Asepsis & Infection Control
A nurse reassesses a client 2 days after abdominal surgery. Which finding requires the nurse to suspect a surgical-site infection and promptly communicate the assessment?
Dry incision without swelling
Erythema, swelling, and purulent drainage at the incision
A small amount of expected postoperative discomfort that is improving
Incision edges remain well approximated
4. B. Erythema, swelling, and purulent drainage at the incision
Swelling, erythema, and purulent drainage are surgical-site infection cues. Well-approximated edges and a dry incision do not indicate
infection; improving discomfort alone is less concerning than purulent drainage with inflammation.
The nurse receives change-of-shift report on four clients. Which client requires the most immediate fall- prevention action?
MULTIPLE CHOICE
An 81-year-old postoperative hip-replacement client with urinary urgency who received oxycodone and has attempted to get
out of bed without calling
A 72-year-old who uses a rolling walker, is alert and oriented, and requests standby assistance before ambulating
A 34-year-old with a seizure disorder who is continent, alert and oriented, and on bedrest until cleared to ambulate
A 45-year-old postoperative client who ambulates independently but walks more slowly because of generalized weakness
26. A. An 81-year-old postoperative hip-replacement client with urinary urgency who received oxycodone and has attempted to get out of bed without calling
The postoperative client has multiple interacting risks: recent fall history, urgency, opioid use, IV/SCD equipment, limited mobility, and
attempts to rise without assistance. The other clients have fewer risks or demonstrate safe judgment and help-seeking behavior.
A nurse discovers a small fire in a client's wastebasket. After removing the client from immediate danger, which action is next according to RACE?
MULTIPLE CHOICE
Activate the alarm.
Document the event in the medical record.
Close doors to contain the fire.
Use the fire extinguisher.
31. A. Activate the alarm.
RACE directs the nurse to Rescue, Alarm, Contain, and Extinguish/Evacuate. Once the client is rescued, activating the alarm summons
help; containment and extinguisher use follow as appropriate.
The nurse plans to teach a client about a newly prescribed treatment. The client is grimacing, rates pain as 8/10, and repeatedly looks toward a noisy hallway. Which action should the nurse take first?
MULTIPLE CHOICE
Proceed with teaching because the client may be discharged soon.
Address the pain and reduce distractions before beginning the teaching discussion.
Provide written instructions and document that teaching was completed.
Ask a family member to receive all teaching instead.
78. B. Address the pain and reduce distractions before beginning the teaching discussion.
Pain, anxiety, location, and distractions interfere with communication. Managing the immediate barrier and creating a more suitable
setting promotes meaningful participation; proceeding or substituting paperwork does not ensure understanding.
A client repeatedly attempts to leave the room while attached to IV tubing. Which nurse statement uses positive phrasing while promoting safety?
MULTIPLE CHOICE
"You are making this difficult for everyone."
"Do not get out of bed again."
"If you get up, you will probably fall."
"Please use the call light, and I will help you get up safely."
90. D. "Please use the call light, and I will help you get up safely."
Positive phrasing states the desired safe behavior and offers help. The other responses emphasize prohibition, blame, or fear and may
undermine therapeutic communication.
A postoperative client asks why the nurse cleans the dressing-cart work surface before setting up a dressing change. Which response best explains the purpose of asepsis?
“Asepsis is freedom from and prevention of disease-causing contamination.”
“Asepsis eliminates every microorganism, including spores, from all clinical surfaces.”
“Asepsis prevents the inflammatory response from occurring at the incision.”
“Asepsis guarantees that a susceptible host cannot develop an infection.”
1. A. “Asepsis is freedom from and prevention of disease-causing contamination.”
Asepsis means freedom from and prevention of disease-causing contamination. Sterilization—not asepsis in general—destroys all
microbes including spores; asepsis does not eliminate normal inflammatory defenses or guarantee that infection cannot occur.
At change of shift, which patient requires the most immediate escalation of individualized fall-prevention measures based on the Morse Fall Scale findings?
MULTIPLE CHOICE
A 70-year-old after a stroke with hypertension, a fall last week, an IV heparin lock, wheelchair dependence with assisted
transfers, impaired gait, and repeated attempts to stand without help.
A 74-year-old after femur repair with diabetes, an IV infusion, a walker for assisted transfers, impaired gait from weight-
bearing restrictions, and consistent adherence to limitations.
A 55-year-old with heart failure and hypertension, an IV infusion, normal gait, no fall history, and consistent use of the call
light.
A 66-year-old with migraines and hypertension, an IV heparin lock, normal gait, no fall history, and appropriate safety
awareness.
51. A. A 70-year-old after a stroke with hypertension, a fall last week, an IV heparin lock, wheelchair dependence with assisted transfers, impaired gait, and repeated attempts to stand without help.
The patient after stroke has multiple high-risk Morse factors: a recent fall, secondary diagnosis, IV/heparin lock, ambulatory aid,
impaired gait, and failure to recognize or follow limitations. The other patients have fewer risk factors and/or reliably follow safety
instructions, although the postoperative patient still needs precautions.
The nurse is planning placement for a client with MRSA in an abdominal incision. Which action is most appropriate?
MULTIPLE CHOICE
Place the client in a private negative-airflow room.
Require a mask for staff only when entering the room.
Require masks for staff and the client whenever the client leaves the room.
Place the client in a private room.
8. D. Place the client in a private room.
The source identifies a private room for MRSA in an incision. A negative-airflow room and routine masking are not the specified
intervention for this scenario.
A client with newly diagnosed advanced cancer sits with clenched fists and says, "Everyone keeps telling me what to do. I am tired of it." Which response by the nurse is most therapeutic?
MULTIPLE CHOICE
"You should focus on the treatment options that may help you."
"There are other clients who are dealing with much worse situations."
"It sounds as though you feel overwhelmed by the decisions and information."
"Why did you wait until now to tell the team you were upset?"
76. C. "It sounds as though you feel overwhelmed by the decisions and information."
Reflecting the client's feeling demonstrates active listening and invites further discussion without judgment. Advising, comparing the
client with others, and asking a "why" question can minimize feelings or sound accusatory.
A nurse calls the primary care provider because a client continues to report pain rated 7/10 one hour after receiving the only prescribed analgesic and is refusing physical therapy. Which statement is the best recommendation portion of an SBAR report?
MULTIPLE CHOICE
"The client has advanced cancer and was admitted yesterday for anemia and fatigue."
"Would you evaluate the client and provide additional pain-management orders so the client can participate in therapy?"
"I am concerned that the current pain regimen is not effective."
"The client's pulse is 105/min, respirations are 20/min, and oxygen saturation is 99% on room air."
80. B. "Would you evaluate the client and provide additional pain-management orders so the client can participate in therapy?"
The recommendation states the needed action clearly and directly. The other statements provide background, assessment data, or
concern, which are important SBAR elements but do not make a specific request.
The nurse receives assignment for four clients. Which client should the nurse identify as having the greatest source-supported risk for a health care-associated infection?
A client who smokes two packs of cigarettes daily
A client with a white blood cell count of 6,000 cells/mm3
A client with an indwelling urinary catheter placed during hospitalization
A client who is slightly underweight and follows a vegetarian die
2. C. A client with an indwelling urinary catheter placed during hospitalization
Urinary catheters are specifically associated with HAIs. The other findings may warrant assessment, but they are not the device-
associated HAI risk identified in the source.
A nurse is preparing the room of an older adult who is weak and requires assistance to ambulate. Which actions should the nurse include to reduce fall risk? Select all that apply.
SATA
Position the bedside table between the client and the bathroom as a resting point.
Raise the upper side rails while the client is in bed.
Place the bed in the lowest position and lock the brakes.
Place frequently used personal belongings within the client's reach.
Raise all four side rails whenever the client is in bed.
Ensure the client knows to request assistance before getting out of bed.
27. C. Place the bed in the lowest position and lock the brakes.; D. Place frequently used personal belongings within the client's reach.; B. Raise the upper side rails while the client is in bed.; F. Ensure the client knows to request assistance before getting out of bed.
A low, locked bed, reachable belongings, upper side rails, and reinforcing use of assistance reduce environmental and unassisted-
mobility risk. Placing furniture in the route to the bathroom creates an obstacle, and raising all four side rails can impede safe exit rather
than promote routine mobility safety.
A client is being discharged with discontinued medications and asks how to dispose of the unused tablets. Which instruction by the nurse is most appropriate?
MULTIPLE CHOICE
"Use a drug take-back location if one is available."
"Keep the medication in case the symptoms return."
"Give the medication to a relative who has the same diagnosis."
"Donate the medication to the local hospital pharmacy."
29. A. "Use a drug take-back location if one is available."
A drug take-back location is the preferred safe-disposal option presented in the safety teaching. Sharing, donating, or saving
discontinued prescriptions can lead to inappropriate medication use and harm.
A nurse is preparing to discuss a frightening new diagnosis with a client. Which actions demonstrate therapeutic nonverbal communication consistent with SOLER? Select all that apply.
SATA
Turn the torso toward the client.
Keep the arms folded tightly across the chest.
Sit at the client's eye level when possible.
Maintain appropriate eye contact.
Look repeatedly at the hallway while the client is speaking.
Maintain an open posture.
77. C. Sit at the client's eye level when possible.; F. Maintain an open posture.; A. Turn the torso toward the client.; D. Maintain appropriate eye contact.
Sitting at eye level, facing the client, using an open posture, and maintaining appropriate eye contact communicate attention and
presence. Folded arms and looking away can convey defensiveness or disinterest.
The nurse is preparing an SBAR call about a deteriorating client. Which information should the nurse gather and organize before contacting the provider? Select all that apply.
SATA
The immediate reason for the call and current concern
Current assessment findings, including pertinent vital signs
Relevant history and events related to the current problem
A clear request or recommended next step
The nurse's personal opinion of the previous shift
Unrelated details from the client's remote medical history
81. A. The immediate reason for the call and current concern; C. Relevant history and events related to the current problem; B. Current assessment findings, including pertinent vital signs; D. A clear request or recommended next step
SBAR organizes the immediate situation, relevant background, assessment findings, and a recommendation. Personal opinions and
unrelated information reduce clarity and can delay an effective response.
A nurse is reviewing processing methods with a newly hired assistive staff member. Which statement requires correction?
“Disinfection uses cleaning products to eliminate microbes on surfaces.”
“Disinfection destroys all microbes, including spores.”
“Sterilization can use heat and/or chemicals.”
“Sterilization destroys all microbes, including spores.”
5. B. “Disinfection destroys all microbes, including spores.”
Disinfection does not kill spores. Sterilization destroys all microbes, including spores, and may use heat and/or chemicals.
The nurse completes a Johns Hopkins fall-risk assessment for a client with a hip fracture. Which findings contribute to this client's fall risk? Select all that apply.
SATA
Alert and oriented behavior with consistent use of the call light
Oxycodone-associated drowsiness
An IV infusion and SCDs in place
Occasional urinary incontinence
Traction stabilizing the affected leg
Use of acetaminophen
33. D. Occasional urinary incontinence; B. Oxycodone-associated drowsiness; C. An IV infusion and SCDs in place; E. Traction stabilizing the affected leg
Elimination urgency/incontinence, sedating medication effects, attached equipment, and traction can create or increase unsafe mobility
risk. Acetaminophen is not identified as the key medication concern in this scenario, and reliable orientation with call-light use is a
protective behavior.
A nurse has selected an appropriate fire extinguisher and is ready to use it on a contained fire. Which action should the nurse take first when applying PASS?
MULTIPLE CHOICE
Pull the pin.
Squeeze the handles together.
Aim at the base of the fire.
Sweep from side to side.
32. A. Pull the pin.
PASS begins with Pull the pin, then Aim at the base, Squeeze the handles, and Sweep side to side. The remaining actions are correct
later steps but are not performed first.
A nursing student who recognizes a documentation error should take responsibility for the mistake and promptly report it through the appropriate clinical supervision pathway rather than attempting to conceal it.
TRUE FALSE
A. False
B. True
79. True
Professionalism includes honesty and ownership of mistakes and actions. Concealing an error compromises accountability,
communication, and patient safety.
A nurse enters a client's room to prepare for a procedure using an AIDET approach. Which actions support a structured, respectful introduction and explanation? Select all that apply.
SATA
Explain what will occur using understandable language.
Use technical terms without checking whether the client understands.
Ask whether the client has questions or concerns after the explanation.
Introduce self and role to the client.
Thank the client for participating and cooperating.
Avoid discussing the expected time involved so the client does not become anxious.
89. D. Introduce self and role to the client.; A. Explain what will occur using understandable language.; C. Ask whether the client has questions or concerns after the explanation.; E. Thank the client for participating and cooperating.
A structured patient interaction includes a respectful introduction, understandable explanation, opportunity for questions, and courteous
closure. Withholding expectations and relying on unexplained jargon create communication barriers.
A nursing student is preparing a teaching poster on blood-borne pathogens. Which group should the student include?
Methicillin-resistant Staphylococcus aureus, VRE, and ESBL-producing organisms
Clostridioides difficile, Salmonella, and Shigella
Mycobacterium tuberculosis, Streptococcus pneumoniae, and Haemophilus influenzae
Hepatitis B, hepatitis C, and HIV
6. D. Hepatitis B, hepatitis C, and HIV
The source identifies hepatitis B, hepatitis C, and HIV as blood-borne pathogens. The other organisms are important infection-control
concerns but are not listed in that blood-borne pathogen group.
A patient has no ordered assistive device but repeatedly steadies themself by grasping the bedside table, wall rail, and furniture while walking to the bathroom. How should the nurse classify the ambulatory-aid element of the Morse Fall Scale?
MULTIPLE CHOICE
Crutches, cane, or walker
No ambulatory aid or bedrest
Furniture
Unable to assess because the patient is walking independently
55. A. Implement hourly rounding to address mobility and toileting needs.
Hourly rounding proactively addresses needs for toileting, position changes, pain control, and assistance before an unsafe self-transfer
occurs. Four side rails may function as a restraint, restraints can worsen injury risk, and family presence does not replace an
individualized nursing plan.
A nurse is assessing factors that can affect client safety. Which factors should the nurse consider? Select all that apply.
SATA
Lighting in the environment
Body functioning
Age
Pollution exposure
Workplace conditions
The nurse's preferred routine for organizing supplies
49. C. Age; B. Body functioning; A. Lighting in the environment; D. Pollution exposure; E. Workplace conditions
Safety is affected by individual factors such as age and body functioning and environmental factors such as lighting, pollution, and
workplace conditions. The nurse's personal organizational preference is not itself a client safety-assessment factor.
The nurse plans to teach a client about a newly prescribed treatment. The client is grimacing, rates pain as 8/10, and repeatedly looks toward a noisy hallway. Which action should the nurse take first?
MULTIPLE CHOICE
Proceed with teaching because the client may be discharged soon.
Address the pain and reduce distractions before beginning the teaching discussion.
Provide written instructions and document that teaching was completed.
Ask a family member to receive all teaching instead.
78. B. Address the pain and reduce distractions before beginning the teaching discussion.
Pain, anxiety, location, and distractions interfere with communication. Managing the immediate barrier and creating a more suitable
setting promotes meaningful participation; proceeding or substituting paperwork does not ensure understanding.
A student nurse has reported a medication-related safety concern to the staff nurse, but the concern remains unresolved. The charge nurse is unavailable. Which action is most appropriate next?
MULTIPLE CHOICE
Escalate the concern to the nurse manager according to the clinical chain of command.
Call the course team leader directly.
Wait until the end of the shift so the concern does not disrupt workflow.
Post a general warning in a group chat without identifying the issue.
96. A. Escalate the concern to the nurse manager according to the clinical chain of command.
When a safety concern is unresolved, the nurse should continue through the established clinical chain of command. Waiting or using
informal communication delays resolution; a course leader is part of the academic, not clinical, escalation pathway.