Results for Lesson 2: Safety and Infection Control

Questions are numbered by the order in which they appeared in the test.
Represents the correct answer.
Question 1
A newly admitted adult client has a diagnosis of hepatitis Answers Correct D
A. The charge nurse should reinforce to the staff members Student's D
that the most significant routine infection control strategy,
in addition to handwashing, is which of these?
A) Place appropriate signs outside and inside the room
Use a mask with a shield if there is a risk of fluid
B)
splash
Wear a gown to change soiled linens from
C)
incontinence
D) Have gloves on while handling bedpans with feces
Review Information: The correct answer is D: Have gloves on while handling
bedpans with feces
The specific measure to prevent the spread of hepatitis A is careful handling and
protection while working with fecal material. All of the other actions are correct but
not the most significant specific approach used with hepatitis A.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Question 2
Which of these actions is the primary nursing intervention Answers Correct A
designed to limit transmission of a client’s Salmonella Student's C
infection?
Wash hands thoroughly before and after client
A)
contact
B) Wear gloves when in contact with body secretions
C) Double glove when in contact with feces or vomitus
D) Wear gloves when disposing of contaminated linens
Review Information: The correct answer is A: Wash hands thoroughly before and
after client contact
Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary
means of contamination. Two million new cases appear each year. Thorough
handwashing can prevent the spread of salmonella. Note that all of the options are
appropriate activities, but handwashing is primary.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing.
Upper Saddle River, N.J.: Pearson Prentice Hall.

Question 3
The nurse is assigned to a client newly diagnosed with Answers Correct D
active tuberculosis. Which of these interventions would be Student's D
a priority for the nurse to implement?
Have the client cough into a tissue and dispose in a
A)
separate bag
Instruct the client to cover the mouth with a tissue
B)
when coughing
Reinforce that everyone should wash their hands
C)
before and after entering the room
Place client in a negative pressure private room and
D)
have all who enter the room use masks with shields
Review Information: The correct answer is D: Place client in a negative pressure
private room and have all who enter the room use masks with shields
A client with active tuberculosis should be hospitalized in a negative pressure room to
prevent respiratory droplets from leaving the room when the door is opened.
Tuberculosis (TB) is caused by spore-forming mycobacteria, more often
Mycobacterium tuberculosis. In developed countries the infection is airborne and is
spread by inhalation of infected droplets. In underdeveloped countries, transmission
also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly
controlled.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 4
The parents of a toddler who is being treated for pesticide Answers Correct B
poisoning ask: “Why is activated charcoal used? What Student's B
does it do?” What is the nurse's best response?
"Activated charcoal decreases the body’s absorption
A)
of the poison from the stomach."
"The charcoal absorbs the poison and forms a
B)
compound that doesn't hurt your child."
"This substance helps to get the poison out of the
C)
body through the gastrointestinal system."
"The action may bind or inactivate the toxins or
D)
irritants that are ingested by children and adults."
Review Information: The correct answer is B: "The charcoal absorbs the poison and
forms a compound that doesn''t hurt your child."
All of the options are correct responses. However, option B is most accurate
information to answer the parents’ questions about the use and action of activated
charcoal. The language is appropriate for a parent''s understanding.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.

Question 5
Which of these clients would the nurse recommend Answers Correct D
keeping in the hospital during an internal disaster at that Student's D
facility?
An adolescent diagnosed with sepsis 7 days ago and
A) whose vital signs are maintained within low normal
limits.
A middle-aged woman known to have had an
B)
uncomplicated myocardial infarction 4 days ago
An elderly man admitted 2 days ago with an acute
C)
exacerbation of ulcerative colitis
A young adult in the second day of treatment for an
D)
overdose of acetometaphen
Review Information: The correct answer is D: A young adult in the second day of
treatment for an overdose of acetometaphen
An overdose of Tylenol requires close observation for 3 to 4 days as well as
Mucomyst PO during that time . A strong risk of liver failure exists immediately
following Tylenol overdose.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.
Question 6
Which of these nursing diagnoses, appropriate for elderly Answers Correct D
clients, would indicate the client is at greatest risk for Student's A
falls?
Sensory perceptual alterations related to decreased
A)
vision
B) Alteration in mobility related to fatigue
C) Impaired gas exchange related to retained secretions
Altered patterns of urinary elimination related to
D)
nocturia
Review Information: The correct answer is D: Altered patterns of urinary elimination
related to nocturia
Nocturia is especially problematic because many elders fall when they rush to reach
the bathroom at night. They may be confused or not fully alert. Inadequate lighting
can increase their chances of stumbling, and then they may fall over furniture or
carpets.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 7
A nurse is reinforcing teaching with a client about Answers Correct B
compromised host precautions. The client is receiving Student's B
filgrastim (Neupogen) for neutropenia. Which lunch
selection suggests the client has learned about necessary
dietary changes?
A) grilled chicken sandwich and skim milk
B) roast beef, mashed potatoes, and green beans
C) peanut butter sandwich, banana, and iced tea
D) barbeque beef, baked beans, and cole slaw
Review Information: The correct answer is B: roast beef, mashed potatoes, and green
beans
The client has correctly selected an appropriate lunch and appears to know the dietary
restrictions. Low granulocyte counts and susceptibility to infection are expected.
Compromised host precautions require that foods are either cooked or canned. Options
A, C and D do not demonstrate learning, as raw fruits, vegetables, and milk are to be
avoided.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical,

Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.
Question 8
A nurse who is assigned to the emergency department Answers Correct A
needs to understand that gastric lavage is a priority in Student's A
which situation?
An infant who has been identified as suffering from
A)
botulism
A toddler who has eaten a number of ibuprofen
B)
tablets
A preschooler who has swallowed powdered plant
C)
food
A school aged child who has taken a handful of
D)
vitamins
Review Information: The correct answer is A: An infant who has been identified as
suffering from botulism
C. botulinum forms a toxin in improperly processed foods in anaerobic conditions. It
is a neurotoxin that impairs autonomic and voluntary neurotransmission and causes
muscular paralysis. Findings appear within 36 hours of ingestion. The nurse should be
aware that all of these clients may be candidates for gastric lavage or for activated
charcoal administration.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Question 9
The nurse is to administer a new medication to a client. Answers Correct B
Which of these actions best demonstrate awareness of safe, Student's D
proficient nursing practice?
Verify the order for the medication. Prior to giving
A) the medication the nurse should say, "Please state
your name."
Upon entering the room the nurse should ask: "What
B) is your name? What allergies do you have?" and then
check the client's name band and allergy band.
As the room is entered say "What is your name?"
C)
then check the client's name band.
Verify the client's allergies on the admission sheet
and order. Verify the client's name on the name plate
D) outside the room then as the nurse enters the room
ask the client "What is your first, middle and last
name?"
Review Information: The correct answer is B: Upon entering the room the nurse
should ask: "What is your name? What allergies do you have?" and then check the
client''s name band and allergy band.
A dual check is always done for a client''s name. This would involve verbal and visual
checks. Since this is a new medication an allergy check is appropriate.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 10
Which approach is the best way to prevent infections when Answers Correct A
providing care to clients in the home setting? Student's A
A) Handwashing before and after examination of clients
Wearing nonpowdered latex-free gloves to examine
B)
the client
Using a barrier between the client's furniture and the
C)
nurse's bag
Wearing a mask with a shield during any
D)
eye/mouth/nose examination
Review Information: The correct answer is A: Handwashing before and after
examination of clients
Handwashing remains the most effective way to avoid spreading infection. However,
too often nurses do not practice good handwashing techniques and do not teach
families to do so. Nurses need to wash their hands before and after touching the client
and before entering the nursing bag. All of the options are correct, and the sequence of
priorities would be options A, C, B, and D.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Question 11
Which of these clients is the priority for the nurse to report Answers Correct B
to the public health department within the next 24 hours? Student's B
A) An infant with a positive culture of stool for Shigella
An elderly factory worker with a lab report that is
B)
positive for acid-fast bacillus smear
A young adult commercial pilot with a positive
C) histopathological examination from an induced
sputum for Pneumocystis carinii
A middle-aged nurse with a history of varicella
D) zoster virus and with crops of vesicles on an
erythematous base that appear on the skin
Review Information: The correct answer is B: An elderly factory worker with a lab
report that is positive for acid-fast bacillus smear
Tuberculosis is a reportable disease because persons who had contact with the client
must be traced and often must be treated with chemoprophylaxis for a designated
time. Options A and D may need contact isolation precautions. Option C -- findings
may indicate the initial stage of autoimmune deficiency syndrome (AIDS).

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 12
A client is diagnosed with methicillin resistant Answers Correct D
staphylococcus aureus pneumonia (MRSA). What type of Student's D
isolation is most appropriate for this client?
A) Reverse
B) Airborne
C) Standard precautions
D) Contact
Review Information: The correct answer is D: Contact
Contact precautions or Body Substance Isolation (BSI) involves the use of barrier
protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever
direct contact with any body fluid is expected. When determining the type of isolation
to use, one must consider the mode of transmission. The hands of personnel continue
to be the principal mode of transmission for methicillin resistant staphylococcus
aureus (MRSA). Because the organism is limited to the sputum in this example,
precautions are taken if contact with the patient''s sputum is expected. A private room
and contact precautions , along with good hand washing techniques, are the best
defenses against the spread of MRSA pneumonia.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 13
After an explosion at a factory one of the employees Answers Correct C
approaches the nurse and says “I am an unlicensed Student's B
assistive personnel (UAP) at the local hospital.” Which of
these tasks should the nurse assign first to this worker who
wants to help care for the wounded workers?
A) Get temperatures
B) Take blood pressure
C) Palpate pulses
D) Check alertness
Review Information: The correct answer is C: Palpate pulses
The heart rates would indicate if the client is in shock or has potential for shock. If the
pulses could not be palpated, those clients would need to be seen first.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:
Assessment & management of clinical problems. St. Louis: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Question 14
A school nurse has a 10 year-old child with a history of Answers Correct D
epilepsy with tonic-clonic seizures attending classes Student's D
regularly. The school nurse should inform the teacher that
if the child experiences a seizure in the classroom, the most
important action to take during the seizure would be to
move any chairs or desks at least 3 feet away from
A)
the child
note the sequence of movements with the time lapse
B)
of the event
provide privacy as much as possible to minimize
C)
frightening the other children
place the hands or a folded blanket under the head of
D)
the child
Review Information: The correct answer is D: place the hands or a folded blanket
under the head of the child
The priority during seizure activity is to protect the person from physical injury. Place
a pillow, folded blanket or your hands under the child''s head to prevent concussion or
other head trauma. The other body parts are at less risk for injury, consequently the
prioritized sequence of the actions above would be options D, A, B, and C.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.

Question 15
When an infant car seat is properly installed, the infant Answers Correct B
should face Student's B
A) forward, so child may look out window
B) backward, so child faces the seat
C) the side window, to increase sensory stimulation
upward, as child lies on back with seat installed
D)
sideways
Review Information: The correct answer is B: backward, so child faces the seat
Nurses are now responsible for promoting the continued safety of infants and children
outside of the hospital. Emergency Department and Women’s Services staff are trained
in child seat placement. Growth and development data indicate that infants still require
support of the head. Therefore, they should be positioned reclining and facing the rear
until their leg muscles are strong enough to kick away from the backseat (about 10-12
months-old) for the greatest protection.

London, M., Ladewig, P., Ball, J., and Bindler, R. (2003). Maternal-Newborn and
Child Nursing. Upper Saddle River, N.J.: Pearson Education.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 16
A parent calls the hospital hot line and is connected to the Answers Correct A
triage nurse. The caller proclaims: “I found my child with Student's A
odd stuff coming from the mouth and an unmarked bottle
nearby.” Which of these comments would be the best tool
for the nurse to determine if the child has swallowed a
corrosive substance?
"Ask the child if the mouth is burning or throat pain
A)
is present."
"Take the child’s pulse at the wrist and see if the
B)
child is has trouble breathing lying flat."
"What color is the child’s lips and nails and has the
C)
child voided today?"
"Has the child had vomiting, diarrhea or stomach
D)
cramps?"
Review Information: The correct answer is A: "Ask the child if the mouth is burning
or throat pain is present."
Local irritation of tissues indicates a corrosive poisoning. The other comments may be
helpful in determining the child’s overall condition, however the question concerns
evaluation for ingesting a caustic substance.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.

Question 17
A client is scheduled to receive an oral solution of Answers Correct A
radioactive iodine (131I). In order to reduce hazards, the Student's A
priority information for the nurse to include in client
teaching is which of these statements?
"In the initial 48 hours, avoid contact with children
A) and pregnant women, and flush the commode twice
after urination or defecation."
"Use disposable utensils for 2 days and if vomiting
B) occurs within 10 hours of the dose, do so in the toilet
and flush it twice."
"Your family can use the same bathroom that you use
C)
without any special precautions."
"Drink plenty of water and empty your bladder often
D)
during the initial 3 days of therapy."
Review Information: The correct answer is A: "In the initial 48 hours, avoid contact
with children and pregnant women, and flush the commode twice after urination or
defecation."
The client''s urine and saliva are radioactive for 24 hours after ingestion, and vomitus
is radioactive for 6 to 8 hours. The client should drink 3 to 4 liters of fluid a day for
the initial 48 hours to help remove the (131I) from the body. Staff should limit contact
with hospitalized clients to 30 minutes per day per person.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 18
A child is admitted to the pediatric unit with a diagnosis of Answers Correct C
suspected meningococcal meningitis. Which admission Student's C
orders should the nurse implement first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h
Review Information: The correct answer is C: Place in respiratory/secretion
precautions
Meningococcal meningitis is a bacterial infection that can be communicated to others.
The initial therapeutic management of acute bacterial meningitis includes
respiratory/secretions precautions, initiation of antimicrobial therapy, monitoring
neurological status along with vital signs, instituting seizure precautions and lastly
maintaining optimum hydration. The first action for nurses to take is initiate any
necessary precautions to protect themselves and others from possible infection. Viral
meningitis usually does not require protective measures of isolation.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.

Question 19
Several clients are admitted to an adult medical unit. For Answers Correct B
which client condition(s) would the nurse institute airborne Student's C
precautions?
Autoimmune deficiency syndrome (AIDS) with
A)
cytomegalovirus (CMV)
A positive purified protein derivative (PPD) test with
B)
an abnormal chest x-ray
A tentative diagnosis of viral pneumonia with
C)
productive brown sputum
D) Advanced carcinoma of the lung with hemoptysis
Review Information: The correct answer is B: A positive purified protein derivative
(PPD) test with an abnormal chest x-ray
The client who must be placed in airborne precautions is the client with these findings
that suggest a suspicious tuberculin lesion. A sputum smear for acid fast bacillus
would be done next. CMV usually causes no signs or symptoms in children and adults
with healthy immune systems. Good handwashing is recommended for CMV. When
signs and symptoms do occur, they are often similar to those of mononucleosis,
including sore throat, fever, muscle aches and fatigue.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 20
The school nurse is teaching the faculty the most effective Answers Correct C
methods to prevent the spread of lice (Pediculus Humanus Student's C
Capitis) in the school. The information that would be most
important to include is reflected in which of these
statements?
"The treatment medication requires reapplication in 8
A)
to 10 days."
"Bedding and clothing can be boiled or steamed to
B)
kill lice."
C) "Children should not share hats, scarves and combs."
"Nit combs are necessary to comb lice eggs (nits) out
D)
of children's hair."
Review Information: The correct answer is C: "Children should not share hats,
scarves and combs."
Head lice live only on human beings and can be spread easily by sharing hats, combs,
scarves, coats and other items of clothing that touch the hair. All of the options are
correct statements, however they do not best answer the question of how to prevent
the spread of lice in a school setting.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.