Infection Investigation
A nurse is preparing to care for a patient on contact precautions. Which PPE is required at minimum when contact with the patient or contaminated items is expected?
A. Surgical mask only
B. Gown and gloves
C. N95 respirator only
D. Sterile gloves only
B. Gown and gloves
RATIONALE
Contact precautions help prevent transmission through direct or indirect contact. Gown and gloves provide protection when contact with the patient or contaminated surfaces is expected.
A nurse is preparing to administer medication. Which information is appropriate to use to verify patient identity?
A. Room number and diagnosis
B. Name and date of birth
C. Bed number and room number
D. Diagnosis and physician name
B. Name and date of birth
RATIONALE
Two reliable patient identifiers must be used. A room number is not an acceptable identifier.
An older adult has thin, fragile skin. Which age-related change contributes to this finding?
A. Increased collagen
B. Increased skin elasticity
C. Decreased collagen and elasticity
D. Increased subcutaneous cushioning
C. Decreased collagen and elasticity
RATIONALE
Aging reduces collagen and elasticity, making the skin more vulnerable to tears and injury.
A nurse observes pink wound drainage that contains both serum and blood. How should the nurse document it?
A. Serous
B. Purulent
C. Sanguineous
D. Serosanguineous
D. Serosanguineous
RATIONALE
Serosanguineous drainage is a mixture of serum and blood, giving it a pink appearance.
A nurse is caring for a patient who has urinary incontinence. Which intervention helps protect skin integrity?
A. Leave the brief in place until the next shift
B. Provide prompt perineal care
C. Avoid assessing the perineal area
D. Apply additional briefs without removing wet ones
B. Provide prompt perineal care
RATIONALE
Urine exposure can irritate and damage skin. Prompt hygiene reduces prolonged moisture exposure.
A nurse is preparing to care for a patient with influenza who is prescribed droplet precautions. Which action is appropriate?
A. Wear a surgical mask when entering the room
B. Wear only gloves when entering the room
C. Keep the patient's room door closed at all times
D. Use sterile gloves for all patient care
A. Wear a surgical mask when entering the room
RATIONALE
Droplet precautions require a surgical mask to protect the nurse from infectious respiratory droplets.
A patient is weak and unsteady when walking. Which nursing action best helps prevent a fall?
A. Encourage the patient to walk without assistance
B. Keep frequently used items and the call light within reach
C. Raise the bed to its highest position
D. Remove the call light to discourage activity
B. Keep frequently used items and the call light within reach
RATIONALE
Making needed items accessible and allowing the patient to request assistance helps reduce fall risk.
A nurse is assessing the skin of a patient with darker skin pigmentation. Which assessment is especially helpful when redness is difficult to see?
A. Assess only the skin color
B. Palpate for warmth and changes in skin texture
C. Skip the pressure-point assessment
D. Assess only the patient's arms
B. Palpate for warmth and changes in skin texture
RATIONALE
Temperature, firmness, and texture changes may help the nurse recognize tissue damage when discoloration is difficult to see.
A patient has a surgical incision with well-approximated edges. What does this mean?
A. The wound edges are separated
B. The wound edges are together
C. The wound contains purulent drainage
D. The wound has exposed bone
B. The wound edges are together
RATIONALE
Well-approximated edges indicate that the wound edges are aligned and closed together.
A patient is unable to change positions independently. Which nursing intervention is appropriate?
A. Reposition the patient regularly
B. Keep the patient in one position
C. Avoid inspecting the patient's skin
D. Massage areas of nonblanchable redness
A. Reposition the patient regularly
RATIONALE
Repositioning helps relieve prolonged pressure and reduces the risk of pressure injuries.
A nurse is caring for a patient with C. difficile. Which hand hygiene method should the nurse use after removing gloves?
A. Alcohol-based hand sanitizer
B. Soap and water
C. A dry paper towel
D. No hand hygiene is needed after wearing gloves
B. Soap and water
RATIONALE
C. difficile produces spores that are difficult to remove with alcohol-based products. Soap and water are needed.
A nurse finds a frayed electrical cord on equipment in a patient's room. What should the nurse do?
A. Continue using it if it still works
B. Cover the damaged area with tape
C. Remove the equipment from use and report the problem
D. Ask the patient to avoid touching the cord
C. Remove the equipment from use and report the problem
RATIONALE
Damaged electrical cords can cause electric shock or fire. Unsafe equipment should not be used.
A patient has been confined to bed for several days. Which areas should the nurse carefully assess for pressure injuries?
A. Sacrum and heels
B. Abdomen and palms
C. Eyelids and ears only
D. Fingertips only
A. Sacrum and heels
RATIONALE
Pressure injuries commonly develop over bony prominences, including the sacrum and heels.
A nurse observes thick, purulent drainage during a dressing change. Which action is appropriate?
A. Ignore the drainage because it is expected
B. Report the finding to the provider
C. Stop documenting the wound
D. Assume the wound has completely healed
B. Report the finding to the provider
RATIONALE
Purulent drainage indicates infection and should be reported.
A nurse is preparing to clean a wound before collecting a wound culture. Which solution is appropriate?
A. Normal saline
B. Alcohol-based hand sanitizer
C. Undiluted household bleach
D. Hand lotion
A. Normal saline
RATIONALE
Cleansing the wound with normal saline before collecting a specimen helps remove surface material.
A nurse is reviewing infection prevention practices. Which actions help interrupt the chain of infection? Select all that apply.
A. Perform hand hygiene between patients
B. Clean shared patient-care equipment
C. Continue wearing the same gloves between patients
D. Properly dispose of contaminated materials
A, B, and D
RATIONALE
Hand hygiene, equipment cleaning, and appropriate disposal reduce the spread of infectious agents. Gloves must be changed between patients.
A nurse is caring for a patient at risk for falls. Which interventions promote safety? Select all that apply.
A. Keep the bed in a low position
B. Provide a call light within reach
C. Keep the environment free of clutter
D. Encourage the patient to walk alone despite weakness
A, B, and C
RATIONALE
A low bed, accessible call light, and clear environment help reduce fall hazards. Patients who are weak may require assistance.
A nurse is assessing a patient for pressure injury risk. Which findings increase the patient's risk? Select all that apply.
A. Limited mobility
B. Poor nutritional intake
C. Decreased sensation
D. Adequate ability to reposition independently
A, B, and C
RATIONALE
Immobility, malnutrition, and sensory loss are important pressure injury risk factors.
Which findings are associated with delayed or impaired wound healing? Select all that apply.
A. Infection
B. Malnutrition
C. Long-term steroid use
D. Adequate nutrition
A, B, and C
RATIONALE
Infection, poor nutrition, and long-term steroid use can interfere with the normal healing process.
A nurse is caring for a patient with a wound. Which observations should be included in wound assessment? Select all that apply.
A. Amount of drainage
B. Color of drainage
C. Odor of drainage
D. Whether the nurse prefers the dressing color
A, B, and C
RATIONALE
The color, amount, and odor of wound drainage help the nurse monitor healing and identify potential complications.
A patient with active pulmonary tuberculosis is admitted. Which action should the nurse take?
A. Place the patient in a negative-pressure room and wear a fitted N95 respirator
B. Place the patient in a regular room and wear gloves only
C. Use a surgical mask as the nurse's only respiratory protection
D. Keep the door open to improve airflow
A. Negative-pressure room and fitted N95 respirator
RATIONALE
Tuberculosis requires airborne precautions. A negative-pressure room and appropriate respiratory protection help prevent airborne transmission.
A patient is confused and repeatedly attempts to climb out of bed. Which nursing approach is most appropriate?
A. Apply restraints immediately
B. Use the least restrictive safety interventions and assess the patient's needs
C. Raise all four side rails as the first intervention
D. Leave the patient alone to encourage independence
B. Use the least restrictive safety interventions and assess the patient's needs
RATIONALE
The nurse should assess why the patient is attempting to get up and use appropriate alternatives before considering restraints.
A patient has a Braden Scale score of 10. Another patient has a score of 20. Which patient is at greater risk for pressure injury?
A. The patient with a score of 20
B. Both have the same risk
C. The patient with a score of 10
D. The score does not relate to pressure injury risk
C. The patient with a score of 10
RATIONALE
The Braden Scale measures pressure injury risk. Lower scores indicate greater risk.
A patient has a pressure injury with visible subcutaneous fat, but no exposed muscle or bone. How should the nurse classify the injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
C. Stage 3
RATIONALE
Stage 3 pressure injuries involve full-thickness skin loss with visible adipose tissue. Muscle and bone are not exposed.
A patient has a pressure injury covered by slough and eschar, preventing the nurse from seeing the wound depth. How should the nurse classify it?
A. Stage 1
B. Stage 2
C. Unstageable
D. Stage 4 automatically
C. Unstageable
RATIONALE
When slough or eschar obscures the depth of full-thickness tissue loss, the injury is unstageable until the extent of tissue damage can be determined.