Safety and Infection Control NCLEX Questions

Question 1 of 5

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

A. Diminished bowel soundsB. Loss of appetiteC. A cold, pale lower legD. Tachypnea

Correct Answer: C

Rationale: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.

Question 2 of 5

A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

A. Diaphoresis with decreased urinary outputB. Increased heart rate with increased respirationsC. Improved respiratory status and increased urinary outputD. Decreased chest pain and decreased blood pressure

Correct Answer: C

Rationale: Improved respiratory status and increased urinary output. Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI disturbances.

Question 3 of 5

Which information is most important for the nurse to reinforce with a male client who is about to undergo a vasectomy?

A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.'B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.'C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you may return to work as soon as you feel up to it.'D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.'

Correct Answer: A

Rationale: All of these options are correct information. The most important point to reinforce is the continuing need to take additional action for birth control until the absence of sperm in the ejaculate is confirmed.

Question 4 of 5

The nurse is using contact precautions to change the soiled bed sheet of the client with Clostridium difficile. In the process, the nurse's right glove and skin on a finger is torn. After removing the soiled gloves, which action is priority?

A. Hold pressure to stop any bleeding.B. Use a bleach wipe to clean the hands.C. Wash the hands with soap and water.D. Cleanse hands using alcohol-based hand rub.

Correct Answer: C

Rationale: C: Soap and water effectively remove C. difficile spores. A: Bleeding may flush pathogens. B: Bleach damages skin. D: Alcohol is ineffective against C. difficile spores.

Question 5 of 5

The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?

A. Stop the infusionB. Slow the rate of infusionC. Take vital signs and observe for further deteriorationD. Administer Benadryl and continue the infusion

Correct Answer: A

Rationale: Stop the infusion. This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion.

Safety and Infection Control NCLEX Questions | Nurselytic

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