NCLEX-RN Safety and Infection Control Practice Questions

Preventing injury and the spread of infection through asepsis, precautions, and a safe environment. It sits under Safe and Effective Care Environment on the NCLEX-RN test plan and carries an approximate weight of 12% of the exam.

Below are 22 practice questions for this domain — 14 multiple-choice and 8 select-all-that-apply. Every item gives a rationale for each option, not just the correct one: on the NCLEX-RN the distractors are usually plausible actions that are simply lower priority, so knowing why an answer is wrong is worth as much as knowing why one is right.

How to use this page. Read the vignette, commit to an answer, and only then open “Show the answer and rationales”. Reading the worked answer first feels productive and teaches almost nothing — the recall attempt is what makes it stick.

Select-all-that-apply items are graded all-or-nothing: partial credit does not exist, so a single missed option loses the whole question.

Easy Multiple choice

1. C. difficile — hand hygiene choice

A nurse finishes caring for a client on contact precautions for Clostridioides difficile infection and removes the gloves and gown before leaving the room. There is no visible soiling on the nurse's hands.

Which hand hygiene method should the nurse use?

  1. Wash the hands with soap and water.
  2. Apply alcohol-based hand rub until the hands are dry.
  3. Skip hand hygiene because gloves were worn during care.
  4. Use an antiseptic wipe on the hands.
Show the answer and rationales

Correct answer: A

  • A. Correct . C. difficile forms spores that alcohol-based hand rub does not kill. Washing with soap and water physically removes the spores, so it is the required method after caring for a client with C. difficile.
  • B. Incorrect . Alcohol-based rub is effective for many organisms but does not destroy C. difficile spores, so it is not adequate after this client contact.
  • C. Incorrect . Gloves are not a substitute for hand hygiene. Hands can become contaminated during glove removal, so hand hygiene is always required after doffing.
  • D. Incorrect . Antiseptic wipes do not reliably remove spores. Soap and water with friction and rinsing is the recommended approach for C. difficile.

Reference: CDC Clean Hands for healthcare providers; CDC C. difficile prevention guidance

Easy Multiple choice

2. Hand hygiene after toileting care

A nurse finishes assisting a client onto and off the bedside commode, removes the gloves, and is about to leave the room to answer another call light.

Which action should the nurse take before leaving the room?

  1. Perform hand hygiene with soap and water because the hands may be contaminated with body fluids.
  2. Skip hand hygiene because gloves were worn during the task.
  3. Apply a fresh pair of gloves over the same hands to save time.
  4. Perform hand hygiene only after reaching the next client's room.
Show the answer and rationales

Correct answer: A

  • A. Correct . Hand hygiene is required after a task involving body fluids and after glove removal, and soap and water is appropriate when contact with body fluids is likely.
  • B. Incorrect . Gloves are not a substitute for hand hygiene; hands can become contaminated during care and glove removal.
  • C. Incorrect . Putting on gloves without first cleaning the hands does not remove pathogens and can spread them to the next client.
  • D. Incorrect . Hand hygiene is required after contact with this client and the surroundings, before leaving the room, not deferred to the next room.

Reference: CDC hand hygiene guidance and WHO five moments for hand hygiene

Easy Multiple choice

3. Influenza — droplet precaution PPE

A nurse is assigned to a client admitted with confirmed seasonal influenza who is on droplet precautions in a private room. The nurse needs to enter the room to take morning vital signs.

Which personal protective equipment should the nurse don before entering?

  1. A surgical mask.
  2. A fit-tested N95 respirator and negative-pressure room.
  3. A gown and gloves only, with no mask.
  4. No protective equipment is needed beyond hand hygiene.
Show the answer and rationales

Correct answer: A

  • A. Correct . Influenza spreads by large respiratory droplets that travel only short distances, so droplet precautions call for a surgical mask within about 3 feet of the client. A private room is also used.
  • B. Incorrect . An N95 and negative pressure are required for airborne organisms such as tuberculosis or measles, not for droplet-spread influenza.
  • C. Incorrect . Gown and gloves address contact transmission. They do not protect the mucous membranes of the face from respiratory droplets, so a mask is the key item here.
  • D. Incorrect . Hand hygiene alone is insufficient for a client on droplet precautions; a surgical mask is required to prevent mucosal exposure to droplets.

Reference: CDC transmission-based precautions (droplet)

Easy Multiple choice

4. Quarantine versus isolation

During an orientation class, a new nurse asks the charge nurse to explain how quarantine differs from isolation in controlling communicable disease.

Which statement by the charge nurse is correct?

  1. Quarantine restricts the movement of people who have been exposed to a communicable disease but are not yet showing symptoms.
  2. Quarantine separates clients who already have a confirmed active infection from everyone else.
  3. Quarantine is the process of destroying all microorganisms, including spores, on contaminated equipment.
  4. Quarantine applies only to clients who require a negative-pressure airborne isolation room.
Show the answer and rationales

Correct answer: A

  • A. Correct . Quarantine separates the exposed-but-well to limit spread during the incubation period, which is precisely what distinguishes it from isolation.
  • B. Incorrect . That describes isolation, which separates those already infected. Quarantine applies to exposed people who are not yet symptomatic.
  • C. Incorrect . That describes sterilization of equipment, not a public-health movement restriction for exposed people.
  • D. Incorrect . Quarantine is a movement restriction for exposed individuals during incubation and is not tied to any specific room type.

Reference: CDC guideline for isolation precautions (quarantine versus isolation principles)

Easy Multiple choice

5. Standard precautions — when to apply

A nursing student tells the nurse that standard precautions only need to be used for clients who have a confirmed infectious diagnosis on the chart.

Which response by the nurse indicates correct understanding of standard precautions?

  1. Standard precautions are used with every client, treating all blood and body fluids as potentially infectious.
  2. Standard precautions are only required when a client has a known infection.
  3. Standard precautions can be skipped if the client looks healthy.
  4. Standard precautions apply only in the intensive care unit.
Show the answer and rationales

Correct answer: A

  • A. Correct . Standard precautions apply to all clients regardless of diagnosis, treating every client's blood, body fluids, secretions, and non-intact skin as potentially infectious.
  • B. Incorrect . Limiting precautions to known infections leaves staff and clients exposed to undiagnosed pathogens. Standard precautions are universal.
  • C. Incorrect . Appearance does not rule out infection; many pathogens are carried before symptoms appear, so precautions are always used.
  • D. Incorrect . Standard precautions apply in every care setting, not just critical care areas.

Reference: CDC standard precautions; CDC infection control basics

Medium Select all that apply

6. Applying a restraint safely

A provider has ordered a nonviolent wrist restraint for a confused client who repeatedly pulls at a needed nasogastric tube after less-restrictive measures have failed.

Which actions should the nurse take to apply and maintain the restraint safely? Select all that apply.

  1. Secure the restraint to a movable part of the bed frame, not to a side rail.
  2. Tie the restraint using a quick-release knot.
  3. Assess circulation, skin integrity, and the client's needs at least every 2 hours.
  4. Confirm that two fingers fit between the restraint and the wrist.
  5. Apply the restraint tightly enough that the client cannot move the wrist at all.
  6. Leave the restraint in place continuously without reassessing whether it is still needed.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Tying a restraint to a side rail can injure the client when the rail is raised or lowered, so it is attached to the part of the frame that moves with the client.
  • B. Correct . A quick-release knot lets the nurse free the client rapidly in an emergency.
  • C. Correct . Nonviolent restraints require ongoing monitoring, commonly at least every 2 hours, to protect circulation, skin, and basic needs.
  • D. Correct . The two-finger check ensures the restraint is snug but not so tight that it impairs circulation.
  • E. Incorrect . An overly tight restraint compromises circulation and skin integrity and can cause injury.
  • F. Incorrect . Restraint orders are time-limited and the ongoing need must be reassessed; the restraint is removed as soon as it is safe.

Reference: The Joint Commission and CMS standards on restraint use

Medium Multiple choice

7. Blood splash to the eye

While emptying a wound drainage container, a nurse is splashed in the eye with blood-tinged drainage from a client whose bloodborne status is unknown.

Which action should the nurse take first?

  1. Immediately flush the affected eye with water or sterile saline for at least 15 minutes.
  2. Apply an alcohol-based antiseptic to the eye to kill any pathogens.
  3. Complete an incident report and notify the supervisor before any first aid.
  4. Close the eye and watch for symptoms of infection to develop.
Show the answer and rationales

Correct answer: A

  • A. Correct . A mucous-membrane exposure is irrigated immediately to reduce the infectious load, and the eye is flushed with water or saline for about 15 minutes.
  • B. Incorrect . Alcohol and other antiseptics must never be placed in the eye; the eye is irrigated only with water or saline.
  • C. Incorrect . Reporting and evaluation are essential, but they follow immediate irrigation; first aid to the eye comes first.
  • D. Incorrect . Delaying irrigation increases risk; the eye must be flushed right away rather than waiting for symptoms.

Reference: OSHA bloodborne pathogens standard and CDC guidance on occupational exposure

Medium Select all that apply

8. Breaking the chain of infection

A nurse is teaching nursing assistants how to interrupt the chain of infection to prevent pathogens from spreading among clients on the unit.

Which actions break a link in the chain of infection? Select all that apply.

  1. Performing hand hygiene before and after every client contact.
  2. Ensuring susceptible clients receive recommended immunizations.
  3. Disposing of soiled dressings in a leakproof biohazard container.
  4. Covering coughs and sneezes and offering tissues.
  5. Reusing a single pair of gloves for several clients to conserve supplies.
  6. Leaving a full sharps container in place until it overflows.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Hand hygiene interrupts the mode of transmission, the link most often responsible for spreading pathogens between clients.
  • B. Correct . Immunization reduces host susceptibility, strengthening the client against infection and breaking that link in the chain.
  • C. Correct . Proper containment controls the reservoir and portal of exit so pathogens are not spread to others.
  • D. Correct . Respiratory hygiene blocks the portal of exit and the mode of transmission for respiratory pathogens.
  • E. Incorrect . Wearing the same gloves between clients carries pathogens from one to the next and promotes transmission rather than stopping it.
  • F. Incorrect . An overfilled sharps container raises the risk of injury and exposure and does nothing to break the chain of infection.

Reference: CDC infection control principles (chain of infection)

Medium Select all that apply

9. Fall prevention — interventions

A nurse admits an 80-year-old client who takes a diuretic and a sedative, has an unsteady gait, and has fallen once at home in the past month. The nurse completes a fall-risk assessment and identifies the client as high risk.

Which interventions should the nurse implement to reduce fall risk? Select all that apply.

  1. Keep the bed in the lowest position with the wheels locked.
  2. Place the call light and personal items within the client's reach.
  3. Perform hourly rounding to anticipate toileting and comfort needs.
  4. Apply a vest restraint to keep the client in bed.
  5. Raise all four side rails to keep the client in bed.
  6. Keep the room dim at all times so the client rests.
Show the answer and rationales

Correct answers: A, B, C

  • A. Correct . A low, locked bed shortens the distance to the floor and prevents the bed from rolling, both of which reduce fall and injury risk.
  • B. Correct . Keeping the call light and belongings within reach lets the client summon help instead of reaching or getting up unassisted.
  • C. Correct . Proactive hourly rounding meets needs before the client tries to get up alone and is an evidence-based fall-prevention strategy.
  • D. Incorrect . Restraints are a last resort, require a provider order, and can increase injury and agitation. They are not a routine fall-prevention measure.
  • E. Incorrect . Raising all four side rails is considered a restraint and can lead to serious injury when a client tries to climb over them.
  • F. Incorrect . A poorly lit room increases the risk of tripping. Adequate lighting and a clear path help prevent falls.

Reference: Agency for Healthcare Research and Quality fall prevention toolkit; MedlinePlus preventing falls

Medium Multiple choice

10. Needlestick — first action

While recapping a needle after drawing blood, a nurse sustains a needlestick injury to the finger from a device used on a client whose bloodborne status is unknown.

Which action should the nurse take first?

  1. Wash the puncture site with soap and water.
  2. Squeeze the puncture site to express blood from the wound.
  3. Notify the supervisor and complete an incident report.
  4. Go to employee health to start HIV post-exposure prophylaxis.
Show the answer and rationales

Correct answer: A

  • A. Correct . The first step after a percutaneous bloodborne exposure is to wash the site thoroughly with soap and water to reduce the infectious load. Reporting and evaluation follow immediately after.
  • B. Incorrect . Squeezing or milking the wound is not recommended because it can force contaminated material deeper into the tissue.
  • C. Incorrect . Reporting and incident documentation are essential and happen quickly, but the immediate first action is to wash the site.
  • D. Incorrect . Evaluation for prophylaxis is important and time-sensitive, but it follows the immediate first step of washing the wound.

Reference: CDC NIOSH bloodborne infectious disease risk factors; CDC best practices for occupational exposure to blood

Medium Select all that apply

11. Neutropenic client — protective environment

A nurse is caring for a client receiving chemotherapy whose absolute neutrophil count is 380 per microliter. The client is placed in a protective environment because of the high risk for infection.

Which interventions should the nurse include in the plan of care? Select all that apply.

  1. Place the client in a positive-pressure room with high-efficiency air filtration.
  2. Restrict fresh flowers and live plants from the room.
  3. Perform strict hand hygiene before entering the room.
  4. Screen visitors and staff for signs of active infection before entry.
  5. Place the client in a negative-pressure room with the door open.
  6. Serve the client raw fruits and fresh salads to boost nutrition.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . A protective environment uses positive pressure relative to the corridor and HEPA-filtered air so airborne pathogens are kept out of the highly susceptible client's room.
  • B. Correct . Fresh flowers, plants, and standing water can harbor fungi and bacteria that endanger a neutropenic client, so they are not permitted.
  • C. Correct . Meticulous hand hygiene is the most effective measure to protect an immunocompromised client from acquiring infection from staff.
  • D. Correct . Anyone with a respiratory or other active infection should not enter, so screening protects the susceptible client from exposure.
  • E. Incorrect . Negative pressure pulls corridor air into the room, which is the opposite of what a neutropenic client needs; protective environments use positive pressure with the door kept closed.
  • F. Incorrect . Raw, unpeeled produce can carry organisms that threaten a neutropenic client; a low-microbial diet is used instead.

Reference: CDC infection control environmental controls (protective environment); CDC guideline for isolation precautions

Medium Multiple choice

12. PPE removal sequence

A nurse has finished providing care for a client on contact and droplet precautions and is preparing to leave the room while wearing gloves, a gown, a surgical mask, and a face shield.

Which piece of personal protective equipment should the nurse remove first?

  1. Gloves.
  2. Face shield.
  3. Gown.
  4. Surgical mask.
Show the answer and rationales

Correct answer: A

  • A. Correct . Gloves are the most contaminated item, so they are removed first to prevent transferring pathogens to the face and other surfaces. The recommended sequence is gloves, then goggles or face shield, then gown, then mask.
  • B. Incorrect . The face shield is removed after the gloves. Removing it first with contaminated gloves risks transferring pathogens toward the face.
  • C. Incorrect . The gown is removed after the gloves and eye protection, not first.
  • D. Incorrect . The mask is removed last, after leaving the patient area, because the front is considered contaminated and the airway is protected until the end of doffing.

Reference: CDC sequence for putting on and removing personal protective equipment

Medium Select all that apply

13. Preventing catheter-associated UTI

A nurse is caring for a client with a newly inserted indwelling urinary catheter and wants to reduce the risk of a catheter-associated urinary tract infection, one of the most common healthcare-associated infections.

Which interventions should the nurse include in the plan of care? Select all that apply.

  1. Keep the drainage bag below the level of the bladder at all times.
  2. Perform hand hygiene before and after handling the catheter or drainage system.
  3. Review the continued need for the catheter daily and advocate for early removal.
  4. Maintain a closed, intact drainage system and avoid disconnecting the tubing.
  5. Irrigate the catheter routinely with sterile saline every shift to keep it patent.
  6. Rest the drainage bag on the bed beside the client during transport for convenience.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Positioning the bag below the bladder prevents urine from flowing back into the bladder, which would introduce pathogens.
  • B. Correct . Hand hygiene around catheter manipulation is a core element of the prevention bundle and limits introduction of organisms.
  • C. Correct . Shortening the time the catheter is in place is the single most effective way to reduce catheter-associated infection risk.
  • D. Correct . Breaks in the closed system create an entry point for pathogens, so the system is kept intact whenever possible.
  • E. Incorrect . Routine irrigation is not recommended and breaks the closed system, increasing rather than reducing infection risk.
  • F. Incorrect . Raising the bag above the bladder allows urine to reflux into the bladder and increases the risk of infection.

Reference: CDC HICPAC guideline for prevention of catheter-associated urinary tract infections

Medium Multiple choice

14. Shared blood glucose meter

A nurse on a busy unit sees a colleague use one client's blood glucose meter to test a second client after quickly wiping the device with an alcohol pad.

Which action by the nurse is most appropriate?

  1. Stop the practice and ensure each client has a dedicated blood glucose meter.
  2. Reassure the colleague that wiping the meter with alcohol makes it safe to share.
  3. Recommend a bleach wipe so the meter can be reused on several clients.
  4. Take no action because the meter only touches intact skin at the fingertip.
Show the answer and rationales

Correct answer: A

  • A. Correct . Glucose meters should never be shared between clients; wiping with alcohol does not reliably remove bloodborne pathogens, and shared meters have caused hepatitis B outbreaks, so each client needs a dedicated device.
  • B. Incorrect . Seventy percent alcohol does not reliably inactivate hepatitis B virus on a blood-contaminated device, so the meter is not safe to share.
  • C. Incorrect . Even with disinfection, a device that contacts blood can transmit hepatitis B; the guidance is not to share glucose meters at all.
  • D. Incorrect . A fingerstick draws blood, so the meter is exposed to blood and sharing it can transmit bloodborne pathogens between clients.

Reference: CDC injection safety guidance on assisted blood glucose monitoring; FDA blood glucose meter use recommendations

Medium Select all that apply

15. Sterile field — recognizing contamination

A nurse sets up a sterile field to assist with a bedside dressing change and is monitoring the field while gathering supplies.

Which situations should the nurse recognize as contaminating the sterile field? Select all that apply.

  1. A sterile item is placed within 1 inch of the edge of the field.
  2. The nurse turns away and the field is briefly out of sight.
  3. Sterile liquid soaks through the drape to the non-sterile surface below.
  4. The nurse adds supplies by dropping them onto the center of the field.
  5. The field is positioned at waist level and remains in full view.
Show the answer and rationales

Correct answers: A, B, C

  • A. Correct . The outer 1-inch border of a sterile field is considered contaminated, so items must be kept inside that margin.
  • B. Correct . A sterile field that is unobserved or out of sight is considered contaminated because its integrity can no longer be verified.
  • C. Correct . Moisture wicks microorganisms upward through the drape by capillary action, so a wet field over a non-sterile surface is contaminated.
  • D. Incorrect . Dropping sterile items onto the center of the field, away from the 1-inch border, is correct technique and does not contaminate it.
  • E. Incorrect . A sterile field kept at or above waist level and in continuous view remains sterile; dropping below the waist is what contaminates it.

Reference: Association of periOperative Registered Nurses guidelines for sterile technique; CDC guideline for isolation precautions

Medium Multiple choice

16. Suspected norovirus outbreak

Over a single shift on a medical unit, three clients in adjacent rooms develop sudden nausea, vomiting, and watery diarrhea. The nurse suspects a norovirus outbreak.

Which action should the nurse take first?

  1. Notify infection control and place the affected clients on contact precautions.
  2. Clean the rooms with an alcohol-based product and continue routine care.
  3. Use alcohol-based hand rub after each client to work more quickly.
  4. Wait to see whether more clients become ill before notifying anyone.
Show the answer and rationales

Correct answer: A

  • A. Correct . A cluster of similar symptoms must be reported promptly so containment can begin, and norovirus spreads by the fecal-oral route, so contact precautions are indicated right away.
  • B. Incorrect . Alcohol is not reliably effective against norovirus; a bleach solution is needed, and this response delays the priority of reporting the cluster.
  • C. Incorrect . Soap and water is preferred during a norovirus outbreak because alcohol does not reliably kill the virus, and hand hygiene alone does not address the cluster.
  • D. Incorrect . Delaying recognition lets the outbreak spread; clusters of similar symptoms must be reported to infection control without delay.

Reference: CDC guideline for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings

Medium Multiple choice

17. Tuberculosis — airborne room setup

A nurse is admitting a client with suspected active pulmonary tuberculosis to an airborne infection isolation room. The nurse observes another staff member preparing the room.

Which observation requires the nurse to intervene?

  1. The door to the negative-pressure room is propped open.
  2. A fit-tested N95 respirator is placed at the doorway for staff.
  3. The room is set to negative pressure relative to the hallway.
  4. A sign on the door alerts visitors to check with the nurse first.
Show the answer and rationales

Correct answer: A

  • A. Correct . Airborne precautions require the negative-pressure room door to stay closed so air flows inward and infectious nuclei are not drawn into the corridor. A propped-open door defeats the negative pressure and must be corrected.
  • B. Incorrect . A fit-tested N95 is the correct respiratory protection for airborne precautions, so this is appropriate and requires no intervention.
  • C. Incorrect . Negative pressure relative to the corridor is exactly what an airborne isolation room requires, so this finding is correct.
  • D. Incorrect . Posting precaution signage so visitors stop and don appropriate protection is standard practice and needs no correction.

Reference: CDC infection control transmission-based precautions; CDC tuberculosis infection control in healthcare facilities

Medium Multiple choice

18. Varicella precautions teaching

A nurse is assigned to a client admitted with disseminated varicella and is reviewing the transmission-based precautions needed before entering the room.

Which statement by the nurse indicates correct understanding of the precautions?

  1. I will use both airborne and contact precautions, wearing an N95 respirator with a gown and gloves.
  2. A surgical mask within three feet is all that is required for this client.
  3. Standard precautions alone are sufficient because the lesions are covered.
  4. Contact precautions with a gown and gloves are enough; no respirator is needed.
Show the answer and rationales

Correct answer: A

  • A. Correct . Varicella requires airborne precautions because it spreads through the air and contact precautions because of the lesions, so an N95 plus a gown and gloves are needed.
  • B. Incorrect . That describes droplet precautions. Varicella is airborne and needs an N95 respirator and a negative-pressure room.
  • C. Incorrect . Varicella is highly contagious and requires transmission-based precautions layered on top of standard precautions.
  • D. Incorrect . Varicella is airborne as well as contact, so a gown and gloves alone are not enough; an N95 respirator and negative-pressure room are also required.

Reference: CDC guideline for isolation precautions (airborne and contact precautions for varicella)

Medium Select all that apply

19. Which clients need airborne precautions

A charge nurse is making assignments and must identify which clients require airborne precautions, with a negative-pressure room and an N95 respirator, rather than droplet or contact precautions.

Which clients require airborne precautions? Select all that apply.

  1. A client with newly diagnosed active pulmonary tuberculosis.
  2. A child admitted with measles.
  3. A client with disseminated herpes zoster.
  4. A client with pertussis.
  5. A client with Clostridioides difficile colitis.
  6. A client with seasonal influenza.
Show the answer and rationales

Correct answers: A, B, C

  • A. Correct . Tuberculosis spreads by tiny droplet nuclei that stay suspended in air, so it requires airborne precautions with a negative-pressure room and an N95 respirator.
  • B. Correct . Measles is highly contagious and airborne, requiring a negative-pressure room and an N95 respirator for anyone entering.
  • C. Correct . Disseminated zoster requires airborne precautions in addition to contact precautions because the virus can spread through the air.
  • D. Incorrect . Pertussis spreads by large respiratory droplets over short distances, so it calls for droplet precautions and a surgical mask, not airborne precautions.
  • E. Incorrect . C. difficile spreads by contact with spores, so contact precautions and soap-and-water hand hygiene are used, not airborne precautions.
  • F. Incorrect . Influenza spreads by droplets, so droplet precautions with a surgical mask are appropriate rather than airborne precautions.

Reference: CDC guideline for isolation precautions (transmission-based precautions)

Hard Multiple choice

20. Highest risk for infection

A nurse on a medical unit is reviewing four assigned clients at the start of the shift and is identifying which client is most vulnerable to a serious infection.

Which client is at the highest risk for developing a serious infection?

  1. A client receiving chemotherapy whose absolute neutrophil count is 300 per microliter.
  2. A 70-year-old client with a clean, well-approximated surgical incision.
  3. A client with a healed pressure injury and intact skin.
  4. A client with a treated urinary tract infection responding to oral antibiotics.
Show the answer and rationales

Correct answer: A

  • A. Correct . An absolute neutrophil count below 500 per microliter is severe neutropenia, which sharply raises the risk of life-threatening infection, making this the most susceptible host.
  • B. Incorrect . Age and surgery add some risk, but an intact, healing incision is a far lower acute risk than severe neutropenia.
  • C. Incorrect . Intact skin is a strong first line of defense, so this client has a relatively low current infection risk.
  • D. Incorrect . An existing infection that is already responding to treatment is a lower acute risk than profound immunosuppression from chemotherapy.

Reference: MedlinePlus and Merck Manual on neutropenia and infection risk

Hard Select all that apply

21. Maintaining surgical asepsis

A nurse is inserting an indwelling urinary catheter using surgical sterile technique and wants to keep the sterile field intact throughout the procedure.

Which actions correctly maintain surgical asepsis? Select all that apply.

  1. Keep all sterile items above waist level and within sight.
  2. Treat the outer 1-inch border of the sterile field as contaminated.
  3. Open the sterile package away from the body without reaching across the field.
  4. If unsure whether an item is sterile, treat it as contaminated and discard it.
  5. Set the sterile supplies down and turn away to gather more items, leaving the field unattended.
  6. Pour sterile solution by reaching directly over the open sterile field.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Anything held below the waist or out of sight is considered contaminated, so sterile items stay above the waist and in view.
  • B. Correct . The 1-inch margin around a sterile field is regarded as nonsterile and is not used for sterile items.
  • C. Correct . Reaching over a sterile field contaminates it, so packages are opened away from the body to keep arms clear of the field.
  • D. Correct . When in doubt, throw it out; any item of uncertain sterility is considered contaminated.
  • E. Incorrect . Turning your back on or leaving a sterile field unattended means it can no longer be considered sterile.
  • F. Incorrect . Reaching across the sterile field to pour contaminates it; solutions are added without arms passing over the field.

Reference: CDC and standard surgical asepsis principles for sterile technique

Hard Multiple choice

22. Violent-behavior restraint order

An adult client in the emergency department becomes violent and a danger to staff, and a provider orders violent or self-destructive behavior restraints after less-restrictive measures fail. A new nurse asks the charge nurse about the rules for this order.

Which statement by the charge nurse is correct?

  1. The order is time-limited to a maximum of 4 hours for an adult and must be renewed if restraint continues.
  2. A single order can keep the client restrained for the entire shift.
  3. The nurse may apply restraints first and obtain the order the next day.
  4. The restraint may be tied to the side rail for quick access.
Show the answer and rationales

Correct answer: A

  • A. Correct . For violent or self-destructive behavior, orders are limited to 4 hours for adults 18 and older and must be renewed within those limits if restraint is still needed. Restraint orders are never written as standing or as needed.
  • B. Incorrect . Restraint orders for violent behavior are time-limited and require renewal; a single order cannot cover an entire shift indefinitely.
  • C. Incorrect . Restraints require a provider order; in an emergency the nurse may initiate them but must obtain the order promptly, not the next day, and a face-to-face evaluation is required within 1 hour.
  • D. Incorrect . Restraints are secured to the bed frame with a quick-release knot, never to a side rail, which could injure the client when the rail is moved.

Reference: CMS Conditions of Participation on patient rights (restraint and seclusion); Joint Commission restraint standards

Keep practising

These same questions are mixed into the interactive quizzes for this domain, where they are graded and feed your spaced-repetition schedule. The timed mock exam draws from every domain at its real test-plan weight.

Study sets in this domain