1.

Question
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. Is highly sensitive to criticism

 B. Rebels against scheduled activities
 C. Still depends on the parents
 D. Loves to tattle

Correct Answer: A. Is highly sensitive to criticism

Option A: Anticipatory guidance is provided by a health care professional to a
parent/caregiver in providing an understanding of a child’s development and
anticipating their growing needs. In a 6-year-old child, a precarious sense of self causes
an overreaction to criticism and a sense of inferiority.
Options B and C: By age 6, most children no longer depend on the parents for daily
tasks and love the routine of a schedule.
Option D: Tattling is more common at age 4 to 5, by age 6, the child wants to make
friends and be a friend.
2. Question
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 topics in the teaching session?

 A. Safety guidelines

 B. Preparation for surgery
 C. Toilet Training
 D. Nursery schools

Correct Answer: A. Safety guidelines

Option A: 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
various accidental injuries.
Option B: Because surgery is not a treatment for gastroenteritis, this topic is
inappropriate.
Options C and D: For parents of a 9-month-old infant, it is too early to discuss nursery
schools or toilet training.
3. Question
Nurse Betina should begin screening for lead poisoning when a child reaches which age?

 A. 3 months
 B. 12 months
 C. 24 months
 D. 30 months

Correct Answer: B. 12 months

The nurse should start screening a child for lead poisoning at age 12 months and
perform repeat screening at age 24, 30, and 36 months.
Option A: 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.
Option C: Regular dental visits should begin at age 24 months.
4. Question
When caring for an 11-month-old infant with dehydration and metabolic acidosis, the
nurse expects to see which of the following?

 A. Tachypnea
 B. Shallow respirations
 C. A reduced white blood cell count
 D. A decreased platelet count

Correct Answer: A. Tachypnea

Option A: 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.
Option B: Initially the breathing is rapid, but as it worsens, it gradually becomes deep
and labored.
Options C and D: Altered white blood cell or platelet counts are not specific signs of
metabolic imbalance.
5. Question
After the nurse provides dietary restrictions to the parents of a child with celiac disease,
which statement by the parents indicates effective teaching?

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

Correct Answer: D. “Our child must maintain these dietary restrictions lifelong.”
Celiac disease is an autoimmune reaction to a protein called gluten. A patient with celiac
disease must maintain dietary restrictions lifelong to avoid the recurrence of clinical
manifestations of the disease. A gluten-free diet should be followed by avoiding barley,
rye, wheat, oats, and triticale.
Options A, B, and C: The other options are not correct because signs and symptoms
will reappear if the patient eats prohibited foods.
6. Question
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 expect to find?

 A. Open anterior and fontanel and closed posterior fontanel

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

Correct Answer: B. 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. Question
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. Dehydration
 B. Hypovolemic shock
 C. Cerebral edema
 D. Heart failure

Correct Answer: C. Cerebral edema

Option C: Due to the inflammation of the meninges, the client is vulnerable to
developing cerebral edema and increased intracranial pressure.
Option A: Fluid overload won’t cause dehydration.
Option B: Hypovolemic shock would occur with an extreme loss of fluid of blood.
 Option D: It would be unusual for an adolescent to develop heart failure unless the
overhydration is extreme.

8. Question
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

Correct Answer: D. Maintaining a consistent, structured environment

Nonorganic failure to thrive refers to decelerated or arrested physical growth and is
related to poor developmental and emotional functioning. The nurse caring for an infant
 with this condition should maintain a consistent, structured environment that provides
interaction with the infant to promote growth and development.
Option A: Encouraging the infant to hold a bottle would reinforce an uncaring feeding
environment.
Option B: The infant should receive social stimulation rather than be confined to bed
rest.
Option C: The number of caregivers should be minimized to promote consistency of
care.

9. Question
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. Color dyes
 C. Kiwifruit
 D. Latex
 Correct Answer: D. Latex
Although the exact cause of latex allergy in people with spina bifida is unknown, it is said
that continuous exposure to products containing rubber from diagnostic exams, multiple
surgeries, and bladder and bowel programs may contribute to it.
Options A and C: If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s
likely to be allergic to latex because these food items can trigger an allergic reaction.
Option B: Some children are allergic to dyes in foods and other products but dyes
aren’t a factor in a latex allergy.

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

 A. Use specially designed dishes for children – for example, a plate with the child’s
favorite cartoon character
 B. Allow the child to feed herself
 C. Only serve the child’s favorite foods
 D. Allow the child to eat at a small table and chair by herself
 Correct Answer: B. Allow the child to feed herself
Option B: The best recommendation is to allow the child to feed herself because the
child’s stage of development is the preschool period of initiative.
Option A: Special dishes would enhance the primary recommendation.
Option C: The child should be offered new foods and choices, not just served her
favorite foods.
Option D: Using a small table and chair would also enhance the primary
recommendation.

11. Question
Nurse Roy is administering total parenteral nutrition (TPN) through a peripheral I.V. line to
a school-age child. What is the smallest amount of glucose that is 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
 Correct Answer: B. 10% glucose
Option B: The amount of glucose that’s considered safe for peripheral veins while still
providing adequate parenteral nutrition is 10%.
Option A: 5% glucose isn’t sufficient nutritional replacement, although it’s sake for
peripheral veins.
Options C and D: Any amount above 10% must be administered via central venous
access.

12. Question
David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which
findings best indicate that the child is free from pain?

 A. Increased heart rate

 B. Decreased urine output
 C. Increased interest in play
 D. Decreased appetite
 Correct Answer: C. Increased interest in play
Option C: One of the most valuable clues to pain is a behavior change. A toddler who is
pain-free likes to play.
Options A and B: An increased heart rate may indicate increased pain; decreased urine
output may signify dehydration.
Option D: A child in pain is less likely to consume food or fluids.

13. Question
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

Correct Answer: C. Assess the child’s current developmental level and plan care
accordingly
The nursing care plan should be prepared 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. Question
Nurse Vincent is teaching the parents of a school-age child. Which teaching topic should
take priority?

 A. Explaining normalcy of fears about body integrity

 B. Keeping a night light on to allay fears
  C. Prevent accidents
 D. Encouraging the child to dress without help

Correct Answer: C. Prevent accidents

Option C: 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.
Options A, B, and D: 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. Question
The nurse is finishing her shift in the pediatric unit. Because her shift is ending, which
intervention takes top priority?

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

Correct Answer: B. Documenting the care provided during her shift

Option B: Documentation should take top priority. Documentation is the only way the
nurse can legally claim that interventions were performed.
Options A, C, and D: 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. Question
Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse
should:
  A. Perform only two-person CPR
 B. Deliver 12 breaths/minute
 C. Place two fingers on the sternum, press down about 1.5 inches deep
 D. Use the heel of one hand for sternal compressions at least 2 inches deep

Correct Answer: D. Use the heel of one hand for sternal compressions at least 2
inches deep
Option D: The nurse should use the heel of one hand at the center of the chest, then
place the heel of the other hand on top of the first hand and lace fingers together and
give 30 compressions that are about 2 inches deep.
Option A: For a small child, a two-person rescue may be inappropriate.
Option B: For a child, the nurse should deliver 20 breaths/minute instead of 12.
Option C: The nurse uses 2 fingers to give 30 quick compressions that are each about
1.5 inches deep appropriate for infants.

17. Question
A 4-month-old with meningococcal meningitis has just been admitted to the pediatric
unit. Which nursing intervention has the highest priority?
  A. Obtaining history information from the parents
 B. Administering acetaminophen (Tylenol)
 C. Instituting droplet precautions
 D. Orienting the parents to the pediatric unit

Correct Answer: C. Instituting droplet precautions

Option C: Institute droplet precautions by providing a private room and wearing a
mask, gloves, and gown for all those who will interact with the child is a priority for a
newly admitted patient with meningococcal meningitis until an appropriate antibiotic
regimen has been given for 24 hours.
Options A and D: Obtaining history information and orienting the parents to the unit
don’t take priority.
Option B: Acetaminophen may be prescribed but administering it doesn’t take priority
over instituting droplet precautions.

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

Correct Answer: D. Developmental readiness of the child

If the child isn’t developmentally ready, the child and parent will become frustrated. Signs
of potty training readiness include pulling at a wet or dirty diaper, awakening dry from a
nap, hiding to go or going to an area to pee or poop, and having predictable bowel
movements.
Option A: Developmental levels of children are individualized and comparison to peers
isn’t useful.
Option B: Consistency is important once toilet training has already started.
Option C: The mother’s positive attitude is important when the child is ready.

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

Correct Answer: D. The foster mother

Option D: 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.
Options A, B, and C: The social workers, the nurse, and the nurse-manager have no
legal rights to give consent in this scenario.

20. Question
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 uric acid from precipitating in the ureters

 B. Enhance the production of uric acid to ensure adequate excretion of urine
 C. Prevent metabolic breakdown of xanthine to uric acid
 D. Ensure that the chemotherapy doesn’t adversely affect the bone marrow

Correct Answer: C. Prevent metabolic breakdown of xanthine to uric acid

Option C: 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.
Options A, B, and D: Allopurinol doesn’t act in the manner described in the other
options.
21. Question
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 equipment 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

Correct 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. Question
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

Correct Answer: C. In 48 to 72 hours

Option C: Tuberculin skin tests of delayed hypersensitivity. If the test results are
positive, a reaction should appear in 48 to 72 hours.
Options A and B: Immediately after the test and within 24 hours are both too soon to
observe a reaction.
Option D: Waiting more than 5 days to evaluate the test is too long because any
reaction may no longer be visible.
23. Question
Nurse Oliver is 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. Whole milk and baby food

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

Correct Answer: B. Iron-rich formula only

Option B: 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.
Options A and C: The Academy doesn’t recommend whole milk until age 12 months,
and skim milk until after age 2 years.
Option D: A child can start eating solid foods at about 6 months old. First foods that
need to be introduced should be soft and easy to swallow such as mashed vegetables or
porridge.
24. Question
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 advise?

 A. “Leave the diaper off while the infant sleeps.”

 B. “Use baby wipes with each diaper change.”
 C. “Switch to cloth diapers until the rash is gone”
 D. “Offer extra fluids to the infant until the rash improves.”

Correct Answer: A. “Leave the diaper off while the infant sleeps.”
Option A: Leaving the diaper off while the infant sleeps helps to promote air circulation
to the area, improving the condition.
Options B and D: Baby wipes contain alcohol, which may worsen the condition. Extra
fluids won’t make the rash better.
Option C: Switching to cloth diapers isn’t necessary; in fact, that may make the rash
worse.
25. Question
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. Call an ambulance immediately

 B. Administer ipecac syrup
 C. Punish the child for being bad
 D. Call the poison control center

Correct Answer: D. Call the poison control center

Option D: Before interviewing in any way, the parents should call the poison control
center for specific directions to avoid death or permanent disability associated with
ingestion of poisonous substances.
Option A: The parents may have to call an ambulance after calling the poison control
center.
Option B: Ipecac syrup is no longer used and recommended by the poison control
center.
Option C: Punishment for being bad isn’t appropriate because the parents are
responsible for making the environment safe.
1. Question
A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis
takes priority?

 A. Impaired urinary elimination related to fluid loss

 B. Ineffective airway clearance related to edema
 C. Disturbed body image related to physical appearance
 D. Risk for infection related to epidermal disruption

Correct Answer: B. Ineffective airway clearance related to edema

Option B: Initially, when a preschool client is admitted to the hospital for burns, the
primary focus is on assessing and managing an effective airway.
Options A, C, and D: Body image disturbance, impaired urinary elimination, and
infection are all integral parts of burn management but aren’t the first priority.
2. Question
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. Temperature of 102°F (38.9°C)

 B. Worsening dyspnea
 C. Gastric distension
 D. Nausea and vomiting

Correct Answer: B. Worsening dyspnea

Option B: 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.
 Options A and D: Nausea and vomiting or an elevated temperature may indicate a fluid
volume deficit.
Option C: Gastric distention may suggest excessive oral fluid intake or infection.

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

 A. Absence of intercostals or substernal retractions

 B. Oxygen saturation of 95%
 C. Mild work of breathing
 D. History of steroid-dependent asthma

Correct Answer: D. History of steroid-dependent asthma

 Option 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.
Options A, B, and C: An oxygen saturation of 95%, mild work of breathing, and absence
of intercostals or substernal retractions are all normal findings.

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

 A. Obtaining skull X-ray

 B. Measuring head circumference
 C. Performing a lumbar puncture
 D. Magnetic resonance imaging (MRI)
 Correct Answer: B. Measuring head circumference
Option B: Measuring head circumference is the most important assessment technique
for recognizing possible hydrocephalus, and is a key part of routine infant screening.
Options A and D: Skull X-rays and MRI may be used to confirm the diagnosis.
Option C: A lumbar puncture isn’t appropriate.

5. Question
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 hydrocortisone cream under the cast using sterile applicator
 B. Apply cool air under the cast with a blow-dryer
 C. Use sterile applicators to scratch the itch
 D. Apply cool water under the cast
 Correct Answer: B. Apply cool air under the cast with a blow-dryer
Option A: Itching underneath a cast can be relieved by directing the blow-dryer, set, on
the cool setting, toward the itchy area.
Options B, C, and D: 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.

6. Question
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. Assess vital signs

 B. Institute seizure precautions
 C. Assess neurologic status
  D. Place in respiratory isolation

Correct Answer: D. Place in respiratory isolation

Option D: 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.
Options A, B, and C: Assessment and instituting seizure precautions should be
performed after the patient is placed on respiratory isolation in order to avoid infecting
other patients.

7. Question
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. Contact isolation
 D. Standard precautions

Correct Answer: C. 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 continue 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.

8. Question
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. Mycoplasma pneumonia

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

Airborne precautions are applied to clients suspected or known to be infected with
microorganisms transmitted by airborne droplets. A 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.
Options A and C: Standard precaution (avoiding contact with blood, body fluids,
secretions, and excretions) is instituted with clients with AIDS, cytomegalovirus, viral
pneumonia.
Options D: Clients infected with mycoplasma pneumoniae can transmit the bacteria
through coughing and sneezing so a droplet and standard precaution is applied.

9. Question
Which of the following is the first priority in preventing infections when providing care for
a client?
  A. Wearing gowns and goggles
 B. Using a barrier between client’s furniture and nurse’s bag
 C. Handwashing
 D. Wearing gloves

Correct Answer: C. 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.
Options A, B, and D: These measures can help avoid the spread of infection but
handwashing will provide the best protection.

10. Question
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. Eating utensils

 B. Hands
 C. Milk products
 D. Droplet nuclei

Correct Answer: D. Droplet nuclei

Option D: 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.
Option B: Hands are the primary method of transmission of the common cold.
Option C: 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.
Option A: The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes
can be transmitted via reservoirs such as linens or eating utensils.
11. Question
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. Place a urine collection bag and specimen cup at the bedside
 B. Order a stat admission CBC
 C. Pad the side rails of his bed
 D. Place a cooling mattress on his bed

Correct Answer: C. Pad the side rails of his bed

Option C: The child has a diagnosis of febrile seizures. Precautions to prevent injury and
promote safety should take precedence.
Option A: Preparing for routine laboratory studies is not as high a priority as preventing
injury and promoting safety.
Option B: Preparing for routine laboratory studies is not as high a priority as preventing
injury and promoting safety.
Option D: 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.
12. Question
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. “I can expect occasional periods of low-grade fever and can take Tylenol every 4
hours.”
 C. “I must wear my Jobst elastic garment all day and can only remove it when I’m going
to bed.”
 D. “If any healed areas break open I should first cover them with a sterile dressing
and then report it.”

Correct Answer: D. “If any healed areas break open I should first cover them with a
sterile dressing and then report it.”
Option D: 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.
Option A: 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.
Option B: 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.
Option C: 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.
13. Question
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. Speak soothingly and provide quiet music

 B. Encourage family phone calls
 C. Limit visits by staff
 D. Position in a bright, busy area

Correct Answer: A. Speak soothingly and provide quiet music

Option A: 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.
Option B: 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.
Option C: The client needs frequent visits by the staff to orient him and to assess his
safety.
Option D: Putting the client in a bright, busy area would probably add to his confusion.
14. Question
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 understand it will be several weeks before all the radiation leaves my body.”
 C. “I told my daughter who is pregnant to either come to see me tonight or wait
until I go home from the hospital.”
 D. “I brought several craft projects to do while the radium is inserted.”

Correct Answer: C. “I told my daughter who is pregnant to either come to see me

tonight or wait until I go home from the hospital.”
Option C: 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.
Option A: The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not
allowed.
Option B: As soon as the radiation source is removed (probably 36 to 72 hours after insertion), the client is no
longer contaminated with radioactivity.
 Option D: 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.

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

Correct Answer: B. A nurse with open, weeping lesions of the hands puts on gloves
before giving direct client care.
Option B: 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 a mask, gown, and gloves.
 Option A: Having the client wear a mask when leaving his private room is appropriate.
Option 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.
Option D: A client with active tuberculosis should be on respiratory precautions.
16. Question
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. Discuss dressing change technique with the nurse at a later date.
 B. Congratulate the nurse on the use of good technique.
 C. Interrupt the procedure to inform the nurse of the need to wash her hands after
removal of the dirty dressing and gloves.
 D. Interrupt the procedure to inform the staff nurse that sterile gloves are not needed to
remove the old dressing.

Correct Answer: C. Interrupt the procedure to inform the nurse of the need to wash
her hands after removal of the dirty dressing and gloves.
 Option C: The staff nurse is doing two things [Link]. Non Sterile 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. Not doing this compromises client
safety and should be brought to the immediate attention of the nurse.
Options A, B, and D: Non Sterile 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.
17. Question
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

Correct Answer: A. Correct illumination of the environment

Option 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.
Option B: The amount of regular exercise is not the most important factor to assess. It
is only indirectly related.
 Options C and D: The resting pulse rate and salt intake are not related to preventing
falls.

18. Question
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.”

Correct Answer: C. “If I question the sterility of any dressing material, I should not
use it.”
 Option C: If there is ever any doubt about the sterility of an instrument or dressing, it
should not be used.
Option A: Anything dropped on the floor is no longer sterile and should not be used.
The statement indicates a lack of understanding.
Option B: The 4 X 4s should be soaked prior to donning the sterile gloves.
Option D: Once the sterile gloves touch the bottle of normal saline they are no longer
sterile. This statement indicates a need for further instruction.
19. Question
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. A private room is always indicated
 C. Isolation gowns are not needed
 D. Gloves should be worn for contact with non intact skin, mucous membranes, or
soiled items

Correct Answer: D. Gloves should be worn for contact with non intact skin, mucous
membranes, or soiled items.
 Option D: 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.
Option A: Masks should only be worn during procedures that are likely to cause
splashes of blood or body fluid.
Option B: A private room is only indicated if the client’s hygiene is poor.
Option C: Gowns should be worn during procedures that are likely to cause splashes of
blood or body fluids.
20. Question
The nurse is evaluating whether a nonprofessional staff understands how to prevent the
transmission of HIV. Which of the following behaviors indicates the correct application of
universal precautions?

 A. An aide wears gloves to feed a helpless client.

 B. A pregnant worker refuses to care for a client known to have AIDS.
 C. A lab technician rests his hand on the desk to steady it while recapping the needle
after drawing blood.
 D. An assistant puts on a mask and protective eyewear before assisting the nurse to
suction a tracheostomy.
Correct Answer: D. An assistant puts on a mask and protective eyewear before
assisting the nurse to suction a tracheostomy.
Option D: Masks and protective eyewear are indicated anytime there is great potential
for the 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.
Option A: 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.
Option B: There is no reason to restrict pregnant workers from caring for persons with
AIDS as long as they utilize universal precautions.
Option 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.
21. Question
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. Sharing pacifiers

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

Correct Answer: C. Bathing together.

 Option C: The mode of transmission of this bacteria is through direct contact with an
infected person through sharing objects or bathing together.
Options A, B, and D: Staph is not spread by coughing and through oral secretions.

22. Question
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 the 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.
 Correct Answer: A. Verbalizes the role of sexual activity in the spread of the disorder.
Option A: 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.
Option B: Unless the client is feeling very ill, there is no need for him to drop his college
classes.
Option C: 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.
Option D: There is no need to limit casual contact with children.

23. Question
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?

Correct Answer: D. How old were you when you became sexually active?
 Option D: The age at which sexual activity began is not relevant as it does not usually
provide information that identifies the presence of risk factors for AIDS.
Option A: Drug use is a risk factor for AIDS where people can get the disease by sharing
the needles or equipment with an infected individual.
Option B: Multiple sex partners is a risk factor for AIDS.
Option C: Birth control methods are important to prevent a baby from being born with
the AIDS virus.

24. Question
Mrs. Parker, a 70-year-old woman with severe macular degeneration, was admitted to the
hospital the day before a 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

Correct Answer: C. Maneuvering safely after orientation to the room.

Option C: 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.
Option A: Independently ambulating around the unit is not appropriate because the
unit environment can change and injury could result.
Option B: Assistance is necessary because of the client’s visual deficit. It is unlikely the
client can see well enough to read the materials.
Option D: Using the bedpan is an unnecessary restriction on the client as she can be
oriented to the bathroom or to call for assistance.

25. Question
Joseph is undergoing 24-hour ambulatory electrocardiography using a Holter monitor to
determine the cause of his frequent episodes of syncope. To prevent electric interruption
from the electrodes to the Holter monitor, Nurse Mike will instruct the client to avoid
which of the following?

 A. Drinking his favorite milkshake

 B. Wearing loose-fitting clothing
 C. Shaving with an electric razor
 D. Standing close to a refrigerator

Correct Answer: C. Shaving with an electric razor

Option C: The client should avoid contact with magnetic or electrical devices such as
magnets, metal detectors, high-voltage areas, and electric blankets where it can
interfere with the function of the monitor.
Options A, B, and D: These activities are not known to cause interruption with the
monitor.
1. Question
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. Administer varicella-zoster immune globulin to the client

 B. Educate the parent about the correct use of acyclovir (Zovirax)
  C. Prepare the client for admission to a private room in the hospital
 D. Teach the parents regarding contact and airborne precaution

Correct Answer: A. Administer varicella-zoster immune globulin to the client

Option A: Varicella-zoster immune globulin administration can prevent the
development of chickenpox in high-risk clients and will typically be prescribed.
Options B and C: Hospitalization and acyclovir therapy may be required if the child
develops a varicella-zoster virus infection.
Option D: Contact and airborne precautions will be implemented to prevent the spread
of infection to other children if the child develops varicella.

2. Question
Which action will you take to most effectively reduce the incidence of hospital-associated
urinary tract infections?

 A. Ensure that clients have enough adequate fluid intake

 B. Teach assistive personnel how to provide good perineal hygiene
  C. Perform dipstick urinalysis for clients with risk factors for UTI
 D. Limit the use of indwelling foley catheter (IFC)

Correct Answer: D. Limit the use of indwelling foley catheter (IFC)

Option D: The most effective way to reduce the incidence of UTIs in the hospital setting
is to avoid using retention catheters. Urinary catheters should only be used for
appropriate purposes and should be discontinued as soon as they are no longer
needed.
Options A, B, and C: These actions also reduce the risk for and/or detect UTI, but
avoidance of indwelling catheter will be more effective.

3. Question
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. Assess risk for further skin breakdown
 B. Plan ways to improve the client's oral protein intake
 C. Obtain wound cultures during dressing changes
 D. Educate the client about home care of the leg ulcer

Correct Answer: C. Obtain wound cultures during dressing changes.

Option C: LPN/LVN education and scope of practice include performing dressing
changes and obtaining specimens for wound culture.
Options A, B, and D: Teaching, assessment, and planning of care are complex actions
that should be carried out by a licensed nurse.

4. Question
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 wears goggles to change linens of a client who has diarrhea caused by C. difficile.

 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 tells the nursing assistant to use an N95 respirator mask when caring for a child who
has pertussis.

Correct Answer: B. The new RN places a child who has chemotherapy-induced

neutropenia into a negative-pressure room.
Option B: 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
clients with RSV infection, they can be placed in rooms with other clients who are infected with the
same microorganism.

5. Question
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. Screening clients for upper respiratory tract symptoms

 B. Call an ambulance to take the client immediately to the hospital
 C. Ask the client about any recent travel to Asia or the Middle East
 D. Determine whether the client has had recommended immunizations

Correct Answer: C. Ask the client about any recent travel to Asia or the Middle East.
Option C: The client’s clinical manifestation suggests 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 A, B, 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. Question
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. Obtain blood, urine, and sputum for cultures

 B. Infuse normal saline at 100ml/hr
 C. Administer methylprednisolone (Solu-Medrol) 1 gram/IV
 D. Place the client on contact and airborne precautions

Correct Answer: D. Place the client on contact and airborne precautions.

Option D: 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 A, B, & C: The other options should also be taken rapidly but are not as
important as preventing transmission of the disease.
7. Question
Four clients with infections arrive at the emergency department with some existing
infection, however, only one private room is available. Which of the following clients 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.

Correct Answer: D. A client with a cough who may have Koch disease.
Option D: 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
[Link] 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. Question
You are caring for four clients who are receiving IV infusions of normal saline. Which client
is at the highest risk for bloodstream infections?

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

Correct Answer: A. A client who has nontunneled central line in the left internal
jugular vein.
Option A: 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.
Option B: Implanted ports are placed under the skin and so are less likely to be
associated with catheter infection than a nontunneled central IV line.
Options C and D: Peripherally inserted IV lines such as midline catheters and PICC lines
are associated with a lower incidence of infection.
9. Question
A client who has frequent watery stools and a possible Clostridium difficile infection is
hospitalized with dehydration. Which nursing action should the charge nurse delegate to
an LPN/LVN?

 A. Assess the client's hydration status

 B. Explain the purpose of ordered stool cultures to the client and family
 C. Administer metronidazole (Flagyl) 500 mg PO as ordered to the client
 D. Review the client's medical history for any risk factors for diarrhea

Correct Answer: C. Administer metronidazole (Flagyl) 500 mg PO as ordered to the

client
Option C: LPN/LVN education and scope of practice and education include the
administration of medications.
Options A, B, 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. Question
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. Provide written information about infection control to all patients.

 B. Ensure that students are immunized according to national guidelines.
 C. Make soap and water readily available in the classrooms.
 D. Teach students how to cover their mouths when coughing.

Correct Answer: B. Ensure that students are immunized according to national

guidelines.
Option B: The incidence of common infectious diseases such as measles, chickenpox,
and mumps has been most effectively reduced by immunization of all school-aged
children. Through vaccination, children will develop immunity without experiencing the
diseases that vaccines prevent.
 Options A, C, and D: The other options are also helpful but will not have a great impact
as immunization.

11. Question
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. Provide oxygen using a non-rebreather mask

 B. Infuse 5% dextrose in water at 75ml/hr
 C. Administer the first dose of oseltamivir (Tamiflu)
 D. Obtain blood and sputum specimens for testing

Correct Answer: A. Provide oxygen using a non-rebreather mask.

Option A: Because the respiratory manifestations associated with avian influenza are
potentially life-threatening, the nurse’s initial action should be to start oxygen therapy.
 Options B, C, and D: The other interventions should be implemented after addressing
the client’s respiratory problem.

12. Question
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. Obtain stool specimens for culture

 B. Place the client on contact precaution
 C. Notify the physician about the loose stools
 D. Instruct the client about correct handwashing

Correct Answer: B. Place the client on contact precaution

 Option B: 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 A, C, and D: The other actions are also needed and should be taken after
placing the client on contact precautions.

13. Question
Which of the following information about a client who has meningococcal meningitis has
the best indicator that you can discontinue droplet precautions?

 A. Pupils are equal and reactive to light

 B. Temperature is lower than 100°F (37.8°C)
 C. Appropriate antibiotics have been given for 24 hours
 D. Cough is productive of clear, nonpurulent mucus
 Correct Answer: C. Appropriate antibiotics have been given for 24 hours.
Option C: Current CDC evidence-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 D: The other information may indicate that the client’s condition is
improving but does not indicate that droplet precaution should be discontinued.

14. Question
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. No negative-airflow rooms are available on the unit

 B. The infection control nurse liaison is not on the unit today
 C. There are several children receiving chemotherapy on the unit
  D. The unit is not staffed with the usual number of RNs

Correct Answer: A. No negative-airflow rooms are available on the unit

Option A: Because clients with rubeola require the implementation of airborne
precautions, which include placement in a negative airflow room, this child cannot be
admitted to the pediatric unit.
Options B, C, and D: The other circumstances may require actions such as staff
reassignments but would not prevent the admission of a client with rubeola.

15. Question
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. Assess the client for signs of infection

 B. Notify hospital security personnel about the client
  C. Escort the client to a decontamination room
 D. Administer ciprofloxacin (Cipro) 250 mg PO

Correct Answer: C. Escort the client to a decontamination room

Option C: 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 A: Assessment of the client for signs of infection should be before
decontamination.
Option B: 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. Question
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

Correct Answer: B. Gown. C. Gloves. E. N95 respirator.

Options B, C, and E: 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. Question
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. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug
resistant organisms.

 B. Screen all newly admitted clients for colonization or infection with MRSA.

 C. Require nursing staff to don gowns to change wound dressings for all clients.

 D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care
areas of the hospital.

Correct Answer: D. Ensure that dispensers for alcohol-based hand rubs are readily available in
all client care areas of the hospital.
Option D: Because the hands of healthcare 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: Because the 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 B: Although some hospitals have started screening newly admitted clients for MRSA, there
is no evidence that this decreases the spread of infection.
Option C: Wearing a gown to care for clients who are not on contact precautions is not necessary.

18. Question
 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?

Remove gloves
Take off goggles
Take off the gown
Remove N95 respirator
Perform hand hygiene

The correct order is shown above:

Rationale:
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. Question
 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. N95 respirator

 B. Surgical Mask
 C. Gloves
 D. Goggles
 E. Gown

Correct Answer: C. Gloves. E. Gown.

Options C and E: A gown and gloves should be used when coming in contact with
linens that may be decontaminated by the client’s wound secretions.
Options A, B, 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. Question
You are preparing to care for a 6-year-old who has just undergone allogeneic stem cell
transplantation and will need protective environment isolation. Which nursing tasks will
you delegate to a nursing assistant? Select all that apply.

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

Correct Answer: C, D, & E

Options C and E: Because all staff who care for clients should be familiar with the
various types of isolation, the nursing assistant will be able to stock the room and post
the precautions on the client’s door.
Option D: 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 A and B: Client teaching and discussion of the reason for protective isolation
fall within the RN-level scope of practice.
21. Question
A 26-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

Correct Answer: Answer: C. Droplet.

Scarlet fever is an infection caused by Group A Streptococcus bacteria. This bacteria lives
in the throat and nose and is highly contagious. It is spread by droplet transmission when
infected individual coughs or sneezes.
22. Question
A newly admitted client with streptococcal pharyngitis (tonsillitis) has been placed on
droplet precaution. Which of the following statements indicates the best understanding of
this type of isolation?

 A. Must maintain a spatial distance of 3 feet

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

Correct Answer: A. Must maintain a spatial distance of 3 feet.

Option A: 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 B: The client requires a private room.
Option C: 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 masks, and eye protection should be worn in giving
direct care.

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

 A. An infant with a runny nose and whose older brother has pertussis.

 B. A travel blogger who needs tuberculosis testing after exposure to a person with TB during his trip.

 C. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg
wound infection.

 D. A pregnant woman with a blister-like rash on the face and is possibly having varicella.

Correct Answer: D. A pregnant woman with a blister-like rash on the face and is
possibly having varicella.
Option D: Chickenpox (Varicella) is transmitted by airborne and 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.
 Options A and C: 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.
Option B: 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.
24. Question
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. Monitor the results of the laboratory culture and sensitivity test.
 B. Educate the client and family members on ways to prevent transmission of VRE.
 C. Implement contact precautions when handling the client.
 D. Collaborate with other departments when the client is transported for the ordered test.

Correct Answer: C. Implement contact precautions when handling the client.

Option C: All hospital personnel who care for the client are responsible for the correct
implementation of contact precautions.
Options A, B, and D: The other options should be carried out by a licensed nurse.
25. Question
Which of the following infection control activities should be delegated to an experienced
nursing assistant?

 A. Screening clients for upper respiratory tract symptoms

 B. Disinfecting blood pressure cuffs after clients are discharged
 C. Demonstrating correct handwashing techniques to client and family
 D. Asking clients about the duration of antibiotic therapy

Correct Answer: B. Disinfecting blood pressure cuffs after clients are discharged
Option B: Nursing assistants can follow agency protocol to disinfect items that come in
contact with intact skin by cleaning with chemicals such as alcohol.
Options A, C, and D: The other options should be carried out by a licensed nurse.