SAFETY AND INFECTION CONTROL NCLEX NURSING 2026
EXAM 2
1. Question1 point(s)
A child has third-degree burns of the hands, face, and chest. Which nursing
diagnosis takes priority?
A. Impaired urinary elimination related to fluid loss
B. Ineffective airway clearance related to edema
Correct Answer
C. Disturbed body image related to physical appearance
Incorrect
D. Risk for infection related to epidermal disruption
Incorrect
Correct Answer: B. Ineffective airway clearance related to edema
Initially, when a preschool client is admitted to the hospital for burns, the primary
focus is on assessing and managing an effective airway. Immediately assess the
patient’s airway, breathing, and circulation. Be especially alert for signs of smoke
,inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice
changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum.
Exposure to materials burn can cause inhalation injury.
Option A: Acute renal failure is one of the major complications of burns and it is
accompanied by a high mortality rate. Most renal failures occur either
immediately after the injury or at a later period when sepsis develops. Late-onset
renal failure is usually the consequence of sepsis and is often associated with
other organ failure.
Option C: Burn injuries are among the most serious causes of radical changes in
body image. The subject of body image and self-image is essential in
rehabilitation, and the nurse must be aware of the issues related to these
concepts and take them seriously into account in drafting out the nursing
program.
Option D: Invasive infection of burn wounds is a surgical emergency because of
the high concentrations of bacteria (>105 CFU) in the wound and surrounding
area, together with new areas of necrosis in unburned tissues. This situation often
is accompanied by signs of sepsis and changes in the burn wound such as black,
blue, or brown discoloration of the eschar.
2. Question1 point(s)
,A 3-year-old child is receiving dextrose 5% in water and half-normal saline
solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid
intake?
A. Temperature of 102°F (38.9°C)
Incorrect
B. Worsening dyspnea
Correct Answer
C. Gastric distension
D. Nausea and vomiting
Incorrect
Correct Answer: B. Worsening dyspnea
Dyspnea and other signs of respiratory distress signify fluid volume excess
(overload), which can occur quickly in a child as fluid shifts rapidly between the
intracellular and extracellular compartments. The excess fluid circulating around
the body can cause waterlogging of the lungs, leading to breathlessness. If fluid
overload goes on for a long term it eventually leads to heart failure.
Option A: An elevated temperature may indicate a fluid volume deficit.
Hypohydration increases heat storage by reducing sweating rate and skin blood
, flow responses for a given core temperature. Hypertonicity and hypovolemia both
contribute to reduced heat loss and increased heat storage.
Option C: Gastric distention may suggest excessive oral fluid intake or infection.
Abdominal distension occurs when substances, such as air (gas) or fluid,
accumulate in the abdomen causing its outward expansion beyond the normal
girth of the stomach and waist. It is typically a symptom of an underlying disease
or dysfunction in the body, rather than an illness in its own right.
Option D: Conditions that cause blood or body fluid loss can cause hypovolemia,
as can inadequate fluid intake. If persistent or severe, diarrhea and vomiting can
deplete body fluids. All living organisms must maintain an adequate fluid balance
to preserve homeostasis. Water constitutes the most abundant fluid in the body,
at around 50% to 60% of the body weight.
3. Question1 point(s)
Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for
a severe asthma exacerbation?
A. Absence of intercostals or substernal retractions
Incorrect
B. Oxygen saturation of 95%
C. Mild work of breathing
D. History of steroid-dependent asthma
EXAM 2
1. Question1 point(s)
A child has third-degree burns of the hands, face, and chest. Which nursing
diagnosis takes priority?
A. Impaired urinary elimination related to fluid loss
B. Ineffective airway clearance related to edema
Correct Answer
C. Disturbed body image related to physical appearance
Incorrect
D. Risk for infection related to epidermal disruption
Incorrect
Correct Answer: B. Ineffective airway clearance related to edema
Initially, when a preschool client is admitted to the hospital for burns, the primary
focus is on assessing and managing an effective airway. Immediately assess the
patient’s airway, breathing, and circulation. Be especially alert for signs of smoke
,inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice
changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum.
Exposure to materials burn can cause inhalation injury.
Option A: Acute renal failure is one of the major complications of burns and it is
accompanied by a high mortality rate. Most renal failures occur either
immediately after the injury or at a later period when sepsis develops. Late-onset
renal failure is usually the consequence of sepsis and is often associated with
other organ failure.
Option C: Burn injuries are among the most serious causes of radical changes in
body image. The subject of body image and self-image is essential in
rehabilitation, and the nurse must be aware of the issues related to these
concepts and take them seriously into account in drafting out the nursing
program.
Option D: Invasive infection of burn wounds is a surgical emergency because of
the high concentrations of bacteria (>105 CFU) in the wound and surrounding
area, together with new areas of necrosis in unburned tissues. This situation often
is accompanied by signs of sepsis and changes in the burn wound such as black,
blue, or brown discoloration of the eschar.
2. Question1 point(s)
,A 3-year-old child is receiving dextrose 5% in water and half-normal saline
solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid
intake?
A. Temperature of 102°F (38.9°C)
Incorrect
B. Worsening dyspnea
Correct Answer
C. Gastric distension
D. Nausea and vomiting
Incorrect
Correct Answer: B. Worsening dyspnea
Dyspnea and other signs of respiratory distress signify fluid volume excess
(overload), which can occur quickly in a child as fluid shifts rapidly between the
intracellular and extracellular compartments. The excess fluid circulating around
the body can cause waterlogging of the lungs, leading to breathlessness. If fluid
overload goes on for a long term it eventually leads to heart failure.
Option A: An elevated temperature may indicate a fluid volume deficit.
Hypohydration increases heat storage by reducing sweating rate and skin blood
, flow responses for a given core temperature. Hypertonicity and hypovolemia both
contribute to reduced heat loss and increased heat storage.
Option C: Gastric distention may suggest excessive oral fluid intake or infection.
Abdominal distension occurs when substances, such as air (gas) or fluid,
accumulate in the abdomen causing its outward expansion beyond the normal
girth of the stomach and waist. It is typically a symptom of an underlying disease
or dysfunction in the body, rather than an illness in its own right.
Option D: Conditions that cause blood or body fluid loss can cause hypovolemia,
as can inadequate fluid intake. If persistent or severe, diarrhea and vomiting can
deplete body fluids. All living organisms must maintain an adequate fluid balance
to preserve homeostasis. Water constitutes the most abundant fluid in the body,
at around 50% to 60% of the body weight.
3. Question1 point(s)
Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for
a severe asthma exacerbation?
A. Absence of intercostals or substernal retractions
Incorrect
B. Oxygen saturation of 95%
C. Mild work of breathing
D. History of steroid-dependent asthma
