1.

A child is admitted to the pediatric unit with a diagnosis of suspected

meningococcal meningitis. Which of the following nursing measures should the
nurse do FIRST?

A. Institute seizure precautions

B. Assess neurologic status
C. Place in respiratory isolation
D. Assess vital signs

2. A client is diagnosed with methicillin-resistant staphylococcus

aureus pneumonia. What type of isolation is MOST appropriate for this client?

A. Reverse isolation
B. Respiratory isolation
C. Standard precautions
D. Contact isolation

3. 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?

A. A diagnosis of AIDS and cytomegalovirus

B. A positive PPD with an abnormal chest x-ray
C. A tentative diagnosis of viral pneumonia
D. Advanced carcinoma of the lung

4. Which of the following is the FIRST priority in preventing infections when

providing care for a client?

A. Handwashing
B. Wearing gloves
C. Using a barrier between client’s furniture and nurse’s bag
D. Wearing gowns and goggles

5. An adult woman is admitted to an isolation unit in the hospital

after tuberculosis was detected during a pre-employment physical. Although
frightened about her diagnosis, she is anxious to cooperate with the therapeutic
regimen. The teaching plan includes information regarding the most common
means of transmitting the tubercle bacillus from one individual to another. Which
contamination is usually responsible?

A. Hands.
B. Droplet nuclei.
C. Milk products.
D. Eating utensils.
6. A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile
seizures. In preparing for his admission, which of the following is the most
important nursing action?

A. Order a stat admission CBC.

B. Place a urine collection bag and specimen cup at the bedside.
C. Place a cooling mattress on his bed.
D. Pad the side rails of his bed.

7. A young adult is being treated for second and third-degree burns over 25% of
his body and is now ready for discharge. The nurse evaluates his understanding of
discharge instructions relating to wound care and is satisfied that he is prepared
for home care when he makes which statement?

a. “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath
water.”
b. “If any healed areas break open I should first cover them with a sterile dressing and then
report it.”
c. “I must wear my Jobst elastic garment all day and can only remove it when I’m going to
bed.”
d. “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”

8. An eighty five year old man was admitted for surgery for benign prostatic
hypertrophy. Preoperatively he was alert, oriented, cooperative, and
knowledgeable about his surgery. Several hours after surgery, the evening nurse
found him acutely confused, agitated, and trying to climb over the protective side
rails on his bed. The most appropriate nursing intervention that will calm an
agitated client is:

A. limit visits by staff.

B. encourage family phone calls.
C. position in a bright, busy area.
D. speak soothingly and provide quiet music.

9. Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse
knows the client understands the procedure when she makes which of the
following remarks the night before the procedure?

A. She says to her husband, “Please bring me a hamburger and french fries tomorrow when
you come. I hate hospital food.”
B. “I told my daughter who is pregnant to either come to see me tonight or wait until I go
home from the hospital.”
C. “I understand it will be several weeks before all the radiation leaves my body.”
D. “I brought several craft projects to do while the radium is inserted.”
10. The nurse in charge is evaluating the infection control procedures on the unit.
Which finding indicates a break in technique and the need for education of staff?

A. The nurse aide is not wearing gloves when feeding an elderly client.
B. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to
another department for testing.
C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client
care.
D. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict
isolation.

11. The charge nurse observes a new staff nurse who is changing a dressing on a
surgical wound. After carefully washing her hands the nurse dons sterile gloves to
remove the old dressing. After removing the dirty dressing, the nurse removes the
gloves and dons a new pair of sterile gloves in preparation for cleaning and
redressing the wound. The most appropriate action for the charge nurse is to:

A. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to
remove the old dressing.
B. congratulate the nurse on the use of good technique.
C. discuss dressing change technique with the nurse at a later date.
D. interrupt the procedure to inform the nurse of the need to wash her hands after removal
of the dirty dressing and gloves.

12. Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The
most important factor to consider in this assessment is:

A. Correct illumination of the environment.

B. amount of regular exercise.
C. the resting pulse rate.
D. status of salt intake.

13. Mrs. Jones will have to change the dressing on her injured right leg twice a day.
The dressing will be a sterile dressing, using 4 X 4s, normal salineirrigant, and
abdominal pads. Which statement best indicates that Mrs. Jones understands the
importance of maintaining asepsis?

A. “If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.”
B. “If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline.”
C. “If I question the sterility of any dressing material, I should not use it.”
D. “I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.”

14. A client has been placed in blood and body fluid isolation. The nurse is
instructing auxiliary personnel in the correct procedures. Which statement by the
nursing assistant indicates the best understanding of the correct protocol for blood
and body fluid isolation?

A. Masks should be worn with all client contact.

B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
C. Isolation gowns are not needed.
D. A private room is always indicated.

15. The nurse is evaluating whether nonprofessional staff understand how to

prevent transmission of HIV. Which of the following behaviors indicates correct
application of universal precautions?

A. A lab technician rests his hand on the desk to steady it while recapping the needle after
drawing blood.
B. An aide wears gloves to feed a helpless client.
C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction
a tracheostomy.
D. A pregnant worker refuses to care for a client known to have AIDS.

16. Jayson, 1 year old child has a staph skin infection. Her brother has also
developed the same infection. Which behavior by the children is most likely to have
caused the transmission of the organism?

A. Bathing together.
B. Coughing on each other.
C. Sharing pacifiers.
D. Eating off the same plate.

17. Jessie, a young man with newly diagnosed acquired immune deficiency
syndrome (AIDS) is being discharged from the hospital. The nurse knows that
teaching regarding prevention of AIDS transmission has been effective when the
client:

A. verbalizes the role of sexual activity in spread of the disorder.

B. states he will make arrangements to drop his college classes.
C. acknowledges the need to avoid all contact sports.
D. says he will avoid close contact with his three-year-old niece.

18. Which question is least useful in the assessment of a client with AIDS?

A. Are you a drug user?

B. Do you have many sex partners?
C. What is your method of birth control?
D. How old were you when you became sexually active?
19. Mrs. Parker, a 70-year-old woman with severe macular degeneration, is
admitted to the hospital the day before scheduled surgery. The nurse’s
preoperative goals for Mrs. M. would include:

A. independently ambulating around the unit.

B. reading the routine preoperative education materials.
C. maneuvering safely after orientation to the room.
D. using a bedpan for elimination needs.

20. A child is undergoing remission induction therapy to treat leukemia. Allopurinol

is included in the regimen. The main reason for administering allopurinol as part of
the client’s chemotherapy regimen is to:

A. Prevent metabolic breakdown of xanthine to uric acid

B. Prevent uric acid from precipitating in the ureters
C. Enhance the production of uric acid to ensure adequate excretion of urine
D. Ensure that the chemotherapy doesn’t adversely affect the bone marrow

Answers and Rationale

1. Answer: C. Place in respiratory isolation

The initial therapeutic management of acute bacterial meningitis includes isolation

precautions, initiation of antimicrobial therapy and maintenance of optimum hydration.
Nurses should take necessary precautions to protect themselves and others from possible
infection.

2. Answer: D. Contact isolation

Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves,
mask, gown, or protective eyewear as appropriate) whenever direct contact with any body
fluid is expected. When determining the type of isolation to use, one must consider the mode
of transmission. The hands of personnel continues to be the principal mode of transmission
for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to
the sputum in this example, precautions are taken if contact with the patient”s sputum is
expected. A private room and BSI, along with good hand washing techniques, are the best
defense against the spread of MRSA pneumonia.

3. Answer: B. A positive PPD with an abnormal chest x-ray

The client who must be placed in airborne precautions is the client with a positive PPD
(purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.

4. Answer: A. Handwashing
Handwashing remains the most effective way to avoid spreading infection. However, too
often nurses do not practice good handwashing techniques and do not teach families to do so.
Nurses need to wash their hands before and after touching the client and before entering the
nursing bag.

5. Answer: B. Droplet nuclei.

Hands are the primary method of transmission of the common cold. The most frequent
means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in
the air as a result of coughing, sneezing, and expectoration of sputum by an infected person.
The tubercle bacillus is not transmitted by means of contaminated food. Contact with
contaminated food or water could cause outbreaks of salmonella, infectious hepatitis,
typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils. Some
exogenous microbes can be transmitted via reservoirs such as linens or eating utensils.

6. Answer: D. Pad the side rails of his bed.

Preparing for routine laboratory studies is not as high a priority as preventing injury and
promoting safety. Preparing for routine laboratory studies is not as high a priority as
preventing injury and promoting safety. A cooling blanket must be ordered by the physician
and is usually not used unless other methods for the reduction of fever have not been
successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and
promote safety should take precedence.

7. Answer: B. “If any healed areas break open I should first cover them with a
sterile dressing and then report it.”

Bathing or showering in the usual manner is permitted, using a mild detergent soap such as
Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead
tissue. The client is taught to report changes in wound healing such as blister formation, signs
of infection, and opening of a previously healed area. Sterile dressings are applied until the
wound is assessed and a plan of care developed. The Jobs garment is designed to place
constant pressure on the new healthy tissue that is forming to promote adherence to the
underlying structure in order to prevent hypertrophic scarring. In order to be effective, the
garment must be worn for 23 hours daily. It is removed for wound assessment and wound
care and to permit bathing. The client must be aware that infection of the wound may occur;
signs of infection, including fever, redness, pain, warmth in and around the wound and
increased or foul smelling drainage must be reported immediately.

8. Answer: D. speak soothingly and provide quiet music.

The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls
from his family will not help a client who is trying to climb over the side rails and may even
add to his danger. Putting the client in a bright, busy area would probably add to
his confusion. The environment is an important factor in the prevention of injuries. Talking
softly and providing quiet music have a calming effect on the agitated client.

9. Answer: B. “I told my daughter who is pregnant to either come to see me tonight

or wait until I go home from the hospital.”

The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are
not allowed. People who are pregnant should not come in close contact with someone who
has internal radiation therapy. The radioactivity could possibly damage the fetus. This
statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours
after insertion), the client is no longer contaminated with radioactivity. Craft projects usually
require the client to sit. The client must remain flat with very little head elevation during the
time the rods are in place.

10. Answer: C. A nurse with open, weeping lesions of the hands puts on gloves
before giving direct client care.

There is no need to wear gloves when feeding a client. However, universal precautions
(treating all blood and body fluids as if they are infectious) should be observed in all situations.
A client with active tuberculosis should be on respiratory precautions. Having the client wear
a mask when leaving his private room is appropriate. Persons with exudative lesions or
weeping dermatitis should not give direct client care or handle client-care equipment until
the condition resolves. Strict isolation requires the use of mask, gown, and gloves.

11. Answer: D. interrupt the procedure to inform the nurse of the need to wash her
hands after removal of the dirty dressing and gloves.

Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves
does not put the client in danger so discussion of this can wait until later. The staff nurse is
doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The
nurse should wash her hands after removing the soiled dressing and before donning sterile
gloves to clean and dress the wound. The nurse should wash her hands after removing the
soiled dressing and before donning the sterile gloves to clean and dress the wound. Not doing
this compromises client safety and should be brought to the immediate attention of the nurse.
The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the
old dressing. However, the use of sterile gloves does not put the client in danger so discussion
of this can wait until later. However, the nurse should wash her hands after removing the
soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this
compromises client safety and should be brought to the immediate attention of the nurse.

12. Answer: A. Correct illumination of the environment.

To prevent falls, the environment should be well lighted. Night lights should be used if
necessary. Other factors to assess include removing loose scatter rugs, removing spills, and
installing handrails and grab bars as appropriate. The amount of regular exercise is not the
most important factor to assess. It is only indirectly related. The resting pulse rate is not
related to preventing falls. The salt intake is not directly related to preventing falls.

13. Answer: C. “If I question the sterility of any dressing material, I should not use
it.”

Anything dropped on the floor is no longer sterile and should not be used. The statement
indicates lack of understanding. Anything dropped on the floor is no longer sterile and should
not be used. The statement indicates lack of understanding. If there is ever any doubt about
the sterility of an instrument or dressing, it should not be used. The 4 X 4s should be soaked
prior to donning the sterile gloves. Once the sterile gloves touch the bottle of normal saline
they are no longer sterile. This statement indicates a need for further instruction.

14. Answer: B. Gloves should be worn for contact with nonintact skin, mucous
membranes, or soiled items.

Masks should only be worn during procedures that are likely to cause splashes of blood or
body fluid. Gloves should be worn for all contact with blood and body fluids, non intact skin
and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns
should be worn during procedures that are likely to cause splashes of blood or body fluids. A
private room is only indicated if the client’s hygiene is poor.

15. Answer: C. An assistant puts on a mask and protective eye wear before
assisting the nurse to suction a tracheostomy.

Needles that have been used to draw blood should not be recapped. If it is necessary to recap
them, an instrument such as a hemostat should be used to recap. The hand should never be
used. Gloves are not necessary when feeding, since there is no contact with mucous
membranes. Although saliva may have small amounts of HIV in it, the virus does not invade
through unbroken skin. There is no evidence in the question to indicate broken skin. Masks
and protective eye wear are indicated anytime there is great potential for splashing of body
fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always
stimulates coughing, which is likely to generate droplets that may splash the health care
worker. Clients who are suctioned frequently or have had an invasive procedure like a
tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant
workers from caring for persons with AIDS as long as they utilize universal precautions.

16. Answer: A. Bathing together.

Direct contact is the mode of transmission for staphylococcus. Staph is not spread by
coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not
spread through oral secretions.
17. Answer: A. verbalizes the role of sexual activity in spread of the disorder.

HIV is spread through direct contact with body fluids such as blood and through sexual
intercourse. Casual contact with other people does not pose a risk of transmission of HIV.
Unless the client is feeling very ill, there is no need for him to drop his college classes. Contact
sports are not contraindicated unless there is a significant chance of bleeding and direct
contact with others. Casual contact with other people does not pose a risk of transmission of
HIV . There is no need to limit casual contact with children.

18. Answer: D. How old were you when you became sexually active?

Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for AIDS. Birth control
methods are important to prevent a baby from being born with the AIDS virus. The age at
which sexual activity began it not relevant as it does not usually provide information that
identifies the presence of risk factors for AIDS.

19. Answer: C. maneuvering safely after orientation to the room.

Independently ambulating around the unit is not appropriate because the unit environment
can change and injury could result. Assistance is necessary because of the client’s visual
deficit. It is unlikely the client can see well enough to read the materials. Maneuvering safely
after orientation to the room is a realistic goal for a person with impaired vision. Orienting the
client to the room should help the client to move safely. Using the bedpan is an unnecessary
restriction on the client as she can be oriented to the bathroom or to call for assistance.

20. Answer: A. Prevent metabolic breakdown of xanthine to uric acid

The massive cell destruction resulting from chemotherapy may place the client at risk for
developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown
of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.