Safety and Infection Control 

In Text Mode:  All questions and answers are given for reading and answering at
your own pace. You can also copy this exam and make a print out.

1. The parents of a child, age 6, who will begin school in the fall ask the nurse
for anticipatory guidance. The nurse should explain that a child of this age:

A. Still depends on the parents

B. Rebels against scheduled activities
C. Is highly sensitive to criticism
D. Loves to tattle

2. While preparing to discharge an 8-month-old infant who is recovering

from gastroenteritis and dehydration, the nurse teaches the parents about
their infant’s dietary and fluid requirements. The nurse should include which
other topic in the teaching session?

A. Nursery schools
B. Toilet Training
C. Safety guidelines
D. Preparation for surgery

3. Nurse Betina should begin screening for lead poisoning when a child

reaches which age?

A. 6 months
B. 12 months
C. 18 months
D. 24 months

4. When caring for an 11-month-old infant with dehydration and metabolic

acidosis, the nurse expects to see which of the following?
A. A reduced white blood cell count
B. A decreased platelet count
C. Shallow respirations
D. Tachypnea

5. After the nurse provides dietary restrictions to the parents of a child with
celiac disease, which statement by the parents indicates effective teaching?

A. “Well follow these instructions until our child’s symptoms disappear.”

B. “Our child must maintain these dietary restrictions until adulthood.”
C. “Our child must maintain these dietary restrictions lifelong.”
D. “We’ll follow these instructions until our child has completely grown and
developed.”

6. A parent brings a toddler, age 19 months, to the clinic for a regular check-
up. When palpating the toddler’s fontanels, what should the nurse expects to
find?

A. Closed anterior fontanel and open posterior fontanel

B. Open anterior and fontanel and closed posterior fontanel
C. Closed anterior and posterior fontanels
D. Open anterior and posterior fontanels

7. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral

fluids. The nurse should monitor this client’s fluid intake because fluid
overload may cause:

A. Cerebral edema
B. Dehydration
C. Heart failure
D. Hypovolemic shock

8. An infant is hospitalized for treatment of nonorganic failure to thrive.

Which nursing action is most appropriate for this infant?

A. Encouraging the infant to hold a bottle

B. Keeping the infant on bed rest to conserve energy
C. Rotating caregivers to provide more stimulation
D. Maintaining a consistent, structured environment

9. The mother of Gian, a preschooler with spina bifida tells the nurse that her
daughter sneezes and gets a rash when playing with brightly colored balloons,
and that she recently had an allergic reaction after eating kiwifruit and
bananas. The nurse would suspect that the child may have an allergy to:

A. Bananas
B. Latex
C. Kiwifruit
D. Color dyes

10. Cristina, a mother of a 4-year-old child tells the nurse that her child is a
very poor eater. What’s the nurse’s best recommendation for helping the
mother increase her child’s nutritional intake?

A. Allow the child to feed herself

B. Use specially designed dishes for children – for example, a plate with the child’s
favorite cartoon character
C. Only serve the child’s favorite foods
D. Allow the child to eat at a small table and chair by herself

11. Nurse Roy is administering total parental nutrition (TPN) through a

peripheral I.V. line to a school-age child. What’s the smallest amount
of glucose that’s considered safe and not caustic to small veins, while also
providing adequate TPN?

A. 5% glucose
B. 10% glucose
C. 15% glucose
D. 17% glucose

12. David, age 15 months, is recovering from surgery to remove Wilms’ tumor.

Which findings best indicates that the child is free from pain?

A. Decreased appetite
B. Increased heart rate
C. Decreased urine output
D. Increased interest in play

13. When planning care for a 8-year-old boy with Down syndrome, the nurse
should:

A. Plan interventions according to the developmental level of a 7-year-old child

because that’s the child’s age
B. Plan interventions according to the developmental levels of a 5-year-old because
the child will have developmental delays
C. Assess the child’s current developmental level and plan care accordingly
D. Direct all teaching to the parents because the child can’t understand

14. Nurse Vincent is teaching the parents of a school-age child. Which

teaching topic should take priority?

A. Prevent accidents
B. Keeping a night light on to allay fears
C. Explaining normalcy of fears about body integrity
D. Encouraging the child to dress without help

15. The nurse is finishing her shift on the pediatric unit. Because her shift is
ending, which intervention takes top priority?

A. Changing the linens on the clients’ beds

B. Restocking the bedside supplies needed for a dressing change on the upcoming
shift
C. Documenting the care provided during her shift
D. Emptying the trash cans in the assigned client room

16. Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child,

age 4. the nurse should:

A. Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm)

B. Deliver 12 breaths/minute
C. Perform only two-person CPR
D. Use the heel of one hand for sternal compressions
17. A 4-month-old with meningococcal meningitis has just been admitted to
the pediatric unit. Which nursing intervention has the highest priority?

A. Instituting droplet precautions

B. Administering acetaminophen (Tylenol)
C. Obtaining history information from the parents
D. Orienting the parents to the pediatric unit

18. Shane tells the nurse that she wants to begin toilet training her 22-month-
old child. The most important factor for the nurse to stress to the mother is:

A. Developmental readiness of the child

B. Consistency in approach
C. The mother’s positive attitude
D. Developmental level of the child’s peers

19. An infant who has been in foster care since birth requires a blood
transfusion. Who is authorized to give written, informed consent for the
procedure?

A. The foster mother

B. The social worker who placed the infant in the foster home
C. The registered nurse caring for the infant
D. The nurse-manager

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

21. A 10-year-old client contracted severe acute respiratory syndrome (SARS)

when traveling abroad with her parents. The nurse knows she must put on
personal protective equipment to protect herself while providing care. Based
on the mode of SARS transmission, which personal protective should the
nurse wear?

A. Gloves
B. Gown and gloves
C. Gown, gloves, and mask
D. Gown, gloves, mask, and eye goggles or eye shield

22. A tuberculosis intradermal skin test to detect tuberculosis infection is

given to a high-risk adolescent. How long after the test is administered should
the result be evaluated?

A. Immediately
B. Within 24 hours
C. In 48 to 72 hours
D. After 5 days

23. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding

after 5 months. The nurse should advise her to include which foods in her
infant’s diet?

A. Iron-rich formula and baby food

B. Whole milk and baby food
C. Skim milk and baby food
D. Iron-rich formula only

24. Gracie, the mother of a 3-month-old infant calls the clinic and states that
her child has a diaper rash. What should the nurse advice?

A. “Switch to cloth diapers until the rash is gone”

B. “Use baby wipes with each diaper change.”
C. “Leave the diaper off while the infant sleeps.”
D. “Offer extra fluids to the infant until the rash improves.”

25. Nurse Kelly is teaching the parents of a young child how to handle
poisoning. If the child ingests poison, what should the parents do first?
A. Administer ipecac syrup
B. Call an ambulance immediately
C. Call the poison control center
D. Punish the child for being bad

26. A child has third-degree burns of the hands, face, and chest. Which nursing
diagnosis takes priority?

A. Ineffective airway clearance related to edema

B. Disturbed body image related to physical appearance
C. Impaired urinary elimination related to fluid loss
D. Risk for infection related to epidermal disruption

27. A 3-year-old child is receiving dextrose 5% in water and half-normal saline

solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid
intake?

A. Worsening dyspnea
B. Gastric distension
C. Nausea and vomiting
D. Temperature of 102°F (38.9° C)

28. Which finding would alert a nurse that a hospitalized 6-year-old child is at
risk for a severe asthma exacerbation?

A. Oxygen saturation of 95%

B. Mild work of breathing
C. Absence of intercostals or substernal retractions
D. History of steroid-dependent asthma

29. Nurse Mariane is caring for an infant with spina bifida. Which technique is
most important in recognizing possible hydrocephalus?

A. Measuring head circumference

B. Obtaining skull X-ray
C. Performing a lumbar puncture
D. Magnetic resonance imaging (MRI)
30. An adolescent who sustained a tibia fracture in a motor vehicle accident
has a cast. What should the nurse do to help relieve the itching?

A. Apply cool air under the cast with a blow-dryer

B. Use sterile applicators to scratch the itch
C. Apply cool water under the cast
D. Apply hydrocortisone cream under the cast using sterile applicator.

Answers and Rationale

1. Answer C. Is highly sensitive to criticism

In a 6-year-old child, a precarious sense of self causes overreaction to criticism and

a sense of inferiority. By age 6, most children no longer depend on the parents for
daily tasks and love the routine of a schedule. Tattling is more common at age 4 to
5, by age 6, the child wants to make friends and be a friend.

2. Answer C. Safety guidelines

The nurse always should reinforce safety guidelines when teaching parents how to
care for their child. By giving anticipatory guidance the nurse can help prevent
many accidental injuries. For parents of a 9-month-old infant, it is too early to
discuss nursery schools or toilet training. Because surgery is not
used gastroenteritis, this topic is inappropriate.

3. Answer C. 18 months

The nurse should start screening a child for lead poisoning at age 18 months and
perform repeat screening at age 24, 30, and 36 months. High-risk infants, such as
premature infants and formula-fed infants not receiving iron supplementation,
should be screened for iron-deficiency anemia at 6 months. Regular dental visits
should begin at age 24 months.

4. Answer D. Tachypnea

The body compensates for metabolic acidosis via the respiratory system, which
tries to eliminate the buffered acids by increasing alveolar ventilation through deep,
rapid respirations, altered white blood cell or platelet counts are not specific signs
of metabolic imbalance.

5. Answer C. “Our child must maintain these dietary restrictions lifelong.”

A patient with celiac disease must maintain dietary restrictions lifelong to avoid
recurrence of clinical manifestations of the disease. The other options are incorrect
because signs and symptoms will reappear if the patient eats prohibited foods.

6. Answer C. Closed anterior and posterior fontanels

By age 18 months, the anterior and posterior fontanels should be closed. The
diamond-shaped anterior fontanel normally closes between ages 9 and 18 months.
The triangular posterior fontanel normally closes between ages 2 and 3 months.

7. Answer A. Cerebral edema

Because of the inflammation of the meninges, the client is vulnerable to developing

cerebral edema and increased intracranial pressure. Fluid overload won’t
cause dehydration. It would be unusual for an adolescent to develop heart failure
unless the overhydration is extreme. Hypovolemic shock would occur with an
extreme loss of fluid of blood.

8. Answer D. Maintaining a consistent, structured environment

The nurse caring for an infant with nonorganic failure to thrive should maintain a
consistent, structured environment that provides interaction with the infant to
promote growth and development. Encouraging the infant to hold a bottle would
reinforce an uncaring feeding environment. The infant should receive social
stimulation rather than be confined to bed rest. The number of caregivers should
be minimized to promote consistency of care.

9. Answer B. Latex

Children with spina bifida often develop an allergy to latex and shouldn’t be
exposed to it. If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s
likely to be allergic to latex. Some children are allergic to dyes in foods and other
products but dyes aren’t a factor in a latex allergy.

10. Answer A. Allow the child to feed herself

The best recommendation is to allow the child to feed herself because the child’s
stage of development is the preschool period of initiative. Special dishes would
enhance the primary recommendation. The child should be offered new foods and
choices, not just served her favorite foods. Using a small table and chair would also
enhance the primary recommendation.

11. Answer B. 10% glucose

The amount of glucose that’s considered safe for peripheral veins while still
providing adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient
nutritional replacement, although it’s sake for peripheral veins. Any amount above
10% must be administered via central venous access.

12. Answer D. Increased interest in play

One of the most valuable clues to pain is a behavior change: A child whose pain-
free likes to play. A child in pain is less likely to consume food or fluids. An
increased heart rate may indicate increased pain; decreased urine output may
signify dehydration.

13. Answer C. Assess the child’s current developmental level and plan care
accordingly

Nursing care plan should be planned according to the developmental age of a child

with Down syndrome, not the chronological age. Because children with Down
syndrome can vary from mildly to severely mentally challenged, each child should
be individually assessed. A child with Down syndrome is capable of learning,
especially a child with mild limitations.

14. Answer A. Prevent accidents

Accidents are the major cause of death and disability during the school-age years.
Therefore, accident prevention should take priority when teaching parents of
school-age children. Preschool (not school-age) children are afraid of the dark, have
fears concerning body integrity, and should be encouraged to dress without help
(with the exception of tying shoes).

15. Answer C. Documenting the care provided during her shift

Documentation should take top priority. Documentation is the only way the nurse
can legally claim that interventions were performed. The other three options would
be appreciated by the nurses on the oncoming shift but aren’t mandatory and don’t
take priority over documentation.

16. Answer D. Use the heel of one hand for sternal compressions

The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse
should use the heels of both hands clasped together and compress the sternum 1½
“to 2” for an adult. For a small child, two-person rescue may be inappropriate. For a
child, the nurse should deliver 20 breaths/minute instead of 12.

17. Answer A. a. Instituting droplet precautions

Instituting droplet precautions is a priority for a newly admitted infant with

meningococcal meningitis. Acetaminophen may be prescribed but administering it
doesn’t take priority over instituting droplet precautions. Obtaining history
information and orienting the parents to the unit don’t take priority.

18. Answer A. Developmental readiness of the child

If the child isn’t developmentally ready, child and parent will become frustrated.
Consistency is important once toilet training has already started. The mother’s
positive attitude is important when the child is ready. Developmental levels of
children are individualized and comparison to peers isn’t useful.

19. Answer A. The foster mother

When children are minors and aren’t emancipated, their parents or designated
legal guardians are responsible for providing consent for medical procedures.
Therefore, the foster mother is authorized to give consent for the blood
transfusion. The social workers, the nurse, and the nurse-manager have no legal
rights to give consent in this scenario.

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.

21. Answer D. Gown, gloves, mask, and eye goggles or eye shield

The transmission of SARS isn’t fully understood. Therefore, all modes of

transmission must be considered possible, including airborne, droplet, and direct
contact with the virus. For protection from contracting SARS, any health care
worker providing care for a client with SARS should wear a gown, gloves, mask, and
eye goggles or an eye shield.

22. Answer C. In 48 to 72 hours

Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a
reaction should appear in 48 to 72 hours. Immediately after the test and within 24
hours are both too soon to observe a reaction. Waiting more than 5 days to
evaluate the test is too long because any reaction may no longer be visible.

23. Answer D. Iron-rich formula only

The American Academy of Pediatrics recommends that infants at age 5 months

receive iron-rich formula and that they shouldn’t receive solid food – even baby
food – until age 6 months. The Academy doesn’t recommend whole milk until age
12 months, and skim milk until after age 2 years.

24. Answer C. “Leave the diaper off while the infant sleeps.”
Leaving the diaper off while the infant sleeps helps to promote air circulation to the
area, improving the condition. Switching to cloth diapers isn’t necessary; in fact, that
may make the rash worse. Baby wipes contain alcohol, which may worsen the
condition. Extra fluids won’t make the rash better.

25. Answer C. Call the poison control center

Before interviewing in any way, the parents should call the poison control center for
specific directions. Ipecac syrup is no longer recommended. The parents may have
to call an ambulance after calling the poison control center. Punishment for being
bad isn’t appropriate because the parents are responsible for making the
environment safe.

26. Answer A. Ineffective airway clearance related to edema

Initially, when a preschool client is admitted to the hospital for burns, the primary
focus is on assessing and managing an effective airway. Body image disturbance,
impaired urinary elimination, and infection are all integral parts of burn
management but aren’t the first priority.

27. Answer A. Worsening dyspnea

Dyspnea and other signs of respiratory distress signify fluid volume

excess (overload), which can occur quickly in a child as fluid shifts rapidly between
the intracellular and extracellular compartments. Gastric distention may suggest
excessive oral fluid intake or infection. Nausea and vomiting or an elevated
temperature may indicate a fluid volume deficit.

28. Answer D. History of steroid-dependent asthma

A history of steroid-dependent asthma, a contributing factor to this client’s high-risk

status, requires the nurse to treat the situation as a severe exacerbation regardless
of the severity of the current episode. An oxygen saturation of 95%, mild work of
breathing, and absence of intercostals or substernal retractions are all normal
findings.

29. Answer A. Measuring head circumference

Measuring head circumference is the most important assessment technique for
recognizing possible hydrocephalus, and is a key part of routine infant screening.
Skull X-rays and MRI may be used to confirm the diagnosis. A lumbar puncture isn’t
appropriate.

30. Answer A. Apply cool air under the cast with a blow-dryer

Itching underneath a cast can be relieved by directing blow-dryer, set, on the cool
setting, toward the itchy area. Skin breakdown can occur if anything is placed under
the cast. Therefore, the client should be cautioned not to put any object down the
cast in an attempt to scratch.

Safety and Infection Control

NCLEX Practice Quiz #3 

Text Mode:  All questions and answers are given on a single page for reading and
answering at your own pace. Be sure to grab a pen and paper to write down your
answers.

1. While working in a pediatric clinic, you receive a telephone call from the
parent of a 10-year-old who is receiving chemotherapy for leukemia. The
client’s sibling has chickenpox. Which of these actions will you anticipate
taking next?

A. Teach the parents regarding contact and airborne precaution.

B. Administer varicella-zoster immune globulin to the client.
C. Prepare the client for admission to a private room in the hospital.
D. Educate the parent about the correct use of acyclovir (Zovirax).

2. Which action will you take to most effectively reduce the incidence of
hospital-associated urinary tract infections?
A. Teach assistive personnel how to provide good perineal hygiene.
B. Ensure that clients have enough adequate fluid intake.
C. Limit the use of indwelling foley catheter (IFC).
D. Perform dipstick urinalysis for clients with risk factors for UTI.

3. You are caring for a client who has been admitted to the hospital with a
leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of
these nursing actions can you delegate to an LPN/LVN?

A. Obtain wound cultures during dressing changes.

B. Plan ways to improve the client’s oral protein intake.
C. Assess risk for further skin breakdown.
D. Educate the client about home care of the leg ulcer.

4. You are the pediatric unit charge nurse today and is working with a new
RN. Which action by the new RN requires the most immediate action on your
part?

A. The new RN tells the nursing assistant to use an N95 respirator mask when
caring for a child who has pertussis.
B. The new RN places a child who has chemotherapy-induced neutropenia into a
negative-pressure room.
C. The new RN admits a new client with respiratory syncytial virus (RSV) infection to
a room with another child who has RSV.
D. The new RN wears goggles to change linens of a client who has diarrhea caused
by C. difficile.

5. A client comes to the outpatient clinic where you work complaining of

abdominal pain, diarrhea, shortness of breath and epistaxis. Which of the
following actions would you take first?

A. Ask the client about any recent travel to Asia or the Middle East.
B. Screening clients for upper respiratory tract symptoms.
C. Determine whether the client has had recommended immunizations.
D. Call an ambulance to take the client immediately to the hospital.

6. A client who has recently traveled to China comes to the emergency

department (ED) with increasing shortness of breath and is strongly
suspected of having a severe acute respiratory syndrome (SARS). Which of
these prescribed actions will you take first?

A. Place the client on contact and airborne precautions.

B. Obtain blood, urine, and sputum for cultures.
C. Administer methylprednisolone (Solu-Medrol) 1 gram/IV.
D. Infuse normal saline at 100ml/hr.

7. Four clients with infections arrive at the emergency department with some
existing infection, however, only one private room is available. Which of the
following client is the most appropriate to assign to the private room?

A. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C).

B. A client with diarrhea caused by C. difficile.
C. A client with a wound infected with VRE.
D. A client with a cough who may have Koch disease.

8. You are caring for four clients who are receiving IV infusions of normal
saline. Which client is at highest risk for bloodstream infections?

A. A client who has a midline IV catheter in the left antecubital fossa.

B. A client with a peripherally inserted central catheter (PICC) line in the right upper
arm.
C. A client with an implanted port in the right subclavian vein.
D. A client who has nontunneled central line in the left internal jugular vein.

9. A client who has frequent watery stools and a possible Clostridium

difficile infection is hospitalized with dehydration. Which nursing action
should the charge nurse delegated to an LPN/LVN?

A. Explaining the purpose of ordered stool cultures to the client and family.

B. Administering the ordered metronidazole (Flagyl) 500 mg PO to the client.
C. Reviewing the client’s medical history for any risk factors for diarrhea.
D. Performing ongoing assessments to determine the client’s hydration.

10. You are a school nurse. Which action will you take to have the most
impact on the incidence of infectious disease in the school?
A. Ensure that students are immunized according to national guidelines.
B. Provide written information about infection control to all patients.
C. Make soap and water readily available in the classrooms.
D. Teach students how to cover their mouths when coughing.

11. You are caring for a newly admitted client with increasing dyspnea
and dehydration who has possible avian influenza (bird flu). Which of these
prescribed actions will you implement first?

A. Administer the first dose of oseltamivir (Tamiflu).

B. Obtain blood and sputum specimens for testing.
C. Provide oxygen using a non-rebreather mask.
D. Infuse 5% dextrose in water at 75ml/hr.

12. A hospitalized 88-year-old client who has been receiving antibiotics for 10

days tells you that he is having frequent watery stools. Which action will you
take first?

A. Place the client on contact precaution.

B. Instruct the client about correct handwashing.
C. Obtain stool specimens for culture.
D. Notify the physician about the loose stools.

13. Which of the following information about a client who has

meningococcal meningitis has the best indicator that you can discontinue
droplet precautions?

A. Cough is productive of clear, nonpurulent mucus.

B. Pupils are equal and reactive to light.
C. Temperature is lower than 100°F (37.8°C).
D. Appropriate antibiotics have been given for 24 hours.

14. You are the charge nurse on the pediatric unit when a pediatrician calls
wanting to admit a child with rubeola (measles). Which of these factors is of
most concern in determining whether to admit the child to your unit?

A. There are several children receiving chemotherapy on the unit.

B. The infection control nurse liaison is not on the unit today.
C. The unit is not staffed with the usual number of RNs.
D. No negative-airflow rooms are available on the unit.

15. A client who states that he may have been contaminated by anthrax
arrives at the ED. The following actions are part of the ED protocol for possible
anthrax exposure or infection. Which action will you take first?

A. Escort the client to a decontamination room.

B. Assess the client for signs of infection.
C. Notify hospital security personnel about the client.
D. Administer ciprofloxacin (Cipro) 250 mg PO.

16. A client has been diagnosed with disseminated herpes zoster. Which
personal protective equipment (PPE) will you need to put on when preparing
to assess the client? Select all that apply

A. Goggles.
B. Gown.
C. Gloves.
D. Shoe covers.
E. N95 respirator.
F. Surgical face mask.

17. As the infection control nurse in an acute care hospital, which action will
you take to most effectively reduce the incidence of health-care-associated
infections?

A. Screen all newly admitted clients for colonization or infection with MRSA.
B. Develop policies that automatically start antibiotic therapy for clients colonized
by multi-drug resistant organisms.
C. Ensure that dispensers for alcohol-based hand rubs are readily available in all
client care areas of the hospital.
D. Require nursing staff to don gowns to change wound dressings for all clients.

18. You are preparing to leave the room after performing oral suctioning on a
client who is on contact and airborne precautions. In which order will you
perform the following actions?
  1. Take off the gown.

 2. Remove N95 respirator.

 3. Perform hand hygiene.

 4. Take off goggles.

 5. Remove gloves.
A. 5, 4, 1, 2, 3
B. 4, 5, 2, 1, 3
C. 1, 2, 4, 5, 3
D. 2, 4, 2, 1, 3

19. You are preparing to change the linens on the bed of a client who has a
draining sacral wound infected by MRSA. Which PPE items will you plan to
use. Select all that apply

A. Gloves.
B. N95 respirator.
C. Surgical Mask.
D. Googles.
E. Gown.

20. You are preparing to care for a 6-year-old who has just undergone
allogeneic stem cell transplantation and will need protective environmental
isolation. Which nursing tasks will you delegate to a nursing assistant? Select
all that apply.

A. Posting the precautions for protective isolation o the door of the client’s room.
B. Stocking the client’s room with the needed PPE items.
C. Talking to the family members about the reasons for the isolation.
D. Reminding visitors to wear a respirator mask, gloves, and gown.
E. Teaching the client to perform thorough hand washing after using the bathroom.

21. A 29-year-old client is diagnosed with scarlet fever. Which of the following
is the most appropriate type of isolation for this client?

A. Airborne.
B. Contact.
C. Droplet.
D. Standard.

22. A newly admitted client with streptococcal pharyngitis (tonsillitis) has

been placed on droplet precaution. Which of the following statements
indicates the best understanding for this type of isolation?

A. The client can be placed in a room with another client with measles (rubeola).
B. A special mask (N95) should be worn when working with the client.
C. Must maintain a spatial distance of 3 feet.
D. Gloves should be only worn when giving direct care.

23. Malcolm is a newly assigned as a triage nurse, on his first day of work, the
following clients arrive at the ED. Which among the client require the most
rapid action to protect other clients in the ED from infection?

A. A travel blogger who needs tuberculosis testing after an exposure to a person

with TB during his trip.
B. An elderly woman who has a history of a methicillin-resistant Staphylococcus
aureus (MRSA) leg wound infection.
C. A pregnant woman with a blister-like rash on the face and is possibly having
varicella.
D. An infant with a runny nose and whose older brother has pertussis.

24. A client with a vancomycin-resistant enterococcus (VRE) infection is

admitted to the medical unit. Which action can be delegated to a nursing
assistant who is assisting with the client’s care?

A. Implement contact precautions when handling the client.

B. Educate the client and family members on ways to prevent transmission of VRE.
C. Monitor the results of the laboratory culture and sensitivity test.
D. Collaborate with other departments when the client is transported for ordered
test.

25. Which of the following infection control activity should be delegated to an

experienced nursing assistant?
A. Asking clients about the duration of antibiotic therapy.
B. Demonstrating correct handwashing techniques to client and family.
C. Disinfecting blood pressure cuffs after clients are discharged.
D. Screening clients for upper respiratory tract symptoms.

Answers and Rationale

Here are the answers and rationale for the NCLEX quiz.

1. Answer: B. Administer varicella-zoster immune globulin to the client.

Varicella-zoster immune globulin administration can prevent the development of

chickenpox in high-risk clients and will typically be prescribed.

 Option A: Contact and airborne precautions will be implemented to prevent the

spread of infection to other children if the child develops varicella.

 Options C and D: Hospitalization and acyclovir therapy may be required if the

child develops a varicella-zoster virus infection.
2. Answer: C. Limit the use of IFC’s.

The most effective way to reduce the incidence of UTIs in the hospital setting is to
avoid using retention catheters.

 Options A, B, and D: These actions also reduce the risk for and/or detect UTI, but
avoidance of indwelling catheter will be more effective.
3. Answer: A. Obtain wound cultures during dressing changes.

LPN/LVN education and scope of practice include performing dressing changes and
obtaining specimens for wound culture.

 Options B, C, and D: Teaching, assessment, and planning of care are complex

actions that should be carried out by a licensed nurse.
4. Answer: B. The new RN places a child who has chemotherapy-induced
neutropenia into a negative-pressure room.
Clients who are neutropenic should be placed in positive-airflow rooms; placement
of the child in a negative airflow room will increase the likelihood of infection for
this client.

 Options A and D: The use of an N95 respirator is not necessary for pertussis, and
goggles are not needed for changing the linens of clients infected with C. difficile;
however, these protections do not increase the risk to the clients.

 Option C: Although private rooms are preferred for clients who need droplet
precautions, such as client with RSV infection, they can be placed in rooms with
other clients who are infected with the same microorganism.
5. Answer: A. Ask the client about any recent travel to Asia or the Middle East.

The client’s clinical manifestation suggest possible avian influenza  (bird flu). If the
client has traveled recently in Asia or the Middle East, where outbreaks of bird flu
have occurred, you will need to institute airborne and contact precautions
immediately.

 Options B, C, and D: The other actions may also be appropriate but are not the
initial action to take for this client, who may transmit the infection to other clients
or staff members.
6. Answer: A. Place the client on contact and airborne precautions.

Since SARS is a severe disease with a high mortality rate, the initial action should be
to protect other clients and health care workers by placing the client in isolation. If
an airborne-agent isolation (negative pressure) room is not available in the ED,
droplet precautions should be initiated until the client can be moved to a negative-
pressure room.

 Options B, C, and D: The other options should also be taken rapidly but are not
as important as preventing transmission of the disease.
7. Answer: D. A client with a cough who may have Koch disease.

Clients with infections that require airborne precautions (such as TB) need to be in
private rooms.

 Option A: Standard precautions are required for the client with toxic shock
syndrome.
  Options B and C: Clients with infections that require contact precautions (such as
C.difficile and VRE infections) should ideally be placed in private rooms; however,
they can be placed in rooms with other clients with the same diagnosis.
8. Answer: D. A client who has nontunneled central line in the left internal
jugular vein.

Several factors increase the risk for infection for this client: central lines are
associated with a higher infection risk, the skin of the neck and chest having a high
number of microorganisms, and the line is tunneled.

 Options A and B: Peripherally inserted IV lines such as midline catheters and PICC
line are associated with a lower incidence of infection.

 Option C: Implanted ports are placed under the skin and so are less likely to be
associated with catheter infection than a nontunneled central IV line.
9. Answer: B. Administering the ordered metronidazole (Flagyl) 500 mg PO to
the client.

LPN/LVN education and scope of practice and education include the administration
of medications.

 Options A, C, and D: Assessment of hydration status, client and family education,

and assessment of risk factors for diarrhea should be done by a licensed nurse.
10. Answer: A. Ensure that students are immunized according to national
guidelines.

The incidence of once common infectious diseases such as measles, chickenpox,

and mumps has been most effectively reduced by immunization of all school-aged
children.

 Options B, C, and D: The other options are also helpful but will not have as great
as an impact as immunization.
11. Answer: C. Provide oxygen using a non-rebreather mask.

Because the respiratory manifestations associated with avian influenza are

potentially life-threatening, the nurse’s initial action should be to start oxygen
therapy.
  Options A, B, and D: The other interventions should be implemented after
addressing the client’s respiratory problem.
12. Answer: A. Place the client on contact precaution.

The client’s age, history of antibiotic therapy, and watery stools suggest that he may
have Clostridium difficile infection. The initial action should be able to place him on
contact precautions to prevent the spread of C. difficile to other clients.

 Options B, C, and D: The other actions are also needed and should be taken after
placing the client on contact precautions.
13. Answer: D. Appropriate antibiotics have been given for 24 hours.

Current CDC evidenced-based guidelines indicate that droplet precautions for

clients with meningococcal meningitis can be discontinued when the client has
received antibiotic therapy for 24 hours.

 Options A, B, and C: The other information may indicate that the client’s
condition is improving but does not indicate that droplet precaution should be
discontinued.
14. Answer: D. No negative-airflow rooms are available on the unit.

Because clients with rubeola require implementation of airborne precautions,

which include placement in a negative airflow room, this child cannot be admitted
to the pediatric unit.

 Options A, B, and C: The other circumstances may require actions such as staff
reassignments but would not prevent the admission of a client with rubeola.
15. Answer: A. Escort the client to a decontamination room.

To prevent contamination of staff or other clients by anthrax, decontamination of

the client by removal and disposal of clothing and showering is the initial action in
possible anthrax exposure.

 Option B:  Assessment of the client for signs of infection should be before

decontamination.

 Option C: Notification of security personnel is necessary in the case of possible

bioterrorism, but this should occur before decontaminating and caring for the
client.
  Option D: According to the CDC guidelines, antibiotics should be administered
only if there are signs of infection or the contaminating substance tests positive
for anthrax.
16. Answer: B. Gown. C. Gloves. E. N95 respirator.

Because herpes zoster is spread through airborne means and by direct contact with
the lesions, you should wear an N95 respirator or high-efficiency particulate air
filter respirator, a gown, and gloves.

 Options A and D: Goggles and shoe covers are not needed for airborne or
contact precautions.

 Option F: Surgical face mask filters only large particles and will not provide
protection from herpes zoster.
17. Answer: C. Ensure that dispensers for alcohol-based hand rubs are readily
available in all client care areas of the hospital.

Because the hands of health care workers are the most common means of
transmission of infection from one client to another, the most effective method of
preventing the spread of infection is to make supplies for hand hygiene readily
available for staff to use.

 Option A: Although some hospitals have started screening newly admitted clients
for MRSA, there is no evidence that this decreases the spread of infection.

 Option B: Because administration of antibiotics to individuals who are colonized

by bacteria may promote the development of antibiotic resistance, antibiotic use
should be restricted to clients who have clinical manifestations of infection.

 Option D: Wearing a gown to care for clients who are not on contact precautions
is not necessary.
18. Answer: A. 5, 4, 1, 2, 3

The sequence will prevent contact of the contaminated gloves and gowns with
areas (such as your hair) that cannot be easily cleaned after client contact and stop
transmission of microorganisms to you and your other clients.

19. Answer: A. Gloves. E. Gown.

A gown and gloves should be used when coming in contact with linens that may be
decontaminated by the client’s wound secretions.
  Options B, C, and D: The other items are not necessary because transmission by
splashes, droplets, or airborne means will not occur when the bed is changed.
20. Answer: A. Posting the precautions for protective isolation o the door of
the client’s room;
B. Stocking the client’s room with the needed PPE items; D. Reminding visitors
to wear a respirator mask, gloves, and gown.

Because all staff who care for clients should be familiar with the various type of
isolation, the nursing assistant will be able to stock the room and post the
precautions on the client’s door. Reminding visitors about previously taught
information is a task that can be done by the nursing assistant, although the RN is
responsible for the initial teaching.

 Options C and E: Client teaching and discussion of the reason for protective
isolation fall within the RN-level scope of practice.
21. Answer: C. Droplet.

Tonsillitis is contagious and is spread by droplet transmission.

22. Answer: C. Must maintain a spatial distance of 3 feet.

The most common forms of transmission of an organism in a client with tonsillitis

are through coughing, sneezing, and talking. Droplets can travel no more than 3ft
so precautions should be maintained when there is a possibility of entering this
distance.

 Option A: Client requires a private room.

 Option B: An N95 mask is not required for this client. A face mask instead can be
used when dealing with the client.

 Option D: Gloves, gowns, face mask and eye protection should be worn in giving

direct care.
23. Answer: C. A pregnant woman with a blister-like rash on the face and is
possibly having varicella.

Chickenpox (Varicella) is transmitted by airborne and that can be easily transferred

to the other clients in the emergency unit. The pregnant woman with the rash
should be isolated right away from other clients through placement in a negative-
pressure room.
  Option A: The client who has been exposed to TB does not place the other clients
at risk for infection because there are no symptoms of active TB.

 Options B and D: Droplet and contact precautions should be instituted for the
clients with pertussis and MRSA infection, but this can be done after isolating the
client with possible varicella.
24. Answer: A. Implement contact precautions when handling the client.

All hospital personnel who care for the client are responsible for correct
implementation of contact precautions.

 Options B, C, and D: The other options should be carried out by a licensed nurse.
25. Answer: C. Disinfecting blood pressure cuffs after clients are discharged.

Nursing assistants can follow agency protocol to disinfect items that come in
contact wth intact skin by cleaning with chemicals such as alcohol.

 Options A, B, and D: The other options should be carried out by a licensed nurse.
Take the Disease Prevention Test
You can do a lot to keep yourself healthy. Staying away from germs, eating a balanced diet, getting enough
rest—all these steps and others can put you on the road to good health. How much do you know about
preventing disease? Take this quiz and find out.

1. How are infectious diseases, such as colds and influenza, most commonly spread?

 A. Breathing viruses in air  B. Hand-to-face contact  C. Drinking infected water  D. Eating

contaminated food

2. Which is the most important hygiene habit to teach young children?

 A. Use a tissue to cover a sneeze  B. Don't share a glass or eating utensil  C. Wash hands
frequently  D. Take a bath daily

3. Chronic stress has been linked to which of these health problems?

 A. Headaches  B. Constipation  C. Depression  D. All of the above

4. Which of the following increases your risk for type 2 diabetes?

 A. Not getting enough exercise  B. Eating too much sugar  C. Being overweight  
D. Advancing age  E. A and C

5. Which of these things can reduce the risk of getting genital herpes or other communicable sexual
diseases?

 A. Male latex condom  B. Female condom  C. Contraceptive foam  D. Birth control pills

6. According to the CDC, when should infants start vaccines against serious diseases?

 A. Birth  B. 2 months old  C. 6 weeks old  D. 6 months old

7. "Sleep hygiene" refers to the promotion of regular sleep. Which of these can help you develop healthy
sleep habits?

 A. Eat a big meal late in the day  B. Go to bed and get up at the same time every day  C. Cut
back on the amount of exercise you get  D. All of the above
Text Mode – Text version of the exam
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 saline irrigant,
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. 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.
16. 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.
17. 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.
18. 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.
19. 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?
20. 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.
21. The parents of a child, age 6, who will begin school in the fall ask the nurse
for anticipatory guidance. The nurse should explain that a child of this age:

A. Still depends on the parents

B. Rebels against scheduled activities
C. Is highly sensitive to criticism
D. Loves to tattle
22. While preparing to discharge an 8-month-old infant who is recovering from
gastroenteritis and dehydration, the nurse teaches the parents about their
infant’s dietary and fluid requirements. The nurse should include which other
topic in the teaching session?

A. Nursery schools
B.  Toilet Training
C.  Safety guidelines
D. Preparation for surgery
23. Nurse Betina should begin screening for lead poisoning when a child
reaches which age?

A. 6 months
B. 12 months
C. 18 months
D. 24 months
24. When caring for an 11-month-old infant with dehydration and metabolic
acidosis, the nurse expects to see which of the following?

A. A reduced white blood cell count

B. A decreased platelet count
C. Shallow respirations
D. Tachypnea
25. After the nurse provides dietary restrictions to the parents of a child with
celiac disease, which statement by the parents indicates effective teaching?

A. “Well follow these instructions until our child’s symptoms disappear.”

B. “Our child must maintain these dietary restrictions until adulthood.”
C. “Our child must maintain these dietary restrictions lifelong.”
D. “We’ll follow these instructions until our child has completely grown and
developed.”
26. A parent brings a toddler, age 19 months, to the clinic for a regular check-
up. When palpating the toddler’s fontanels, what should the nurse expects to
find?

A. Closed anterior fontanel and open posterior fontanel

B. Open anterior and fontanel and closed posterior fontanel
C. Closed anterior and posterior fontanels
D. Open anterior and posterior fontanels
27. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral
fluids. The nurse should monitor this client’s fluid intake because fluid
overload may cause:

A. Cerebral edema
B. Dehydration
C. Heart failure
D. Hypovolemic shock
28. An infant is hospitalized for treatment of nonorganic failure to thrive.
Which nursing action is most appropriate for this infant?

A. Encouraging the infant to hold a bottle

B. Keeping the infant on bed rest to conserve energy
C. Rotating caregivers to provide more stimulation
D. Maintaining a consistent, structured environment
29. The mother of Gian, a preschooler with spina bifida tells the nurse that her
daughter sneezes and gets a rash when playing with brightly colored balloons,
and that she recently had an allergic reaction after eating kiwifruit and
bananas. The nurse would suspect that the child may have an allergy to:

A. Bananas
B. Latex
C. Kiwifruit
D. Color dyes
30. Cristina, a mother of a 4-year-old child tells the nurse that her child is a
very poor eater. What’s the nurse’s best recommendation for helping the
mother increase her child’s nutritional intake?

A. Allow the child to feed herself

B. Use specially designed dishes for children – for example, a plate with the
child’s favorite cartoon character
C. Only serve the child’s favorite foods
D. Allow the child to eat at a small table and chair by herself
31. Nurse Roy is administering total parental nutrition (TPN) through a
peripheral I.V. line to a school-age child. What’s the smallest amount of
glucose that’s considered safe and not caustic to small veins, while also
providing adequate TPN?

A. 5% glucose
 B. 10% glucose
C. 15% glucose
D. 17% glucose
32. David, age 15 months, is recovering from surgery to remove Wilms’ tumor.
Which findings best indicates that the child is free from pain?

A. Decreased appetite
B. Increased heart rate
C. Decreased urine output
D. Increased interest in play
33. When planning care for a 8-year-old boy with Down syndrome, the nurse
should:

A. Plan interventions according to the developmental level of a 7-year-old child

because that’s the child’s age
B. Plan interventions according to the developmental levels of a 5-year-old
because the child will have developmental delays
C. Assess the child’s current developmental level and plan care accordingly
D. Direct all teaching to the parents because the child can’t understand
34. Nurse Vincent is teaching the parents of a school-age child. Which
teaching topic should take priority?

A. Prevent accidents
B. Keeping a night light on to allay fears
C. Explaining normalcy of fears about body integrity
D. Encouraging the child to dress without help
35. The nurse is finishing her shift on the pediatric unit. Because her shift is
ending, which intervention takes top priority?

A. Changing the linens on the clients’ beds

B. Restocking the bedside supplies needed for a dressing change on the upcoming
shift
C. Documenting the care provided during her shift
D. Emptying the trash cans in the assigned client room
36. Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child,
age 4. the nurse should:

A. Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm)

B. Deliver 12 breaths/minute
C. Perform only two-person CPR
 D. Use the heel of one hand for sternal compressions
37. A 4-month-old with meningococcal meningitis has just been admitted to
the pediatric unit. Which nursing intervention has the highest priority?

A. Instituting droplet precautions

B. Administering acetaminophen (Tylenol)
C. Obtaining history information from the parents
D. Orienting the parents to the pediatric unit
38. Shane tells the nurse that she wants to begin toilet training her 22-month-
old child. The most important factor for the nurse to stress to the mother is:

A. Developmental readiness of the child

B. Consistency in approach
C. The mother’s positive attitude
D. Developmental level of the child’s peers
39. An infant who has been in foster care since birth requires a blood
transfusion. Who is authorized to give written, informed consent for the
procedure?

A. The foster mother

B. The social worker who placed the infant in the foster home
C. The registered nurse caring for the infant
D. The nurse-manager
40. 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
41. A 10-year-old client contracted severe acute respiratory syndrome (SARS)
when traveling abroad with her parents. The nurse knows she must put on
personal protective equipment to protect herself while providing care. Based
on the mode of SARS transmission, which personal protective should the
nurse wear?

A. Gloves
B. Gown and gloves
 C. Gown, gloves, and mask
D. Gown, gloves, mask, and eye goggles or eye shield
42. A tuberculosis intradermal skin test to detect tuberculosis infection is
given to a high-risk adolescent. How long after the test is administered should
the result be evaluated?

A. Immediately
B. Within 24 hours
C. In 48 to 72 hours
D. After 5 days
43. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding
after 5 months. The nurse should advise her to include which foods in her
infant’s diet?

A. Iron-rich formula and baby food

B. Whole milk and baby food
C. Skim milk and baby food
D. Iron-rich formula only
44. Gracie, the mother of a 3-month-old infant calls the clinic and states that
her child has a diaper rash. What should the nurse advice?

A. “Switch to cloth diapers until the rash is gone”

B. “Use baby wipes with each diaper change.”
C. “Leave the diaper off while the infant sleeps.”
D. “Offer extra fluids to the infant until the rash improves.”
45. Nurse Kelly is teaching the parents of a young child how to handle
poisoning. If the child ingests poison, what should the parents do first?

A. Administer ipecac syrup

B. Call an ambulance immediately
C. Call the poison control center
D. Punish the child for being bad
46. A child has third-degree burns of the hands, face, and chest. Which
nursing diagnosis takes priority?

A. Ineffective airway clearance related to edema

B. Disturbed body image related to physical appearance
C. Impaired urinary elimination related to fluid loss
D. Risk for infection related to epidermal disruption
47. A 3-year-old child is receiving dextrose 5% in water and half-normal saline
solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid
intake?

A. Worsening dyspnea
B. Gastric distension
C. Nausea and vomiting
D. Temperature of 102°F (38.9° C)
48. Which finding would alert a nurse that a hospitalized 6-year-old child is at
risk for a severe asthma exacerbation?

A. Oxygen saturation of 95%

B. Mild work of breathing
C. Absence of intercostals or substernal retractions
D. History of steroid-dependent asthma
49. Nurse Mariane is caring for an infant with spina bifida. Which technique is
most important in recognizing possible hydrocephalus?

A. Measuring head circumference

B. Obtaining skull X-ray
C. Performing a lumbar puncture
D. Magnetic resonance imaging (MRI)
50. An adolescent who sustained a tibia fracture in a motor vehicle accident
has a cast. What should the nurse do to help relieve the itching?

A. Apply cool air under the cast with a blow-dryer

B. Use sterile applicators to scratch the itch
C. Apply cool water under the cast
D. Apply hydrocortisone cream under the cast using sterile applicator.
Answers and Rationales
1. Answer C. 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 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. 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 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. 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.  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. 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. 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. 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. 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. 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. 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.  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. 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, nonintact 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 B. 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, nonintact 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.
16. Answer C. 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 mucus 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.
17. Answer A. 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.
18. Answer A. The AIDS virus 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 AIDS. 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 AIDS. There is no need to limit casual contact with children.
19. Answer D. 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.
20. Answer C. 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.
21. Answer C.In a 6-year-old child, a precarious sense of self causes overreaction
to criticism and a sense of inferiority. By age 6, most children no longer depend
on the parents for daily tasks and love the routine of a schedule. Tattling is more
common at age 4 to 5, by age 6, the child wants to make friends and be a friend.
22. Answer C. The nurse always should reinforce safety guidelines when teaching
parents how to care for their child. By giving anticipatory guidance the nurse can
help prevent many accidental injuries. For parents of a 9-month-old infant, it is
too early to discuss nursery schools or toilet training. Because surgery is not used
gastroenteritis, this topic is inappropriate.
23. Answer C. The nurse should start screening a child for lead poisoning at age 18
months and perform repeat screening at age 24, 30, and 36 months. High-risk
infants, such as premature infants and formula-fed infants not receiving iron
supplementation, should be screened for iron-deficiency anemia at 6 months.
Regular dental visits should begin at age 24 months.
24. Answer D. The body compensates for metabolic acidosis via the respiratory
system, which tries to eliminate the buffered acids by increasing alveolar
ventilation through deep, rapid respirations, altered white blood cell or platelet
counts are not specific signs of metabolic imbalance.
25. Answer C. A patient with celiac disease must maintain dietary restrictions
lifelong to avoid recurrence of clinical manifestations of the disease. The other
options are incorrect because signs and symptoms will reappear if the patient eats
prohibited foods.
26. Answer C. By age 18 months, the anterior and posterior fontanels should be
closed. The diamond-shaped anterior fontanel normally closes between ages 9 and
 18 months. The triangular posterior fontanel normally closes between ages 2 and
3 months.
27. Answer A. Because of the inflammation of the meninges, the client is
vulnerable to developing cerebral edema and increase intracranial pressure. Fluid
overload won’t cause dehydration. It would be unusual for an adolescent to
develop heart failure unless the overhydration is extreme. Hypovolemic shock
would occur with an extreme loss of fluid of blood.
28. Answer D. The nurse caring for an infant with nonorganic failure to thrive
should maintain a consistent, structured environment that provides interaction
with the infant to promote growth and development. Encouraging the infant to
hold a bottle would reinforce an uncaring feeding environment. The infant should
receive social stimulation rather than be confined to bed rest. The number of
caregivers should be minimized to promote consistency of care.
29. Answer B. Children with spina bifida often develop an allergy to latex and
shouldn’t be exposed to it. If a child is sensitive to bananas, kiwifruit, and
chestnuts, then she’s likely to be allergic to latex. Some children are allergic to
dyes in foods and other products but dyes aren’t a factor in a latex allergy.
30. Answer A. The best recommendation is to allow the child to feed herself
because the child’s stage of development is the preschool period of initiative.
Special dishes would enhance the primary recommendation. The child should be
offered new foods and choices, not just served her favorite foods. Using a small
table and chair would also enhance the primary recommendation.
31. Answer B. The amount of glucose that’s considered safe for peripheral veins
while still providing adequate parenteral nutrition is 10%. Five percent glucose
isn’t sufficient nutritional replacement, although it’s sake for peripheral veins.
Any amount above 10% must be administered via central venous access.
32. Answer D. One of the most valuable clues to pain is a behavior change: A child
who’s pain-free likes to play. A child in pain is less likely to consume food or
fluids. An increased heart rate may indicate increased pain; decreased urine
output may signify dehydration.
33. Answer C. Nursing care plan should be planned according to the developmental
age of a child with Down syndrome, not the chronological age. Because children
with Down syndrome can vary from mildly to severely mentally challenged, each
child should be individually assessed. A child with Down syndrome is capable of
learning, especially a child with mild limitations.
34. Answer A. Accidents are the major cause of death and disability during the
school-age years. Therefore, accident prevention should take priority when
teaching parents of school-age children. Preschool (not school-age) children are
afraid of the dark, have fears concerning body integrity, and should be
encouraged to dress without help (with the exception of tying shoes).
35. Answer C. Documentation should take top priority. Documentation is the only
way the nurse can legally claim that interventions were performed. The other
three options would be appreciated by the nurses on the oncoming shift but aren’t
mandatory and don’t take priority over documentation.
36. Answer D. The nurse should use the heel of one hand and compress 1” to 1½ “.
The nurse should use the heels of both hands clasped together and compress the
sternum 1½ “to 2” for an adult. For a small child, two-person rescue may be
inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of
12.
37. Answer A. Instituting droplet precautions is a priority for a newly admitted
infant with meningococcal meningitis. Acetaminophen may be prescribed but
administering it doesn’t take priority over instituting droplet precautions.
Obtaining history information and orienting the parents to the unit don’t take
priority.
38. Answer A. If the child isn’t developmentally ready, child and parent will
become frustrated. Consistency is important once toilet training has already
started. The mother’s positive attitude is important when the child is ready.
Developmental levels of children are individualized and comparison to peers isn’t
useful.
39. Answer A. When children are minors and aren’t emancipated, their parents or
designated legal guardians are responsible for providing consent for medical
procedures. Therefore, the foster mother is authorized to give consent for the
blood transfusion. The social workers, the nurse, and the nurse-manager have no
legal rights to give consent in this scenario.
40. Answer A. 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.
41. Answer D. The transmission of SARS isn’t fully understood. Therefore, all
modes of transmission must be considered possible, including airborne, droplet,
and direct contact with the virus. For protection from contracting SARS, any
health care worker providing care for a client with SARS should wear a gown,
gloves, mask, and eye goggles or an eye shield.
42. Answer C. Tuberculin skin tests of delayed hypersensitivity. If the test results
are positive, a reaction should appear in 48 to 72 hours. Immediately after the test
and within 24 hours are both too soon to observe a reaction. Waiting more than 5
days to evaluate the test is too long because any reaction may no longer be
visible.
43. Answer D. The American Academy of Pediatrics recommends that infants at
age 5 months receive iron-rich formula and that they shouldn’t receive solid food
 – even baby food – until age 6 months. The Academy doesn’t recommend whole
milk until age 12 months, and skim milk until after age 2 years.
44. Answer C. Leaving the diaper off while the infant sleeps helps to promote air
circulation to the area, improving the condition. Switching to cloth diapers isn’t
necessary; in fact, that may make the rash worse. Baby wipes contain alcohol,
which may worsen the condition. Extra fluids won’t make the rash better.
45. Answer C. Before interviewing in any way, the parents should call the poison
control center for specific directions. Ipecac syrup is no longer recommended.
The parents may have to call an ambulance after calling the poison control center.
Punishment for being bad isn’t appropriate because the parents are responsible for
making the environment safe.
46. Answer A. Initially, when a preschool client is admitted to the hospital for
burns, the primary focus is on assessing and managing an effective airway. Body
image disturbance, impaired urinary elimination, and infection are all integral
parts of burn management but aren’t the first priority.
47. Answer A. Dyspnea and other signs of respiratory distress signify fluid volume
excess (overload), which can occur quickly in a child as fluid shifts rapidly
between the intracellular and extracellular compartments. Gastric distention may
suggest excessive oral fluid intake or infection. Nausea and vomiting or an
elevated temperature may indicate a fluid volume deficit.
48. Answer D. A history of steroid-dependent asthma, a contributing factor to this
client’s high-risk status, requires the nurse to treat the situation as a severe
exacerbation regardless of the severity of the current episode. An oxygen
saturation of 95%, mild work of breathing, and absence of intercostals or
substernal retractions are all normal findings.
49. Answer A. Measuring head circumference is the most important assessment
technique for recognizing possible hydrocephalus, and is a key part of routine
infant screening. Skull X-rays and MRI may be used to confirm the diagnosis. A
lumbar puncture isn’t appropriate.
50. Answer A. Itching underneath a cast can be relieved by directing blow-dryer,
set, on the cool setting, toward the itchy area. Skin breakdown can occur if
anything is placed under the cast. Therefore, the client should be cautioned not to
put any object down the cast in an attempt to scratch.
 Isolation Precautions NCLEX Practice Questions
This quiz will test your knowledge on infection control for isolation precautions in preparation
for the NCLEX exam.

 1. Select ALL the patients that would be placed in droplet precautions:*

o  A. A 5 year old patient with Chicken Pox.

o  B. A 36 year old patient with Pertussis.

o  C. A 25 year old patient with Scarlet Fever.

o  D. A 56 year old patient with Tuberculosis.

o  E. A 69 year old patient with Streptococcal Pharyngitis.

o  F. A 89 year old patient with C. Diff.

 2. A patient with Disseminated Herpes Zoster requires routine tracheostomy suction.

Select the appropriate PPE you will wear:*

o A. Surgical mask, goggles, gown

o B. N95 mask, face shield, gown, gloves

o C. N95 mask, gown, face shield

o D. Surgical mask, face shield, gown, gloves

 3. A 6 year old female is diagnosed with Varicella. What type of isolation precautions will
be initiated for this patient?*

o A. Droplet

o B. Airborne

o C. Airborne and Contact

o D. Droplet and Contact

 4. You're patient is being transported to special procedures for a PICC line placement.
The patient is in droplet precautions. What are your nursing actions to ensure proper transport
of the patient?*

o A. Notify the receiving department and place a surgical mask on the patient.

o B. Place an N95 mask on the patient and notify the receiving department.

o C. Cancel transport and notify the physician for further orders.

o D. Notify the receiving department and place goggles, gown, and mask on the
patient.

 5. Select ALL the conditions that warrant airborne precautions:*

o  A. Noravirus

o  B. Hepatitis A

o  C. Measles

o  D. Varicella

o  E. Disseminated Varicella Zoster

o  F. Tuberculosis

o  G. Whooping Cough

o  H. RSV

o  I. Epiglottitis

 6. A patient is diagnosed with Hepatitis A and is incontinent of stool. What type of

precautions would be initiated?*

o A. Contact

o B. Standard

o C. Droplet
o D. Contact and Droplet

 7. You'rer providing care to a patient with C. Diff. After removing the appropriate PPE,
you would perform hand hygiene by:*

o A. Using hand sanitizer

o B. Using soap and water

o C. Using soap and water only if hands are soiled but can use hand sanitizer

o D. Using either hand sanitizer or soap and water

 8. Which of the following patients would be in contact precautions? Select-all-that-

apply:*

o  A. A 8 year old patient with lice.

o  B. A 85 year old patient with CRE (Klebisella Pneumoniae).

o  C. A 65 year old patient with Noravirus.

o  D. A 75 year old patient with Disseminated Herpes Zoster.

o  E. A 12 year old patient with impetigo.

o  F. A 9 year old with RSV.

 9. You’re providing an in-service on transmission-based precautions to a group of nursing

students. Which statement made by a student warrants re-education about the topic?*

o A. “I will make sure that any patient who is in droplet precaution wears a
surgical mask when being transported.”

o B. “Patients with airborne diseases such as Meningitis require a special room

with negative air pressure.” (droplet precaution)

o C. “I will always wear a gown and gloves when entering a room of a patient in
contact precautions.”

o D. “If I provide care to patients with C. Diff, Noravirus, and Rotavirus

infections, I will always wash my hands with soap and water, not hand sanitizer.”
 10. Your patient in droplet precautions has family visiting. A family member asks how far
they should stand away from the patient while visiting. Your response is:*

o A. 2 feet or more

o B. 3 feet or more

o C. Stand at the doorway

o D. 6 feet or more

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