ATI RN
Infection Prevention and Control NCLEX Questions Questions
Question 1 of 5
The nurse is admitting a 70-year-old patient for a procedure. The patient has type I diabetes mellitus with significant peripheral neuropathy, atrial fibrillation controlled with antiarrhythmic medications, and osteoarthritis bilaterally in his knees. He is also on anticoagulants with an INR of 3.0. Given that the nurse knows about the individual risk factors that raise the risk of a fall, accident, or injury while hospitalized, which of the following should be identified as the most significant risk factor for this patient?
Correct Answer: B
Rationale: The correct answer is B: peripheral neuropathy. Peripheral neuropathy significantly impairs sensation and coordination, increasing the risk of falls and injuries. The patient's age and comorbidities like diabetes, atrial fibrillation, and anticoagulant therapy already pose risks, but peripheral neuropathy directly affects the patient's ability to perceive and react to potential hazards, making it the most significant risk factor in this case. Atrial fibrillation and anticoagulant therapy increase the risk of bleeding but are not directly related to falls. Bilateral knee osteoarthritis may contribute to mobility issues but is not as directly associated with fall risk as peripheral neuropathy.
Question 2 of 5
A nurse is caring for a patient receiving intravenous drug therapy via an infusion pump. The pump continues to sound an alarm and the nurse is unsure if it is administering the drug correctly. Which of these is the correct course of action for the nurse to follow?
Correct Answer: D
Rationale: The correct course of action for the nurse is D. First, discontinuing the infusion ensures patient safety. Next, replacing the pump with a functioning one guarantees proper drug administration. Restarting the infusion maintains therapy continuity. Labeling the broken pump allows for proper identification and handling of faulty equipment. Placing the broken pump in a designated area prevents its inadvertent reuse. Overall, this approach prioritizes patient safety, continuity of care, and proper equipment management.
Question 3 of 5
A client with a history of falls and hearing deficit resides in an assistive care facility. He is preparing for his discharge home. The home health nurse reviews fall prevention strategies with the client as he prepares to transition home. Which statement by the client indicates a need for further education?
Correct Answer: D
Rationale: The correct answer is D. Placing rugs at doorways and stairs can increase the risk of falls as they can become tripping hazards. Step-by-step rationale: 1. Rugs can easily slide or bunch up, causing a trip hazard. 2. Doorways and stairs are high-traffic areas where falls are more likely. 3. The client should avoid using rugs in these areas to prevent falls. Summary: A, B, and C are incorrect because they all promote safe practices for fall prevention, such as marking spills, avoiding climbing on step stools, and wearing hearing aids for increased awareness.
Question 4 of 5
A severe storm with tornado warning is announced over a facility’s overhead speakers. Which of the following actions by the facility nurses is inappropriate?
Correct Answer: C
Rationale: The correct answer is C because opening curtains and blinds during a severe storm with a tornado warning can pose a risk to the safety of the clients and nurses. By opening the curtains, the nurses are exposing themselves and the clients to potential flying debris or broken glass from shattered windows due to the storm. This action goes against the basic safety protocol of seeking shelter in an interior room away from windows during severe weather. Reassigning clients to interior rooms (A), moving clients away from windows (B), and closing interior doors of the facility (D) are appropriate actions as they aim to minimize the risk of harm to the clients and nurses during the storm.
Question 5 of 5
A client presents to the emergency department delirious and combative. The client becomes a danger to himself and to the staff caring for him. Which of the following actions is most appropriate?
Correct Answer: D
Rationale: The correct answer is D: Administer intramuscular sedative medication to the client. This option addresses the immediate safety concern by calming the delirious and combative client, preventing harm to themselves and others. Sedative medication can help manage the client's behavior and facilitate a safe environment for both the client and the staff. Rationale: 1. Removing objects (Option A) does not address the client's behavior and may not effectively manage the situation. 2. Applying wrist restraints (Option B) can lead to physical and psychological harm, should only be used as a last resort, and does not address the underlying cause of the behavior. 3. Recruiting staff to physically hold the client (Option C) is unsafe, may escalate the situation, and poses a risk of injury to both the client and staff.