NCLEX-PN safety and infection control practice questions
NCLEX-PN · safety and infection control
NCLEX-PN safety and infection control practice questions
You stop the harm first: isolation, falls, equipment, and the order that keeps the unit safe. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five safety and infection control questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?
A. ability to breathe
B. pallor or cyanosis of the skin
C. number of accompanying family members
D. motor function
Show answer and rationale
Correct answer: C — number of accompanying family members
During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.
Question 2
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?
A. "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."?
B. "I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding."?
C. "I can clean around the tube with water and mild soap."?
D. "I should avoid using Vaseline around the nostril and tube."?
Show answer and rationale
Correct answer: A — "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."?
The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.
Question 3
The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
A. The client was repositioned on his right side at 1100.
B. The client was bathed, and the skin was assessed head-to-toe at 0900 with no abnormal findings.
C. The client's PEG tube was changed 6 months ago.
D. The client's indwelling urinary catheter was last changed 5 days ago.
Show answer and rationale
Correct answer: D — The client's indwelling urinary catheter was last changed 5 days ago.
When caring for a comatose client, it is crucial to monitor and maintain the integrity of the indwelling urinary catheter to prevent urinary tract infections and other complications. Changing the urinary catheter less frequently than recommended increases the risk of infection. In this scenario, the most concerning issue is the prolonged duration since the last change of the indwelling urinary catheter, which poses an immediate risk to the client's health. While repositioning every 2 hours is essential to prevent skin breakdown, the most critical aspect in this case is the catheter care. Bathing and skin assessment are important for overall hygiene and skin integrity but are not as urgent as catheter care. The timing of the PEG tube change, while relevant for care planning, is not as immediate a concern as the indwelling urinary catheter status.
Question 4
Which of the following statements indicates adequate dietary understanding in a client with constipation?
A. "I should decrease my intake of fluids."?
B. "I should decrease my level of activity."?
C. "I should increase my intake of apples."?
D. "I should increase my intake of milk."?
Show answer and rationale
Correct answer: C — "I should increase my intake of apples."?
The correct answer is, "I should increase my intake of apples."? This statement indicates adequate dietary understanding in a client with constipation because apples are a good source of fiber, which helps alleviate constipation. Adequate fiber intake is essential for promoting bowel regularity. Choices A and B are incorrect as decreasing fluids and activity level can worsen constipation. Insufficient fluid intake can lead to hard stools, exacerbating constipation. Decreasing activity can also slow down bowel movements. Choice D is incorrect because milk is not a high-fiber food and may not effectively address constipation. While milk can have a mild laxative effect on some individuals, it is not a primary solution for constipation, especially when compared to high-fiber foods like apples.
Question 5
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO®. How many milliliters of fluid did the patient ingest?
A. 440 ml
B. 480 ml
C. 220 ml
D. 660 ml
Show answer and rationale
Correct answer: B — 480 ml
To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO® (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO®) = 480 ml. Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids. Choice A, 440 ml, is incorrect as it does not account for the correct calculation. Choice C, 220 ml, is incorrect as it is significantly lower than the correct total. Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.
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Question 6
What does carrying a donor card for organ donation mean?
A. medical care is altered to obtain organs for donation in the event of serious injuries
B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
C. a client is allowed to revoke their decision for organ donation at any time
D. a client is considered an organ donor for multiple organs or tissues
Correct answer:
Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.
Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
A. The client verbalizes knowledge of a maintenance diet.
B. The client demonstrates assertiveness with family.
C. The client verbalizes her body size accurately.
D. The client demonstrates control of obsessive behaviors.
Correct answer:
The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.
The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
A. You can lie down in 1 hour.
B. You can lie down in 30 minutes if your NG residual is below 50 mL.
C. You can lie down in about 30 minutes.
D. Yes, feel free to lie down.
Correct answer:
After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications. Therefore, the most appropriate response is to advise the client to lie down in 1 hour. Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes. Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness. Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.
When the healthcare provider is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should they measure?
A. corner of the mouth to the tragus of the ear
B. corner of the eye to the top of the ear
C. tip of the chin to the sternum
D. tip of the nose to the earlobe
Correct answer:
When selecting the correct size of an oropharyngeal airway, the healthcare provider should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to maintain a clear air passage for exchange. Measuring from the corner of the eye to the top of the ear (Choice B) is inaccurate and not a standard measurement for selecting the size of an oropharyngeal airway. Measuring from the tip of the chin to the sternum (Choice C) is irrelevant to determining the correct size of the airway. Similarly, measuring from the tip of the nose to the earlobe (Choice D) is also incorrect and does not provide the necessary measurement for selecting an oropharyngeal airway size.
A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
Correct answer:
A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.
When should the biohazard emblem be affixed to containers according to the orientation nurse educator reviewing the biohazard legend with a class of new employees?
A. when there is presence of blood and body fluids.
B. when there is the need for droplet precautions.
C. when there is contact isolation.
D. when there is the potential for airborne transmission.
Correct answer:
The correct answer is 'when there is presence of blood and body fluids.' When handling body substances like blood and body fluids, the risk of transmission of infections increases. Federal regulations mandate warning labels on containers to alert employees and waste collectors. The biohazard emblem consists of a three-ring symbol overlaying a central concentric ring. Blood, wound drainage, feces, and urine are examples of body fluids that can transmit infections and diseases to others. The other choices, B, C, and D, are incorrect because the presence of the biohazard emblem is specifically linked to the handling of blood and body fluids, not to droplet precautions, contact isolation, or airborne transmission.
When caring for clients with Buck’s Traction, the major areas of importance should be:
A. nutrition, elimination, comfort, safety
B. ROM exercises, transportation
C. nutrition, elimination, comfort, safety
D. elimination, safety, isotonic exercises
Correct answer:
When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications. Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.
The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?
A. Inform the client that ear pain may occur and is normal.
B. Provide ice water and a straw to promote easy fluid consumption.
C. Provide hot tea to soothe the throat.
D. Monitor vitals every 15 minutes.
Correct answer:
The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.
The nurse uses prioritization to determine all of the following except:
A. time allotment for certain tasks.
B. appropriate interventions.
C. treatment procedures.
D. the need for client education.
Correct answer:
The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
A. The history and presentation might indicate chickenpox, a highly contagious disease.
B. The lesions might indicate a noncontagious infection that does not require isolation.
C. The history and presentation might indicate an infectious illness called impetigo.
D. The lesions are not contagious unless others have open wounds or lesions themselves.
Correct answer:
The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy. Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever. Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection. Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.
About these NCLEX-PN safety and infection control questions
NCLEX-PN safety and infection control practice questions for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the NCLEX-PN exam guide.
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