, or environmental surfaces, so contact precautions are required in addition to standard precautions. This includes gown and gloves upon room entry and dedicated or disinfected equipment to prevent cross-transmission. “Respiratory isolation” is used for pathogens that spread via airborne or droplet routes as the dominant mechanism, which is not the key control point for MRSA. Reverse isolation is intended to protect severely immunocompromised clients from acquiring infections, not to contain MRSA from spreading to others.

Question 38

The nurse is admitting a patient with a diagnosis of measles. What is the appropriate transmission precaution for the nurse to initiate?

Accepted Answer

Answer reason: Measles (rubeola) is one of the most contagious infections and spreads via airborne transmission from aerosolized respiratory particles that can remain suspended and travel in the air. This requires airborne precautions, including a fit-tested N95 (or higher) respirator and placement in a negative-pressure room when available. Droplet precautions are insufficient because they target larger particles that travel short distances, whereas measles can spread beyond 3–6 feet and linger after the patient leaves. Initiating the correct isolation promptly is a key infection-control action to prevent healthcare-associated transmission, especially to susceptible staff and other patients.

Question 39

A nursing intervention for a patient with hepatitis B would include which of the following types of isolation?

Accepted Answer

Answer reason: This includes consistent hand hygiene and appropriate PPE (especially gloves) when anticipating contact with blood, body fluids, or contaminated sharps/needles. Enteric isolation targets fecal-oral pathogens (e.g., C. difficile) and does not address the main transmission route for hepatitis B. “Strict isolation” is not indicated for hepatitis B in typical healthcare settings and would represent unnecessary restriction compared with evidence-based precautions.

Question 40

Which of the following nursing procedures when preforming tracheostomy care is inappropriate?

Accepted Answer

Answer reason: Using only clean technique during suctioning increases the chance of contaminating the trachea and lungs with skin or environmental flora. By contrast, dressing care is often performed with clean technique unless the institution requires sterile supplies, and maintaining oxygenation is essential because suctioning can rapidly cause hypoxemia. Keeping the inner cannula sterile while cleaning also aligns with infection-prevention principles because it will be reinserted into the airway.

Question 41

The nurse is caring for a patient with hepatitis B. The nurse understands that high risk groups for acquiring this virus include which of the following?

Accepted Answer

Answer reason: Hemodialysis settings involve frequent vascular access, blood handling, and potential needlestick or mucosal exposures, which increases transmission risk if precautions fail. Standard precautions, safe injection practices, and vaccination are especially important for staff in these environments. In contrast, food handling is not a typical transmission route for hepatitis B, which is not spread via casual contact or food.

Question 42

The nurse is admitting a newborn with a low-grade fever, high-pitched whooping cough, and cyanosis. The nurse should arrange which type of precautions for this patient?

Accepted Answer

Answer reason: A newborn with paroxysmal “whooping” cough and cyanosis is high risk for severe disease and can shed organism-laden secretions during coughing fits, making source control essential. Droplet precautions (mask within close range, private room/cohorting, standard precautions) directly target this route of transmission. Airborne isolation is reserved for organisms that remain suspended over long distances (e.g., TB, measles, varicella), which is not the typical mode for pertussis. Contact precautions alone would not adequately address spread via large respiratory droplets during coughing episodes.

Question 43

A nurse provides care to a client with a Clostridioides difficile (C. diff.) infection. Which infection control precaution does the nurse implement?

Accepted Answer

Answer reason: C. difficile is transmitted via spores through the fecal–oral route, so contact precautions are required to prevent organism spread via hands and clothing. Gown and gloves during care reduce contamination of the nurse’s skin and uniform and limit environmental transmission. Alcohol-based hand sanitizer is unreliable against spores, so soap-and-water hand hygiene is needed instead, making that choice unsafe. A mask is not routinely indicated because C. diff is not spread by droplet or airborne routes, and room placement near the nurses’ station does not address the mode of transmission.

Question 44

In accordance with standard precaution guidelines, when should a nurse wear gloves during nursing interventions?

Accepted Answer

Answer reason: Gloves are required when there is potential contact with bodily fluids such as saliva. Oral hygiene exposes the nurse to mucous membranes and secretions, requiring standard precautions.

Question 45

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions?

Accepted Answer

Answer reason: A positive PPD plus an abnormal chest radiograph raises concern for active TB disease until proven otherwise, so the client should be placed in an airborne infection isolation room with N95/respirator use. In contrast, viral and mycoplasma pneumonias are typically managed with droplet (and standard) precautions rather than airborne, and AIDS/CMV does not by itself indicate airborne isolation. The safest nursing action is to implement airborne precautions immediately while diagnostic confirmation is pursued to prevent unit-wide transmission.

Question 46

A client diagnosed with active TB would be hospitalized primarily for which of the following reasons?

Accepted Answer

Answer reason: Active tuberculosis is an airborne infection, so the highest priority is protecting others via rapid initiation of airborne isolation (negative-pressure room) and ensuring transmission-based precautions are followed. Hospitalization is primarily indicated when isolation cannot be reliably maintained or when public health risk is significant, because untreated or inadequately isolated active TB can spread through droplet nuclei. Evaluating condition and determining medication needs can often be done outpatient once diagnosis is established, and TB treatment is generally indicated rather than contingent on inpatient observation. Assessing compliance is important (e.g., DOT), but it is not the primary reason for hospitalization compared with immediate infection-control needs.

Question 47

The nurse is caring for four clients on a medical-surgical floor. Which client requires immediate isolation precautions?

Accepted Answer

Answer reason: TB is transmitted via airborne droplet nuclei that remain suspended and can infect others at a distance, so it requires rapid implementation of airborne precautions to prevent unit-wide exposure. A new TB diagnosis with cough (including hemoptysis) indicates potential infectious pulmonary TB until proven otherwise, warranting immediate placement in an airborne infection isolation room and use of an N95 respirator. By contrast, influenza is typically managed with droplet precautions, and routine bacterial pneumonia is usually standard (or droplet in select situations) rather than airborne. Although C. difficile requires contact precautions with soap-and-water hand hygiene, the broader immediate airborne transmission risk on a med-surg floor makes suspected infectious TB the highest priority for prompt isolation.

Question 48

Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves?

Accepted Answer

Answer reason: An oral exam involves direct contact with the mouth’s mucous membranes and saliva, so gloves are indicated to reduce transmission risk and protect the nurse from exposure. By contrast, routine breast, integumentary, and ophthalmic assessments typically involve intact skin only and do not inherently require gloves unless there are open lesions, drainage, or other exposure risks. Therefore, the oral examination is the one that requires gloves in a standard physical assessment.

Question 49

A patient with influenza is experiencing tachycardia, tachypnea, fever, and dyspnea. The patient presses his call light and tells the nurse through the phone that he is feeling worse, and is having trouble taking a deep breath. The nurse’s best response is?

Accepted Answer

Answer reason: Because influenza is transmitted via droplets, the nurse must apply appropriate precautions before entering to protect self and prevent spread while still responding urgently. Reassessment allows rapid evaluation of oxygenation (work of breathing, SpO2, lung sounds) and timely escalation (oxygen, rapid response) based on findings. Deferring care or sending juice does not address the respiratory threat, and calling for more medication is premature without an in-person assessment of severity and needs.

Question 50

There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room?

Accepted Answer

Answer reason: Suspected pulmonary tuberculosis should be placed in a private negative-pressure room (airborne isolation) as soon as possible to reduce exposure risk in a crowded ED. Contact-transmitted infections like C. difficile and VRE also benefit from private rooms, but they are primarily spread through direct contact and can often be managed with strict contact precautions and dedicated equipment if a private room is limited. Toxic shock syndrome is not typically managed with transmission-based isolation beyond standard precautions unless another specific transmissible infection is suspected.

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