NCLEX Questions on Safety and Infection Control

Extract:

Question 1 of 5

An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

Correct Answer: B

Rationale: Check the client's gag reflex. When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.

Question 2 of 5

The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?

A. Breath sounds can be heard bilaterally B. Mist is visible in the T-Piece C. Pulse oximetry of 88 BPM D. Client is unable to speak

Correct Answer: C

Rationale: Pulse oximetry of 88 BPM. Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings.

Question 3 of 5

Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?

A. Eat a light diet for the rest of the day B. Rest for the next 24 hours since the preparation and the test is tiring C. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D. Measure the urine output for the next day and immediately notify the health care provider if it should decrease

Correct Answer: D

Rationale: This information would alert to the complication of acute renal failure which may occur as a complication from the dye and the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye injection.

Question 4 of 5

The nurse provides a collection container to the client for collecting a sputum specimen for culture and sensitivity. Which additional interventions should the nurse implement? Select all that apply.

A. Tell the client to spit into the container 2 to 3 times during the day. B. Wear gloves and protective eyewear when handling the specimen. C. After collection, place the sealed container in a clean plastic bag. D. Place a biohazard alert symbol on the bag containing the specimen container. E. Send the specimen to the laboratory within 30 minutes of collection.

Correct Answer: C,D,E

Rationale: C: A clean bag prevents external contamination. D: A biohazard symbol indicates infectious material. E: Prompt delivery ensures accurate results. A: Single morning collection is preferred. B: Eyewear is unnecessary.

Question 5 of 5

The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action?

A. lower extremity pitting edema B. rales C. jugular vein distension D. weakness in left arm

Correct Answer: D

Rationale: weakness in left arm. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload and are not medical emergencies.

NCLEX Questions on Safety and Infection Control | Nurselytic

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