NCLEX Test Safety and Infection Control Answers and Rationale

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1. B. Gonorrhea must be reported to the public health department. Bacterial vaginitis, genital herpes, and HPV aren’t reportable diseases.
2. D. Telling the client about the personal protective equipment worn to administer the chemotherapy drugs educates the client about the administration process and helps allay his anxiety.
3. A. The client should swab the labia minora from front to back, using one swab for each swipe. This technique cleans from the area of least contamination to the area of greatest contamination.
4. B. When a sharps-disposal container isn’t nearby, a nurse should use the one-handed scoop technique to prevent needle-stick injury while transporting the needle to a sharps-disposal container.
5. C. A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body’s first line of defense against infection, any skin opening places the client at risk for infection.
6. B. The nurse must maintain skeletal traction continuously to ensure its effectiveness. The nurse should assess skin for breakdown; however, maintaining skeletal traction takes priority.
7. A. To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized.
8. B. Immediate isolation is required because the incubation period for chickenpox is 2 to 3 weeks, and a client is commonly isolated 1 week after exposure to avoid the risk of outbreak.
9. A. An 18 month-old who ate an undetermined amount of crystal drain cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize this substance.
10. C. The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order.
11. C. A serving size at this age is about 2 tablespoons
In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake.
12. D. Record these normal findings
The question is D. The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age.
13. A. "When a child asks a question, give a simple answer." During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1 answer. When they are ready, they will ask about the other pieces.
14. C. A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the client for signs of impaired circulation, such as cool, pale fingers.
15. B. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action.
16. A. Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.
17. B. Skin testing is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of immune response.
18. A. The nurse should always move from the center outward in ever-larger circles when cleaning a around a wound drain because the skin near the drain site is more contaminated than the site itself.
19. D. An infant with a surgically repaired cleft lip must be fed with a rubber dropper or Breck feeder to prevent sucking or suture line trauma.
20. A. When a nurse has omitted am ordered medication, she should first notify the prescriber, nursing supervisor, and pharmacist.