NCLEX-PN
Safety and Infection Control NCLEX RN Questions Questions
Extract:
Question 1 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.
Question 2 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 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
Which of these findings would the nurse more closely associate with dehydration in a 10 month-old infant?
Correct Answer: A
Rationale: Status of the eyes and the tongue. Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110.
Question 5 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.