NCLEX-PN
Safety and Infection Control NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the client with DM who has an open wound on the left heel. Which assessment findings should the nurse associate with a wound infection? Select all that apply.
Correct Answer: A,B,C,E
Rationale: A: Fever indicates possible infection. B: Warmth suggests inflammation or infection. C: Purulent drainage is a sign of infection. E: Elevated WBC count indicates an immune response to infection. D: Reduced sensation is related to neuropathy, not infection.
Question 2 of 5
The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
Correct Answer: A
Rationale: Non-steroidal anti-inflammatory drugs (NSAIDs). Medications with NSAIDs may increase the response to Coumadin (warfarin) and increase the risk of bleeding.
Question 3 of 5
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
Question 4 of 5
A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.
Question 5 of 5
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
Correct Answer: A
Rationale: Applying suction for more than 10 seconds may result in hypoxia. Although options B, C, and D are important during suctioning a tracheostomy, hypoxia results from actions that decrease the oxygen supply.