RATIONALES/GRADED A+/2026 UPDATE/100% CORRECT /INSTANT
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SECTION 1: SAFETY & INFECTION CONTROL (Questions 1–20)
Question 1
A nurse is preparing to administer IV therapy to an adult client who reports having multiple
allergies. Which client allergy should the nurse bring immediately to the charge nurse's attention
before initiating therapy?
A) Eggs
B) Latex
C) Seafood
D) Bee stings
Correct Answer: B
Rationale: Latex allergies can pose a significant risk during IV therapy due to the common use
of latex-containing materials (e.g., gloves, IV tubing seals, injection ports). Identifying and
preventing latex exposure is crucial for client safety. While other allergies may be important, latex
presents an immediate risk during IV initiation.
Question 2
A nurse is caring for a client who has influenza and is on isolation precautions. Which action
should the nurse take to prevent the spread of infection?
A) Wear a mask when working within 3 feet of the client
B) Administer metronidazole
C) Don protective eyewear before entering the room
D) Place the client in a negative airflow room
Correct Answer: A
,Rationale: Influenza is transmitted via droplet transmission. The nurse should wear a mask
when working within 3 feet of the client. Droplet precautions require a mask, not negative airflow
(which is for airborne precautions). Metronidazole is an antibiotic, not an infection control
measure.
Question 3
A nurse is admitting a client who has tuberculosis. Which type of transmission precautions
should the nurse plan to initiate?
A) Droplet
B) Airborne
C) Protective environment
D) Contact
Correct Answer: B
Rationale: Tuberculosis is transmitted via airborne particles and requires airborne precautions,
including a negative pressure room and N95 respirator. Droplet precautions are for infections like
influenza, contact precautions for organisms like MRSA, and protective environment for
immunocompromised clients.
Question 4
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following
actions should the nurse take to prevent infection?
A) Empty the drainage bag daily
B) Keep the drainage bag above the level of the bladder
C) Secure the catheter tubing to the client's thigh
D) Irrigate the catheter with sterile water every shift
Correct Answer: C
Rationale: Securing the catheter tubing to the client's thigh prevents tension on the catheter
and reduces the risk of trauma and infection. The drainage bag should be kept below the level of
the bladder to prevent backflow, not above. Irrigation should only be done with a prescription.
Question 5
,A nurse is preparing to insert a urinary catheter for a female client. Which technique should the
nurse use to maintain sterility?
A) Clean technique
B) Sterile technique
C) Medical asepsis
D) Surgical asepsis
Correct Answer: D
Rationale: Urinary catheter insertion requires surgical asepsis (sterile technique) because the
procedure involves entering a sterile body cavity. Sterile gloves, sterile drapes, and sterile
equipment must be used. Clean technique (medical asepsis) is not sufficient for this invasive
procedure.
Question 6
Which of the following clients is at the highest risk for falls?
A) A 45-year-old client with a fractured ankle
B) A 70-year-old client with decreased visual acuity and generalized weakness
C) A 30-year-old client with a urinary tract infection
D) A 50-year-old client with hypertension
Correct Answer: B
Rationale: Fall risk factors include decreased visual acuity, generalized weakness, urinary
frequency, gait and balance problems, cognitive dysfunction, and medication side effects. The
elderly client with multiple risk factors (decreased vision and weakness) is at highest risk.
Question 7
A nurse obtains a prescription for wrist restraints for a client who is trying to pull out their NG
tube. Which action should the nurse take?
A) Attach the restraints securely to the side rails of the client's bed
B) Apply the restraints to allow as little movement as possible
C) Allow room for two fingers to fit between the client's skin and the restraints
D) Remove the restraints every 4 hours
Correct Answer: C
Rationale: Restraints should allow room for two fingers to fit between the client's skin and the
restraint to prevent circulation impairment and skin breakdown. Restraints should be attached to
, the bed frame (not side rails, which can cause injury if the side rail is lowered), allow for some
movement, and be removed every 2 hours for assessment.
Question 8
What is the most important action when entering a patient's room?
A) Introduce yourself
B) Perform hand hygiene
C) Verify the patient's identity
D) Close the door for privacy
Correct Answer: B
Rationale: Hand hygiene is the single most important intervention to prevent the spread of
infection. While introducing yourself, verifying identity, and providing privacy are important, hand
hygiene is the priority for infection control.
Question 9
A client is placed on seizure precautions. Which of the following should the nurse ensure is
available at the bedside?
A) Restraints
B) Oxygen, suction, and oral airway
C) Emergency medications only
D) A padded tongue depressor
Correct Answer: B
Rationale: Seizure precautions require having oxygen, suction, and an oral airway at the
bedside. Padded side rails should also be used. Never place anything in the client's mouth during
a seizure. Restraints should not be used during a seizure.
Question 10
During a seizure, the nurse should: