NCLEX Test Safety and Infection Control

1.    A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of vaginal discharge. Which STD must be reported to the public health department?
a.    Bacterial vaginitis
b.    Gonorrhea
c.    Genital Herpes
d.    Human papillomavirus (HPV)
2.    When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client’s anxiety?
a.    “You may have a seat over here.”
b.    “We wear gowns and gloves to administer chemotherapy drugs because they’re very dangerous.”
c.    “You look anxious, don’t worry you will get used to this place.”
d.    “As a precaution, we wear gowns, goggles, and gloves to administer the medication.”
3.    To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client clean the area?
a.    By swabbing the labia minora from front to back
b.    By cleaning the labia minora from back to front
c.    By cleaning the labia majora from back to front
d.    By swabbing the entire perineal area
4.    After administering an I.M. injection, a nurse notices there isn’t a sharps-disposal container nearby. Which action should the nurse take?
a.    Hold the barrel of the syringe in one hand. With the other hand, push the cap into place over the needle.
b.    With one hand, use the needle to sccop up the cap. Holding the barrel in one hand, carry the syringe to the closest sharps-disposal container.
c.    With one hand, use the needle scoop up the cap. Holding the barrel in one hand, carry the syringe to the closest trash container.
d.    Hold the barrel of the syringe in one hand. With the other hand, push the cap into place over the needle. Carry the syringe to the closest sharps-disposal container.
5.    Which nursing diagnosis takes highest priority for a client with a compound fracture?
a.    Imbalanced nutrition: Less than body requirements related to immobility
b.    Impaired physical mobility related to trauma
c.    Risk for infection related to effects of trauma
d.    Activity intolerance related to weight-bearing limitations
6.    After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?
a.    Monitoring the client for skin breakdown
b.    Maintaining traction continuously to ensure its effectiveness
c.    Supporting the traction weights with a chair or table to prevent accidental slippage
d.    Restricting the client’s fluid and fiber intake to reduce the movement required for bedpan use.
7.    A nurse is about to give a full-term neonate his first bath. How should the nurse proceed?
a.    Bathe the neonate only after his vital signs have stabilized
b.    Clean the neonate with medicated soap
c.    Scrub the neonate’s skin to remove the vernix caseosa
d.    Wash the neonate from feet to hand
8.    A 3-year-old child is admitted to the hospital with an acute exacerbation of asthma. The child’s history reveals that the child was exposed to chickenpox 1 week ago. When would this child require isolation?
a.    Isolation isn’t required
b.    Immediate isolation is required
c.    Isolation is required 10 days after exposure
d.    Isolation is required 12 days after exposure
9.  The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?
a. An 18 month-old who ate an undetermined amount of crystal drain cleaner
b. A 14 month-old who chewed 2 leaves of a philodendron plant
c. A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)
d. A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
10. The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother’s lap. Which of the following should the nurse do first?
a. Elicit reflexes
b.Measure height and weight
c. Auscultate heart and lungs
d. Examine the ears
11. Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client?
a. An accurate measurement of intake is not reliable
b.The food pyramid is not used in this age group
c. A serving size at this age is about 2 tablespoons
d. Total intake varies greatly each day
12. The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take?
a. Notify the health care provider
b. Palpate the anterior fontanel
c. Feel the posterior fontanel
d. Record these normal findings
13. An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child’s question, “Where do babies come from?” What is the nurse’s best response to the parent?
a. “When a child asks a question, give a simple answer.”
b. “Children ask many questions, but are not looking for answers.”
c. “This question indicates interest in sex beyond this age.”
d. “Full and detailed answers should be given to all questions.”
14. A client has a soft wrist-safety device. Which assessment finding should the nurse consider normal?
a.    A palpable radial pulse
b.    A palpable ulnar pulse
c.    Cool pale fingers
d.    Pink nail beds
15. The nurse is performing wound care sing surgical asepsis. Which practice violates surgical asepsis?
a.    Holding sterile objects above the waist
b.    Pouring solution onto a sterile field cloth
c.    Considering a 1” edge around the sterile field contaminated
d.    Opening the outermost flap of a sterile package away from the body
16. Which assessment finding by the nurse contraindicates the application of a heating pad?
a.    Active bleeding
b.    Reddened abscess
c.    Edematous lower leg
d.    Purulent wound drainage
17. A positive Mantoux test indicates that the client:
a.    Is actively immune to tuberculosis
b.    Has produced an immune response
c.    Will develop full-blown tuberculosis
d.    Has an active case of tuberculosis
18. Which action by the nurse is essential when cleaning the area around a Jackson-Pratt wound drain?
a.    Clean from the center outward in a circular motion
b.    Removing the drain before cleaning the skin
c.    Cleaning Briskly around the site with alcohol
d.    Wearing sterile gloves and mask
19. An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?
a.    Single-hole nipple
b.    Plastic spoon
c.    Paper straw
d.    Rubber dropper
20. What is the first action that a nurse should take after omitting an ordered medication?
a.    Notify the prescriber, nursing supervisor, and pharmacist
b.    Document the omission and reason
c.    Write an incident report
d.    Give an extra dose at the next scheduled time.

Answers and Rationale