NCLEX-RN Safety & Infection Prevention & Control Exam

A client is admitted to the orthopedic unit after being involved in a motor vehicle accident and sustaining a fracture of the right humerus.

> What is the nurse’s priority intervention for this client?

The nurse is caring for a client with Guillain-Barré syndrome and is reviewing orders placed by the healthcare provider (HCP).

> Which order should the nurse clarify with the HCP?

The nurse is reviewing post-procedure care for the client who has undergone a diagnostic renal scan.

> Which is the priority intervention to include in the plan of care?

A client presents to the clinic for evaluation of a ring-shaped rash with central clearing on his left upper leg. The client denies any burning or itching but does report some increased fatigue.

> Which initial question should the nurse ask to help identify the source of the rash?

A client is scheduled for a diagnostic imaging study that uses ionizing radiation.

> Which question is most essential for the nurse to ask during pre-procedure screening?

A home care nurse completes an initial visit with an older adult who reports taking numerous prescribed and nonprescribed medications each day. The medication list includes several drugs with similar names and purposes.

> What should the nurse do first?

A pregnant client’s rubella titer indicates immunity. The client asks whether it is safe for her toddler to receive scheduled immunizations.

> What is the nurse’s best response?

During a therapy group, a client angrily states, “I’m going to hurt someone in here.”

> What is the nurse’s most appropriate initial response?

A nurse assists a client with a tracheostomy to turn in bed when accidental decannulation occurs. Re-insertion with the original tube is unsuccessful.

> While awaiting the rapid response team, which action should the nurse take next?

The nurse is preparing an in-service for new staff about prevention and management of Clostridioides difficile infection on a medical unit that has had several recent cases.

> Which topics should the nurse include? Select all that apply.

A child with leukemia is receiving chemotherapy. Morning labs return with a platelet count of 25,500/mm³ (25.5 × 10⁹/L).

> Which intervention should the nurse include in the plan of care based on this result?

A client is prescribed total parenteral nutrition with lipid emulsion. Before administration, the nurse completes an allergy assessment.

> Which reported allergy would require withholding the lipid emulsion and notifying the provider?

The nurse prepares to perform a capillary blood glucose test.

> Which actions help ensure an accurate result? Select all that apply.

A nurse enters a client’s room and notices flames coming from a trash receptacle. The nurse assists the client safely into the hallway.

> What action should the nurse take next?

A nurse is creating an individualized plan of care for a client with advanced Alzheimer’s disease who requires assistance with all activities of daily living and frequently wanders.

> Which problem should the nurse identify as the highest priority?

A client experiencing acute mania begins making sexual advances toward visitors in a shared unit space. After the nurse sets firm behavioral limits, the client becomes verbally aggressive and threatens physical harm.

> Which intervention should the nurse implement next?

A child with scabies is prescribed lindane.

> Which finding requires the nurse to question the prescription?

During routine tracheostomy care, the nurse notes soft tissue swelling around the stoma without redness or drainage.

> What is the nurse’s next action?

A nurse is preparing to assist with hygiene care for a hospitalized client who has profuse watery diarrhea and a confirmed diagnosis of Clostridioides difficile infection.

> Which personal protective equipment is required before entering the room?

A nurse teaches the parent of a child living with AIDS about infection control and monitoring at home.

> Which instructions should the nurse include? Select all that apply.