NCLEX-PN
Safety and Infection Control NCLEX RN Questions Questions
Extract:
Question 1 of 5
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
Correct Answer: B
Rationale: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.
Question 2 of 5
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
Question 3 of 5
The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?
Correct Answer: D
Rationale: D: Hand hygiene is critical to prevent pathogen introduction. A: Visitors with colds should avoid entry. B: Flowers can harbor microbes. C: Precautions don't improve neutrophil counts.
Question 4 of 5
The nurse is using contact precautions when caring for the client. When changing the client's IV solution bag, the nurse inadvertently touches the end of the exposed spike of the tubing. Which is the most appropriate action by the nurse?
Correct Answer: C
Rationale: C: The contaminated spike requires new sterile tubing to prevent infection. A: Using contaminated tubing risks infection. B: Changing gloves doesn't address tubing contamination. D: Alcohol cannot sterilize the spike.
Question 5 of 5
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.