Infection Prevention
While setting up a sterile field for a urinary catheter insertion, which action by the nurse immediately compromises the sterile field?
A. Keeping the sterile field in direct line of vision at or above waist level.
B. Allowing a 1-inch (2.5 cm) border around the drape to be considered unsterile.
C. Reaching directly over the opened sterile field to retrieve a pair of sterile gloves.
D. Opening the outermost flap of the sterile kit away from the body.
C. Reaching over a sterile field risks dropping microscopic microorganisms or dander from clothing and skin onto the sterile drape. The outermost flap should be opened away first, and items must be added from the sides without crossing directly over the field.
A client has been experiencing severe vomiting and diarrhea for two days. Which assessment finding should the nurse expect to observe?
A. Bounding radial pulses and high blood pressure
B. Low blood pressure and dry, cracked mucous membranes
C. Crackles in lung bases and neck vein distension
D. Sudden weight gain of 4 pounds
Correct B
Severe vomiting and diarrhea lead to fluid volume deficit (dehydration). Classic signs include hypotension (low blood pressure), tachycardia, dry mucous membranes, decreased skin turgor, and weight loss.
A nurse is caring for an older adult client with presbycusis . Which action should the nurse take when communicating with this client?
A. Raise the pitch of the voice and speak loudly into the client's ear.
B. Speak in a normal tone while facing the client directly at eye level.
C. Exaggerate lip movements to facilitate lip-reading.
D. Shout sentences rapidly to maintain the flow of conversation.
B
Presbycusis results in loss of high-frequency tones. Raising pitch or shouting makes speech distorted and harder to understand. Facing the client directly at eye level allows them to observe facial expressions and lip movements while hearing clear, lower-pitched speech.
A nurse is evaluating a student nurse who is applying non-pharmacological thermotherapy to clients experiencing pain. Which actions by the student nurse require IMMEDIATE intervention by the clinical instructor? (Select All That Apply)
A. Applying a warm heating pad directly to the abdomen of a client with suspected acute appendicitis.
B. Placing a barrier cloth between a cold pack and the client's bare skin.
C. Leaving a hot water bottle on a diabetic client's lower leg for 45 minutes continuously.
D. Applying an ice pack to an acute ankle sprain during the first 24 hours post-injury.
E. Placing a heating pad on a client's lower back who has an implanted cardiac pacemaker.
A, C
A requires intervention: Heat causes vasodilation and increased blood flow, which can cause an inflamed appendix to rupture, leading to peritonitis.
B is correct practice: A cloth barrier prevents frostbite and tissue breakdown.
C requires intervention: Thermal applications must be limited to 15 to 20 minutes at a time to prevent rebound vasoconstriction/tissue ischemia, especially in diabetic clients with reduced peripheral sensation.
D is correct practice: Cold therapy causes vasoconstriction, reducing acute edema and inflammation in the first 24–48 hours.
E is acceptable: Localized low heat to the lower back does not interfere with a thoracic pacemaker, provided skin integrity is checked.
A nurse is monitoring a client admitted to the step-down unit with a closed head injury. Which assessment finding is the EARLIEST and most sensitive indicator of increasing intracranial pressure (ICP)?
A. Sluggish pupillary response to light
B. Decerebrate posturing when stimulated
C. Change in level of consciousness (LOC)
D. Cushing’s triad (bradycardia, hypertension, irregular respirations)
C.
A change in level of consciousness (e.g., restlessness, irritability, confusion, lethargy) is always the earliest and most sensitive indicator of deteriorating cerebral function and rising ICP. Sluggish pupils, decerebrate posturing, and Cushing’s triad are late signs indicating severe brain stem compression.
Standard Precautions apply to all patients receiving care, regardless of their diagnosis or presumed infection status. Which body fluid is EXEMPT from Standard Precautions unless visible blood is present?
A. Saliva
B. Sweat
C. Wound drainage
D. Urine
Answer: B
Rationale: Standard Precautions apply to blood, all body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes. Sweat does not carry a risk for transmitting bloodborne or common opportunistic pathogens unless visibly contaminated with blood.
A nurse is caring for a client with low blood pressure who feels dizzy when getting out of bed. Which safety actions should the nurse take? (Select All That Apply)
A. Have the client sit on the edge of the bed dangle legs before standing.
B. Instruct the client to change positions slowly.
C. Encourage the client to march in place quickly upon standing.
D. Keep the call light within the client's reach.
E. Assist the client when ambulating.
A,B, D, E
Dizziness upon standing indicates postural (orthostatic) hypotension, which creates a high fall risk. Dangling at the bedside, moving slowly, keeping the call light accessible, and providing physical assistance directly prevent falls and injuries.
A nurse is preparing the room for a client admitted with severe macular degeneration. Which safety interventions should the nurse include? (Select All That Apply)
A. Place item trays within the client's central field of vision.
B. Ensure high-contrast colors are used on stairs and eating utensils.
C. Keep the room well-lit and ensure pathways are clear of clutter.
D. Describe the placement of food on the dinner tray using a clock-face pattern.
E. Place a sign on the door instructing staff to avoid announcing themselves upon entering.
B, C, D
Macular degeneration causes loss of central vision, leaving peripheral vision intact (so A is incorrect). High contrast aids boundary recognition, clear pathways prevent falls, and the clock-face pattern 12:00 top, 6:00 bottom helps with meal orientation. Staff should always announce themselves verbally upon entering (making E incorrect).
A nurse is disposing of intravenous tubing and empty bags that contained cytotoxic chemotherapy agents. Which actions demonstrate proper hazardous waste management? (Select All That Apply)
A. Discard chemotherapy bags and tubing into a yellow, leak-proof biohazard container.
B. Place soiled linens in a labeled, leak-resistant hazardous waste laundry bag.
C. Wear double chemotherapy-tested gloves and a moisture-resistant gown when handling body fluids.
D. Dispose of needles used for chemotherapy directly into a standard red sharps container.
E. Flush client body fluids down the toilet, instructing the client to flush twice with the lid down.
A, B, C, E
Cytotoxic waste (bags, tubing, PPE) goes into designated yellow hazardous waste containers, not standard red sharps (D is incorrect). Body waste contains chemotherapy metabolites for 48 hours; double-gloving/gowns prevent skin absorption, and flushing twice with the lid down prevents aerosolization of hazardous chemicals.
A nurse is assessing a client with a severe traumatic brain injury. Which set of vital signs indicates that the client is experiencing Cushing’s Triad?
A. BP 90/60 mmHg, Heart Rate 112 bpm, Respiratory Rate 26 breaths/min
B. BP 174/58 mmHg, Heart Rate 48 bpm, Respiratory Rate 10 breaths/min
C. BP 140/90 mmHg, Heart Rate 98 bpm, Respiratory Rate 20 breaths/min
D. BP 118/76 mmHg, Heart Rate 54 bpm, Respiratory Rate 12 breaths/min
B
Cushing’s Triad is a late, critical indicator of significantly increased intracranial pressure (ICP) and impending brainstem herniation. It is defined by three specific cardinal vital sign changes:
Widening Pulse Pressure / Systolic Hypertension: The difference between systolic and diastolic pressure widens significantly (e.g., 174 - 58 = 116
Bradycardia: A abnormally low heart rate (e.g., 48 bpm).
Irregular/Bradypneic Respirations: Slow, irregular, or Cheyne-Stokes breathing patterns (e.g., 10 breaths/min).
Option A represents signs of shock/hypovolemia (hypotension, tachycardia, tachypnea).
Options C & D do not demonstrate the classic triad of widening pulse pressure paired with bradycardia and respiratory depression.
A nurse is assigning a room for a newly admitted client with suspected active Pulmonary Tuberculosis. Which room assignment and PPE combination are required for this client?
A. Private room with positive pressure; surgical mask
B. Semi-private room with 3-foot distance; face shield
C. Airborne Infection Isolation Room with negative pressure; N95 respirator
D. Standard room with door open; gown and gloves
C. Tuberculosis requires Airborne Precautions. The patient must be placed in a negative-pressure room (Airborne Infection Isolation Room) with at least 6 to 12 air exchanges per hour, and healthcare personnel must wear a fit-tested N95 (or higher) respirator before entering.
LIMIT TRANSPORT PUT A MASK ON THE CLIENT
Measles, Tuberculosis, Varicella and Covid,
A nurse is assessing a client with fluid volume overload (hypervolemia). Which assessment findings should the nurse expect? (Select All That Apply)
A. Swelling (edema) in the feet and ankles
B. Jugular vein distension (JVD) when sitting upright
C. Crackles heard upon listening to lung sounds
D. Dry skin and extreme thirst
E. Rapid, unexpected weight gain
A, B, C, E
Excess fluid in the body causes fluid to back up into the tissues (edema), neck veins (JVD), and lungs (crackles), leading to rapid weight gain. Dry skin and extreme thirst (Option D) are signs of dehydration/fluid volume deficit.
A nurse is administering prescribed Timolol eye drops to a client with glaucoma. Which action by the nurse demonstrates proper administration technique?
A. Pressing lightly on the inner lacrimal duct (nasolacrimal punctum) for 1 to 2 minutes after instillation.
B. Dropping the medication directly onto the client's cornea.
C. Wiping the eye dropper tip with a sterile alcohol swab between drops.
D. Instructing the client to squeeze their eyelids tightly shut immediately after the drop.
A. Applying gentle pressure to the nasolacrimal duct (punctal occlusion) for 1 to 2 minutes prevents systemic absorption of the beta-blocker (Timolol), preventing systemic side effects like bradycardia and hypotension. Drops belong in the lower conjunctival sac, never directly on the sensitive cornea.
A nurse is teaching a community health class on early detection of solid tissue cancers. Which assessment finding should the nurse instruct clients to report to a healthcare provider as a potential early warning sign of cancer?
A. A skin lesion or sore that fails to heal after several weeks
B. Unexplained weight gain of 10 pounds in 1 week
C. Mild joint stiffness occurring immediately after morning exercise
D. Transient muscle cramping following physical exertion
A
C – Change in bowel or bladder habits
A – A sore that does not heal
U – Unusual bleeding or discharge
T – Thickening or lump in the breast, testicles, or elsewhere
I – Indigestion or difficulty swallowing
O – Obvious change in a wart or mole
N – Nagging cough or hoarseness
A nurse is preparing to administer 1,000 mL of 0.9 Normal Saline IV to infuse over 8 hours. The IV administration tubing has a drop factor of 15 gtt/ml. What drip rate should the nurse set in drops per minute (gtt/min)? (Round to the nearest whole number).
A. 21 gtt/min
B. 31 gtt/min
C. 42gtt/min
D. 125gtt/min
B
gtts/min =15gtts/ml x1000ml/8hrs x1hr/60min
A nurse is caring for an adult client with acute leukemia whose laboratory results reveal a White Blood Cell (WBC) count of 1,200 and a low Neutrophil Count 350/mm Which of the following interventions should the nurse include in the client's plan of care? (Select All That Apply)
A. Place the client in a private room with positive air pressure ventilation.
B. Prohibit fresh-cut flowers, potted plants, and standing water in the room.
C. Obtain rectal temperatures every 4 hours to monitor for fever.
D. Instruct the client to avoid raw fruits and vegetables that cannot be peeled.
E. Assign a dedicated nurse who is also caring for a client with a localized Staphylococcus aureus wound infection.
F. Administer a low-microbial (neutropenic) diet and ensure all foods are thoroughly cooked.
A, B, D, F
A is CORRECT: Clients with severe neutropenia or WBC require a protective environment (Neutropenic Precautions), which includes a private room with positive air pressure to ensure air flows out of the room rather than drawing unfiltered air and pathogens in.
B is CORRECT: Fresh flowers, plants, and standing water harbor environmental pathogens such as Pseudomonas aeruginosa and Aspergillus spores, posing a severe infection risk to an immunocompromised client.
C is INCORRECT: Invasive rectal procedures (rectal temperatures, suppositories, enemas) are strictly contraindicated due to the risk of traumatizing fragile mucosal tissue, which can introduce normal intestinal flora directly into the bloodstream and lead to sepsis.
D is CORRECT: Raw or unpeeled fruits and vegetables can carry soil-borne bacteria and fungi. Only foods that can be washed and peeled or thoroughly cooked should be consumed.
E is INCORRECT: Staff caring for a neutropenic client must not simultaneously care for clients with active, transmissible infections to prevent cross-contamination.
F is CORRECT: A neutropenic diet minimizes exposure to food-borne pathogens by eliminating undercooked meats, unpasteurized dairy, and raw/uncooked items.
A nurse is teaching a client about ways to help lower high blood pressure at home. Which recommendation should the nurse include?
A. Increase daily salt and canned soup intake.
B. Limit daily sodium (salt) intake and stay physically active.
C. Stop taking prescribed blood pressure pills as soon as readings look normal.
D. Restrict all water intake to less than 2 cups per day.
Answer B
Reducing sodium intake and maintaining regular exercise are key non-pharmacological ways to reduce blood pressure. Salt increases fluid retention, which raises blood pressure. Blood pressure medications should never be stopped without provider guidance.
A nurse is preparing to administer a prescribed ophthalmic ointment to a client with an eye infection. Which actions should the nurse take to ensure proper administration? (Select All That Apply)
A. Apply a thin ribbon of ointment along the inner edge of the lower conjunctival sac.
B. Move the ointment tube from the inner canthus to the outer canthus during application.
C. Place the ointment directly onto the center of the client's cornea for fast absorption.
D. Instruct the client to close their eye gently and roll the eyeball around after application.
E. Hold the ointment tube tip approximately 1/2inch away from the eye to prevent contamination.
F. Rub the eyelid vigorously in a circular motion for 1 minute to spread the medication.
A, B, D, E
A is CORRECT: Ointment belongs in the lower conjunctival sac (created by gently pulling down the lower eyelid), not directly on the eye itself.
B is CORRECT: Applying from the inner canthus to the outer canthus follows the eye's natural drainage and tear flow, ensuring even distribution.
C is INCORRECT: Medication should never be applied directly onto the sensitive cornea, as this triggers a painful blinking reflex and increases the risk of corneal abrasion.
D is CORRECT: Having the client close their eye gently and roll the eye around safely spreads the melted ointment across the eye surface without causing trauma.
E is CORRECT: Keeping the tube tip 1/2 inch away ensures the tip never touches the eyelid, lashes, or eyeball, preventing contamination of the remaining tube contents.
F is INCORRECT: Vigorous rubbing is contraindicated because it can force infection deeper into the ocular tissues or cause injury to the delicate eyelid and cornea.
A nurse is assessing a client who has had an indwelling urinary catheter in place for 5 days. Which assessment findings should alert the nurse to a potential catheter-associated urinary tract infection (CAUTI)? (Select All That Apply)
A. Suprapubic pain or lower abdominal discomfort
B. Cloudy, foul-smelling urine in the drainage bag
C. Fever and new-onset chills
D. New-onset confusion or altered mental status in an older adult
E. Pale, straw-colored urine with a clear output of 50 mL/hr
A,B,C,D
A is CORRECT: Localized inflammation from a bladder infection causes pain or tenderness over the suprapubic area.
B is CORRECT: Pyuria (white blood cells in urine) and bacterial growth cause urine to appear turbid (cloudy) and produce a strong, foul odor.
C is CORRECT: Systemic signs of infection, such as fever, chills, and tachycardia, indicate that the urinary infection may be ascending or becoming systemic (urosepsis).
D is CORRECT: In older adults, classic localized UTI symptoms (like dysuria or fever) are frequently absent; acute confusion, lethargy, or delirium is often the primary presenting sign of a CAUTI.
E is INCORRECT: Clear, pale yellow urine with adequate volume (30mL/hr is a normal, expected finding.
A provider orders 750 mL of 0.9% Normal Saline IV to infuse over 5 hours The IV administration set has a drop factor of 20gtt/mL. What drip rate should the nurse set in drops per minute (gtt/min) (Round to the nearest whole number).
A. 25 gtt/min
B. 50 gtt/min
C. 75 gtt/min
D. 150 gtt/min
B
gtts/min = 20gtts/ml x 750ml/5hr x1hr/60min
A nurse is preparing a sterile field to perform a complex dressing change for a surgical client. Which of the following actions by the nurse demonstrate proper adherence to sterile technique? (Select All That Apply)
A. Reaching directly across the sterile drape to pick up sterile forceps from the far edge.
B. Opening the outermost flap of the sterile package away from the nurse's body first.
C. Resting sterile gloved hands at hip level while waiting for a sterile solution to be poured.
D. Considering the outer 1-inch (2.5 cm) border around the edges of the drape to be unsterile.
E. Keeping the sterile field in direct line of sight and at or above waist level at all times.
F. Holding sterile supplies at least 6 inches above the field when dropping them onto the drape.
B, D, E, F
A is INCORRECT: Reaching across or directly over a sterile field introduces micro-droplets, dander, and airborne organisms from clothing and skin, immediately contaminating the sterile zone. The nurse should step around the table or reach from the side without crossing over the open field.
B is CORRECT: When opening a wrapped sterile item or kit, the outermost flap must be opened away from the nurse's body first to prevent reaching over an unsterile surface or contaminating the inner contents.
C is INCORRECT: Sterile gloved hands must always be kept above waist level and in front of the chest. Allowing hands to drop to the hip or below the waist renders them unsterile due to lack of visibility and potential contact with unsterile scrub material.
D is CORRECT: The outer 1-inch (2.5 cm) border surrounding a sterile drape is considered contaminated and unsterile. All sterile items must be dropped or placed strictly inside this inner perimeter.
E is CORRECT: A sterile field must always remain in direct line of vision and at or above waist height. Anything that falls below waist level or moves out of the nurse's line of sight is considered contaminated.
F is CORRECT: Dropping sterile supplies onto the field from approximately 6 inches above ensures the item lands safely within the sterile zone without touching the unsterile 1-inch border or forcing the nurse's hands over the field.
S (Situation): "I am caring for a client admitted with fluid volume overload who has suddenly developed severe dyspnea and work of breathing."
B (Background): "The client has a history of heart failure and received 1,000 mL of IV fluids over the past shift. Current blood pressure is 178/96 mmHg."
A (Assessment): "The client is laying down in bed, gasping for air, tachypneic at 32 breaths/min, with audible crackles bilaterally and an SpO 84 % on room air."
R (Recommendation): "Immediate nursing intervention and provider escalation are required."
Question: Based on the SBAR report above, place the nurse's next actions in the correct sequential order (from first action to last action):
Administer prescribed supplemental oxygen via nasal cannula.
Elevate the head of the bed to high-Fowler’s position.
Notify the healthcare provider of the client's acute respiratory distress.
Perform a focused respiratory assessment (listen to lung sounds and check pulse oximetry).
2 1 4 3
1st Action (2): Elevate the head of the bed to high-Fowler’s position.
(Immediate non-pharmacological positioning: Gravity drops the diaphragm and reduces venous return to an overloaded heart, easing lung expansion instantly.)
2nd Action (1): Administer prescribed supplemental oxygen via nasal cannula.
(With severe dyspnea identified in the SBAR report, providing immediate supplemental oxygen is the direct physical action to treat hypoxemia right after positioning.)
3rd Action (4): Perform a focused respiratory assessment.
(Re-evaluate lung sounds and SpO 2 to determine the client's immediate response to the positioning and oxygen interventions before placing the provider call.)
4th Action (3): Notify the healthcare provider.
(Escalate to the provider with complete, updated assessment findings to receive new orders, such as rapid-acting IV loop diuretics).
An 84-year-old client with a history of mild vascular dementia is admitted to the orthopedic unit following a total hip replacement. On post-op day 2, the client suddenly becomes agitated, attempts to climb out of bed, and reports seeing "spiders crawling on the IV pole." Vital signs are: BP 138/84, HR104 bpm, RR 22bpm, Temperature 101.2 oral , and SPO2 stat 95% on room air.
Which nursing action is the FIRST priority?
A. Re-orient the client firmly and explain that spiders are not present in the room.
B. Obtain a prescription for wrist restraints to prevent the client from pulling at lines.
C. Perform a focused assessment and review recent laboratory results for a potential physiological cause.
D. Request an immediate order for an antipsychotic medication to manage agitation.
C
Option C is CORRECT: The client is exhibiting signs of Delirium (acute onset, fluctuating agitation, visual hallucinations, tachycardia, fever) superimposed on underlying dementia. Delirium is a medical emergency caused by an underlying physiological trigger (e.g., surgical site infection, urinary tract infection, hypoxia, electrolyte imbalance, or adverse drug reaction). The nurse's first priority is to assess and identify the underlying physiological cause so it can be treated.
Option A is INCORRECT: Firmly arguing or forcing reality on an agitated, delirious client increases anxiety and can trigger a catastrophic reaction.
Option B is INCORRECT: Physical restraints are a last resort and often exacerbate delirium, increase agitation, and create a higher fall/injury risk.
Option D is INCORRECT: Chemical restraints (antipsychotics/sedatives) mask symptoms without addressing the underlying root cause (e.g., an untreated infection or hypoxia) and should not be the initial action.
A nurse is preparing to remove a nasogastric (NG) tube from a client whose intestinal motility has returned. Which action should the nurse instruct the client to take at the exact moment the tube is being withdrawn?
A. "Take a deep breath and hold it."
B. "Inhale and exhale rapidly in short, shallow breaths."
C. "Take a deep breath and cough forcefully."
D. "Take a slow, deep breath in and out continuously."
A
Verify order & assess bowel sounds/flatus.
Place towel across client's chest & flush tube with 30ml of air (clears liquid so it doesn't drip into pharynx).
Unpin tube from gown and unclamp/disconnect suction.
Instruct client to hold breath, then pull tube out in one smooth, continuous motion.
A family member wants to play loud, energetic music to help wake up a client with increased intracranial pressure (ICP). What is the nurse's best response?
A. "Loud music is fine, as long as we keep the room lights dimmed."
B. "Environmental stimulation like loud music can cause dangerous spikes in brain pressure."
C. "Energetic music is helpful because it stimulates neurological recovery."
D. "Music is allowed only if the client's bed is lowered completely flat."
B
Option B is CORRECT: High sensory stimulation (loud sounds, bright lights, frequent touch) increases cerebral metabolic demand and directly triggers spikes in ICP. The nurse must maintain a quiet, low-stimulus environment.
Option A is INCORRECT: Dimming lights does not negate the ICP spikes caused by loud audio stimulation.
Option C is INCORRECT: Sensory overload increases intracranial pressure rather than aiding safe recovery.
Option D is INCORRECT: Lowering the bed flat restricts jugular venous drainage and sharply increases ICP; the head of the bed should remain at 30 degrees.