NCLEX-PN
Safety and Infection Control NCLEX Questions Questions
Extract:
Question 1 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?
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.
Question 2 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?
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 3 of 5
The hospitalized client has protective precautions (reverse isolation) in place because of severe neutropenia. Which statement by the nurse to the NA is correct regarding the use of protective precautions?
Correct Answer: B
Rationale: B: Minimizing time outside the room reduces pathogen exposure. A, D: Gloves and masks are not required unless infection is present. C: Positive, not negative, air pressure is needed.
Question 4 of 5
The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?
Correct Answer: D
Rationale: When I put the baby in a back lying position that's how I find it hours later.' Atonic cerebral palsy is characterized by low muscle tone and lack of movement, so the baby remaining in the same position for hours supports this diagnosis.
Question 5 of 5
The nurse is caring for hospitalized clients. Which nursing actions require the nurse to use sterile gloves? Select all that apply.
Correct Answer: D,E
Rationale: D: Sterile gloves are required for urinary catheter insertion to prevent introducing pathogens. E: Sterile gloves are needed for tracheostomy suctioning to minimize infection risk. A, B, C involve non-sterile procedures.