Safety and Infection Control NCLEX PN

Extract:

Question 1 of 5

The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

Correct Answer: B

Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

Question 2 of 5

The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

A. We will call the health care provider if the child develops acne.' B. Our child should brush and floss carefully after every meal.' C. We will skip the next dose if vomiting or fever occur.' D. When our child is seizure-free for 6 months, we can stop the medication.'

Correct Answer: B

Rationale: Our child should brush and floss carefully after every meal.' Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.

Question 3 of 5

The nurse observes that the NA enters the client room, provides direct care, and then exits without performing any hand hygiene. Which is the appropriate initial action of the nurse?

A. Inform the nurse manager about the NA's performance. B. File a facility incident or variance report immediately. C. Talk to the NA immediately about performing hand hygiene. D. Tell the client to remind all staff to perform hand hygiene.

Correct Answer: C

Rationale: C: Immediate discussion with the NA addresses the issue directly and promotes compliance. A, B: These are secondary actions. D: Client involvement is inappropriate.

Question 4 of 5

The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?

A. Prepare a statement for the hospital spokesperson to release to the news agencies B. Recommend that only staff with recent negative tuberculin skin tests provide care C. Implement measures to notify the local or state health department about the case D. Notify the nearest infectious disease facility and prepare the client for transfer

Correct Answer: C

Rationale: C: TB is a reportable disease, requiring health department notification. A: Media release is inappropriate. B: All staff can provide care with precautions. D: Transfer is unnecessary.

Question 5 of 5

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

A. Decreased carbohydrates and fat B. Decreased sodium and potassium C. Increased potassium and protein D. Increased sodium and fluids

Correct Answer: B

Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.

Safety and Infection Control NCLEX PN | Nurselytic

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NCLEX-PN

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