Answers Graded A+
1. The home health nurse is caring for a client who is 1&2
identified as high risk for falls. What observations Placing a grab
would indicate a therapeutic response to home fall bar in a slip-
prevention education? pery tub can assist
the client in get-
1. Installs a grab bar in the tub ting into and out
2. Turns night lights on at bedtime of tub. Turning on
3. Only use assistive devices when leaving home. night lights at night
4. Goes barefoot while in the home. ensures that the
5. Uses throw rugs in walking areas to prevent slip- client can navigate
ping. safely, this reduc-
Select all ing the risk of falls.
2. A nurse is caring for a client diagnosed with the Ebola 1, 2, 4, 5
virus who is experiencing vomiting and diarrhea. What The nurse should
personal protective equipment should be worn by the wear a single-use
nurse while providing care to this client? (disposable) im-
permeable gown
1. Single-use impermeable gown OR a single-use
2. Powered Air Purifying Respirator (PAPR) or N95 impermeable cov-
respirator. erall. Either a
3. One pair of sterile gloves PAPR or a dispos-
4. Single-use boot covers able. NOSH-certi-
5. Single-use apron fied N95 respi-
Select all rator should be
worn to reduce
the risk of con-
tamination in the
case of an emer-
gency situation
where a poten-
tially aerosol-gen-
erating procedure
would be per-
formed. The PAPR
reduces the risk
of self-contamina-
tion while provid-
ing client care, but
, NCLEX-PN Safety and Infection Control Test with Verified
Answers Graded A+
the N95 respirator
is less likely bulky.
If the N95 respira-
tor is selected for
use, nurses should
be extremely care-
ful to make sure
that they do not
accidentally touch
their faces under
the face shield dur-
ing client care. Dis-
posable boot cov-
ers should be worn
and should extend
to at least mid-calf.
Some agencies
may add the sin-
gle use shoe cov-
ers over the boot
covers to reduce
the risk of contami-
nating the underly-
ing shoes.
3. When disposing of waste in a client's room, the nurse 1 & 5
would place which items in a biohazard red bag? Chest drainage
units should
1. Chest drainage unit be capped and
2. Doxorubicin IV bag and tubing placed in a
3. Staples removed from an abdominal incision large red biohaz-
4. Tramadol 50 mg tablet prescribed but refused by ard bag for dis-
client. posal. Dressings
5. Soiled dressing soiled with human
6. Paper trash with identifying client information waste, blood or
Select all body fluids should
be disposed of in a
red biohazard bag.
, NCLEX-PN Safety and Infection Control Test with Verified
Answers Graded A+
4. The nurse is assessing the client's blood pressure us- 3
ing an electronic blood pressure machine and notes Since the client
that the blood pressure reading is much higher than does not have a
it has been since admission. The client denies history history of hyper-
of hypertension. What action should the nurse take? tension and has
not had elevat-
1. Call the primary healthcare provider and report the ed blood pres-
elevated blood pressure. sure since admis-
2. Check the blood pressure again in 4 hours and sion, the nurse
compare to the current blood pressure. should question
3. Re-check the blood pressure using a manual blood the accuracy of
pressure cuff the electronic
4. Call the nursing supervisor and prepare for a pos- blood pressure
sible hypertensive emergency. machine. There-
fore, the nurse
should re-check
the BP using a
manual cuff to
determine if the
high blood pres-
sure reading was
accurate.
5. A farm worker comes into the clinic reporting 1
headache, dizziness, and muscle twitching after work- These are symp-
ing in the fields. What condition does the nurse sus- toms of pesticide
pect? exposure when
combined with the
1. Pesticide exposure details given of
2. Heat stroke coming from the
3. Anthrax poisoning fields. Death can
4. Gastroenteritis result from se-
vere acute pesti-
cide poisoning.
6. A nurse is working with community officials to de- 2, 3, 4
crease the incidence of violence in the community.
Which primary preventive measures might the nurse These are all
suggest? appropriate inter-
, NCLEX-PN Safety and Infection Control Test with Verified
Answers Graded A+
ventions for the
1. Provide a safe haven for victims of violence nurse to suggest
2. Provide educational programs about types of vio- to the communi-
lence ty The key is pre-
3. Form a neighborhood watch program vention. The nurse
4. Develop a media campaign identifying risk factors is teaching ways
of potential abuse. to prevent vio-
5. Provide for the immediate removal of a victim of lence before it oc-
violence from the home. curs. Primary pre-
vention is true pre-
Select all vention.
7. The nurse is reinforcing information about car acci- 2.
dent prevention to a group of high school students. According to the
Who would the nurse include as the highest risk for a Centers for Dis-
motor vehicle crash (MVC)? ease Control and
Prevention (CDC),
1. Males who have just turned 19 years of age. crash risk is par-
2. Drivers who have recently acquired a driver's li- ticularly high dur-
cense. ing the first year
3. A group of students that carpool to the senior prom the teenagers are
4. Female students who drive to weekly football eligible to drive.
games Though teenagers
who are 19
years old, carpool-
ing to the senior
prom, and driving
to weekly football
games are also
at risk for an
MVC, they are not
the highest-risk n
teenage group.
8. A client is brought to the emergency room follow- 3.
ing a serious motor vehicle accident. Standing or- Even in an emer-
ders include initiating an IV line and inserting a foley gency, the nurse
catheter. What action should the nurse take first? follows the nursing
process by initial-