NCLEX Questions Safety and Infection Control

Extract:

Question 1 of 5

An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be

Correct Answer: A

Rationale: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than 'pain') to reveal the presence of pain. There is no evidence that pain of older adults is less intense, and it is necessary for the nurse to assess the pain thoroughly before implementing pain relief measures.

Question 2 of 5

The nurse is using contact precautions for the client with Clostridium difficile. While the nurse transfers the client from the bed to the commode, the client has loose stool that falls on the floor. After positioning the client on the commode, how should the nurse proceed to cleanse the floor?

A. Wipe up the stool with toilet paper and then clean the area with soap and water B. Wipe up the stool with toilet paper and then clean the area with a 1:10 bleach-water solution C. Call housekeeping personnel to come clean the floor now with the unit's mop and bucket D. Wipe up the stool and apply the alcohol-based hand wash to cleanse the area of stool

Correct Answer: B

Rationale: B: Bleach solution effectively kills C. difficile spores. A: Soap and water are insufficient. C: Housekeeping delays action and risks spread. D: Alcohol is ineffective against C. difficile.

Question 3 of 5

A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?

A. What are you taking for pain and does it provide total relief?' B. Did your provider recommend that you be tested for Chlamydia?' C. Do you have any questions about your care?' D. Did you know a consequence of epididymitis is infertility?'

Correct Answer: B

Rationale: Did your provider recommend that you be tested for Chlamydia?' Epididymitis can result from Chlamydia infection, in which case the client's sexual partners should be tested as well. All of the questions should be asked, however, determining the reason for the client's referral is the most important to start with.

Question 4 of 5

While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?

A. As you urinate more, you will need less medication to control fluid.' B. You will have to take this medication for about a year.' C. The medication must be continued so the fluid problem is controlled.' D. Please talk to your health care provider about medications and treatments.'

Correct Answer: C

Rationale: The medication must be continued so the fluid problem is controlled.' This is the most therapeutic response and gives the client accurate information.

Question 5 of 5

The provider order reads 'Aspirate nasogastric (NG) feeding tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?

A. Hold the tube feeding and notify the provider B. Administer the tube feeding as scheduled C. Irrigate the tube with diet cola soda D. Apply intermittent suction to the feeding tube

Correct Answer: A

Rationale: Hold the tube feeding and notify the provider. A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal placement.

NCLEX Questions Safety and Infection Control | Nurselytic

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