Saunders NClex-PN Fun: Infection Control
A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client? Select all that apply. 1. Check temperature at least every 4 hours. 2. Monitor white blood cell count daily as prescribed. 3. Eliminate fruits and vegetables from the client's diet. 4. Remove fresh flowers or plants from the client's room. 5. Administer oxygen to maintain the oxygen saturation level greater than 97%.
Correct Answer: 1, 2, 4
A client is diagnosed with Haemophilus influenzaepneumonia. In addition to standard precautions, which other precautions should be institutedimmediately by the nurse? 1. Droplet precautions 2. Contact precautions 3. Airborne precautions 4. Neutropenic precautions
Correct Answer: 1
The nurse receives the culture test results for a client who developed a bloodstream infection from a central venous device. The culture report indicates that the infection is exogenous. The client asks the nurse how she could have contracted this infection. Which should the nurse include in the explanation of potential sources of infectious organisms? Select all that apply. 1. The health care facility 2. The nurse caring for the client 3. The client's use of homeopathy 4. The use of high doses of antibiotic therapy 5. The use of contaminated intravenous fluids 6. The reactivation of a previous dormant organism
Correct Answer: 1, 2, 5
A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions? 1. Places the client in a private room 2. Wears gloves, gown, and goggles when changing the client's colostomy bag 3. Wears a gown when caring for the client and removes the gown immediately after leaving the client's room 4. Places the client in a semiprivate room with another client who has active infection with the same microorganism but who has no other infection
Correct Answer: 3
A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for further teachingis necessary when the client makes which statement? 1. "I need to breastfeed my baby." 2. "I can continue to hug and hold my other children." 3. "It may be 2 years before I know if my baby has HIV." 4. "My husband and I can still sleep together in the same bed."
Correct Answer: 1
The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? 1. "I can give my child acetaminophen for fever." 2. "I will watch for any hearing loss that may occur." 3. "I know that I will need to watch for any rash that my child may develop." 4. "I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."
Correct Answer: 4
An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention? 1. Determining what common food item was ingested by those affected 2. Reviewing the signs and symptoms related to the Salmonellabacteria 3. Notifying the U.S. Centers for Disease Control and Prevention (CDC) 4. Teaching the basic methods for preventing food contamination to those affected
Correct Answer: 1
The nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery? 1. Discussing the normal involution process with the client 2. Encouraging early ambulation and the return to daily activities 3. Reviewing hand-washing techniques and pericare with the client 4. Instructing the client in proper positioning of the infant to facilitate breastfeeding
Correct Answer: 3
The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? 1. Wear gloves only. 2. Wear a mask and gloves. 3. Wear a gown and gloves. 4. Avoid touching the client's clothes.
Correct Answer: 3
The nurse is giving a client a bed bath and drops the towel on the floor. The nurse should take which action? 1. Use a bath blanket as a towel. 2. Borrow a towel from the client's roommate. 3. Wash the hands, pick up the towel, and shake it off. 4. Wash the hands and go to the linen room to obtain another towel.
Correct Answer: 4
A child is diagnosed with bacterial conjunctivitis and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse should make which response to the parent? 1. "The child can return to school immediately." 2. "The child cannot return to school until seen by the primary health care provider (PHCP) in 1 week." 3. "The child should be kept home until the antibiotic eye drops have been administered for 1 week." 4. "The child should be kept home until the antibiotic eye drops have been administered for 24 hours."
Correct Answer: 4
In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies should the nurse bring to the child's room to prevent the transmission of the virus? 1. Mask and gloves 2. Gown and gloves 3. Goggles and gloves 4. Gown, gloves, and goggles
Correct Answer: 1
The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement? 1. "I should use disposable plates, forks, and knives." 2. "I should cough into tissues and throw them away carefully." 3. "It's important to cover my mouth if I laugh, sneeze, or cough." 4. "It's very important to wash my hands after I touch my mask, tissues, or body fluids."
Correct Answer: 1
The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure? 1. Discard used tissues in a plastic bag. 2. Wash hands at least four times a day. 3. Brush teeth and rinse the mouth once a day. 4. Turn the head to the side if coughing or sneezing.
Correct Answer: 1
The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action? 1. Change the IV tubing. 2. Wipe the tubing with Betadine. 3. Scrub the tubing with an alcohol swab. 4. Scrub the tubing before attaching it to the IV bag.
Correct Answer: 1
The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply. 1. Perform hand hygiene after removal of PPE. 2. Perform hand hygiene before donning any PPE. 3. When removing PPE, always remove gloves first. 4. Gloves should be applied under the sleeves of the gown. 5. Leaving the room wearing PPE for several minutes is permissible. 6. Protective eyewear and face shield are indicated if there is risk of splatter.
Correct Answer: 1, 2, 3, 6
A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply. 1. Get plenty of sleep and rest. 2. Take all medications as prescribed. 3. Eat plenty of fresh fruits, salads, and vegetables. 4. Wash your hands frequently with antibacterial soap. 5. Having indoor plants is permissible, but no outdoor gardening. 6. Contact the primary health care provider (PHCP) if even a low-grade fever develops.
Correct Answer: 1, 2, 4, 6
A client with tuberculosis, whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. What should the nurse tell the client? 1. "Five sputum cultures must be negative before returning to work." 2. "Three sputum cultures must be negative before returning to work." 3. "A sputum culture and a chest x-ray must be negative before returning to work." 4. "A sputum culture and a Mantoux test must be negative before returning to work."
Correct Answer: 2
The nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which instruction will have the greatest impact on minimizing the spread of the virus? 1. Using personal protective equipment appropriately 2. Understanding the implementation of airborne precautions 3. Knowing the HIV status of every client currently on the unit 4. Determining whether the client has been placed in protective isolation
Correct Answer: 1
The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply. 1. Put on a mask. 2. Don gown and gloves. 3. Apply shoe protectors. 4. Wear a pair of protective goggles. 5. Have the client wear a mask and goggles.
Correct Answer: 1, 2, 4
Following a cleft lip repair, the nurse reinforces instructions to the parents of the infant. Which of the instructions should be given to the parents of the infant? Select all that apply. 1. Monitor frequency of diaper changes. 2. Cleanse the surgical site with normal saline 3. Offer the infant a pacifier in between feedings. 4. Do not use a car seat until the incision is healed. 5. Apply prescribed antibiotic ointment to the surgical site.
Correct Answer: 1, 2, 5
The nurse performs an audit in the hospital intensive care unit of clients who have indwelling urinary catheters. Which observations, found in the audit, pose a risk for a health care-associated infection? Select all that apply. 1. Drainage bag port touching the floor 2. Dependent loop in the catheter tubing 3. Cleansing around the catheter with soap and water twice daily 4. A stabilizing device in place to keep the catheter from moving 5. Use of one measuring container between two clients with the same pathogen in the urine 6. Using a sterile syringe through the tubing port cleansed with antiseptic to obtain a urine specimen
Correct Answer: 1, 2, 5
The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review? Select all that apply. 1. Needle-stick injuries 2. Use of latex condoms 3. Transmission by breast milk 4. Mutually monogamous relationships 5. Inconsistent use of protective equipment
Correct Answer: 1, 3, 5
The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV? Select all that apply. 1. Wear an N95 respirator when in the client's room. 2. Recap all needles to prevent accidental needle sticks. 3. Perform hand hygiene before and after contact with the client. 4. Use biohazard bags for items saturated with blood and bodily fluids. 5. Wear personal protective equipment when contact with blood and other bodily fluids are anticipated.
Correct Answer: 3, 4, 5
A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client? 1. "You will be isolated from your newborn after delivery." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."
Correct Answer: 4
The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which should be the appropriate form of isolation to use to prevent the spread of infection to others? 1. Droplet precautions isolation 2. Enteric precautions 3. Contact precautions 4. Standard precautions
Correct Answer: 4
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse reinforces discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further teaching? 1. "I can use an ophthalmic analgesic ointment at night if I have eye discomfort." 2. "I do not need to be concerned about spreading this infection to others in my family." 3. "I should apply a warm compress before instilling antibiotic drops if purulent discharge is present in my eye." 4. "I should perform a saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present."
Correct Answer: 2
The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which items when performing this care? 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear
Correct Answer: 2
The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother? 1. Isolate the child from others because the virus is transmitted by breathing and coughing. 2. Wash sheets and towels used by the child separately in bleach to prevent the spread of the infection to the others. 3. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva. 4. Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection through the urine and feces.
Correct Answer: 3
The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. Neutropenic precautions have been implemented. Which activity should the nurse question if observed while caring for this client? 1. The family brings a bouquet of plastic flowers to brighten the client's room. 2. The family member with a cold wears a mask while visiting for a short period of time. 3. The client orders lunch of soup, salad with tomatoes and cucumbers, and an apple. 4. The client wears a mask while being transported to the interventional radiology department.
Correct Answer: 3
The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1. Contact 2. Enteric 3. Droplet 4. Neutropenic
Correct Answer: 3
The nurse is preparing to comb the hair of a child client who has been treated for pediculosis (lice) at a clinic. Which additional instructions should the nurse give the parents of the child? Select all that apply. 1. Having pediculosis once gives the child immunity. 2. All head wear and bed linens should be washed in hot water. 3. The presence of lice in a child are evidence of neglect and poor hygiene. 4. A parent should observe all persons in the household for presence of lice or nits 5. If others in the household are found to have pediculosis, they all must be treated and have the nits removed from their hair.
Correct Answer: 2, 4, 5
The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse should avoid which action? 1. Clamping the tubing of the drainage bag 2. Obtaining the specimen from the urinary drainage bag 3. Aspirating a sample from the port on the tubing attached to the drainage bag 4. Wiping the port on the tubing with an alcohol swab before inserting the syringe
Correct Answer: 2
The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which nursing action would be most appropriate in preparing the client for the test? 1. Plan to have the MRI performed at the bedside. 2. Place a surgical mask on the client for transport and for contact with other individuals. 3. Ask that the MRI department be called to tell technicians in the department to wear masks. 4. Ask that the MRI department be called to tell the technician that the test will have to be delayed until the airborne precautions are discontinued.
Correct Answer: 2
The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse use during the bathing of this client? 1. Gloves 2. Gown and gloves 3. Gown, gloves, and mask 4. Gown and gloves to change the bed linens and gloves only for the bath
Correct Answer: 2
Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply. 1. Empty the urinary drainage bag every 12 hours. 2. Use indwelling urinary catheters judiciously. 3. Remove indwelling catheters when no longer needed. 4. Use strict aseptic technique when inserting all urinary catheters. 5. Do not insert straight catheters into a client more than once a day. 6. Irrigate all indwelling catheters every day to prevent obstruction.
Correct Answer: 2, 3, 4
The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves? 1. Insert left hand into left glove. 2. Insert right hand into right glove. 3. Place gloved right hand under the cuff of left glove. 4. Pick up right glove at cuff with left thumb and forefinger.
Correct Answer: 4
A hospitalized child with leukemia has received chemotherapy by the intravenous (IV) route, and a discharge to home is being planned. Laboratory values indicate that the child is neutropenic. The child is being treated daily by cleansing and the application of a topical antibiotic on an open area from an old IV site. The nurse reinforces instructions to the mother regarding the signs of infection at this affected site. Which statement by the mother indicates that the mother understands the instructions? 1. "Pus at the site means that an infection is present." 2. "I will clean the site and apply the topical ointment every day." 3. "If I see redness at the site, I don't need to worry as long as there is no pus." 4. "If the temperature is elevated, I don't need to be concerned, because this is normal with affected white blood cells."
Correct Answer: 2
The nurse should plan to reinforce instructions to which clients about the risk for transmission of disease through blood and sexual contact? Select all that apply. 1. A client diagnosed with hepatitis A virus 2. A client diagnosed with hepatitis B virus 3. A client diagnosed with hepatitis C virus 4. A client diagnosed with Rocky Mountain spotted fever 5. A client with a wound infection with Staphylococcus aureus 6. A client diagnosed with human immunodeficiency virus (HIV)
Correct Answer: 2, 3, 6
In developing a plan of care for a client hospitalized with tuberculosis (TB), the nurse should place emphasis on which intervention? 1. Instructions on deep-breathing techniques 2. An increase in fluid intake to at least 3000 mL a day 3. The strict adherence to following airborne precautions 4. Special assistance in order to perform activities of daily living (ADLs)
Correct Answer: 3
A health care worker who signed a waiver and never received the hepatitis B vaccine receives a needle stick from a client who has hepatitis B. Which treatments are indicated for the health care worker under this situation? Select all that apply. 1. Vitamin C orally 2. Ciprofloxacin orally 3. Hepatitis B immune globulin 4. Initiate hepatitis B vaccine series 5. Cleanse needlestick site with soap and water
Correct Answer: 3, 4, 5
A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor vital signs. 2. Change dressing as needed. 3. Change infusion tubing every 24 hours. 4. Use strict aseptic technique when caring for the catheter. 5. Contact the primary health care provider for a prescription for antibiotics.
Correct Answer: 2, 3, 4
A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications. 2. The most lethal form of anthrax is contacted by inhalation of the spores. 3. Anthrax can be transmitted by consumption of meat from an infected animal. 4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.
Correct Answer: 4
When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution should the nurse institute before making contact with the client? 1. Don a mask and gloves. 2. Put on a pair of gloves. 3. Put on a gown and gloves. 4. Don a mask and a gown.
Correct Answer: 3
The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply. 1. Wear a mask if within 3 feet of the client. 2. Place a mask on the client when client is outside the room. 3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene. 5. Keep the door of the room shut except when entering or exiting the client's room.
Correct Answer: 3, 4
The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? 1. A staff member who has never had roseola 2. A staff member who has never had mumps 3. An unlicensed assistive personnel who has never had chickenpox 4. An unlicensed assistive personnel who has never had German measles
Correct Answer: 3
The nurse is working with an unlicensed assistive personnel (UAP) to care for clients. While observing the UAP's delivery of care, the nurse notes which actions by the UAP that indicates the need for further teaching regarding standard precautions? Select all that apply. 1. Does not wear gloves to comb a client's hair 2. Wears gloves and holds dirty linen away from own clothing 3. Removes gloves and immediately uses computer to document care 4. Uses alcohol-based hand sanitizer upon entering the room of a client 5. Uses soap and water to wash hands for 5 seconds and then dries hands 6. Empties collection bag of an indwelling urinary catheter without wearing gloves
Correct Answer: 3, 5, 6
The nurse prepares the client for irrigation of an abdominal wound. Refer to video. Click on the Question Video button to view a video showing preparation procedures. After preparation, the nurse should appropriately don which article(s) to perform the procedure? 1. Gloves 2. Gloves and a gown 3. Gloves and goggles 4. Gloves, gown, and goggles
Correct Answer: 4
A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce? Select all that apply. 1. Wash soiled clothes in hot water. 2. Disinfect surfaces with 100% bleach. 3. Use gloves when handling body fluids. 4. Encourage a minimum of 12 hours sleep per day. 5. Other members of the household should not share a bathroom. 6. Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes.
Correct Answer: 1, 3, 6
The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first? 1. Location of supplies 2. The handling of equipment 3. Proper hand-washing technique 4. Method to report signs of infection
Correct Answer: 3
The nurse is changing a dressing on the wound of a postsurgical client who is receiving contact precautions because of a history of methicillin-resistant Staphylococcus aureus (MRSA) from a previous surgery. Which interventions should the nurse follow? Select all that apply. 1. Wear a mask and apply a mask to the client. 2. Observe the incision line for redness and drainage. 3. Medicate the client for pain after the dressing change. 4. Press firmly on the incision to determine if drainage is present. 5. Change gloves between removal of the old dressing and applying the new.
Correct Answer: 2, 5
The nurse reinforces instructions to a client diagnosed with impetigo. Which statements by the client indicate a need for further teaching? Select all that apply. 1. "I need to continue with the antibiotics as prescribed." 2. "I can wash my laundry with other household members' items." 3. "I need to wash my hands thoroughly and frequently throughout the day." 4. "I should not wash the lesions of the infection once the skin lesions have scabbed over". 5. "I need to separate my dishes and wash them separately from the dishes of other household members."
Correct Answer: 2, 4
A 70-year-old client who has been treated for cellulitis of the leg asks the nurse how to improve resistance to infection. Which measures should the nurse reinforce in the teaching plan? Select all that apply. 1. Take a hot bath or shower twice daily. 2. Balance activity, rest, and avoid stress. 3. Eat mainly organic fruits and vegetables. 4. Keep skin on arms and legs well lubricated. 5. Wash any breaks in the skin with soap and water. 6. Receive recommended vaccines against influenza and pneumonia.
Correct Answer: 2, 4, 5, 6
A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the primary health care provider's office because the leukemic child has never had chickenpox. The nurse should make which response to the mother? 1. "There is no need to be concerned." 2. "Keep the child out of school for a 2-week period." 3. "Bring the child to the office for an injection called immune globulin." 4. "Monitor the child for an elevated temperature and call the primary health care provider if a temperature occurs."
Correct Answer: 3
A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection? 1. Wear a mask when at home with family members. 2. Have a weekly sputum culture to follow the course of the infection. 3. Wear a mask when in contact with people outside of the family until medications are effective. 4. Have a bacille Calmette-Guérin (BCG) vaccination to protect other people from exposure.
Correct Answer: 3
The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items? 1. Gloves and a gown 2. Gloves, mask, and goggles 3. Gloves, mask, gown, and goggles 4. Gloves, gown, and shoe protectors
Correct Answer: 3
The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply. 1. Use a dry table that is below waist level. 2. Open the distal flap of a sterile package first. 3. Prepare the sterile field just before the planned procedure. 4. Don clean gloves before touching items on the sterile field. 5. Place the sterile field 1 foot behind the working area and out of view of the client. 6. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.
Correct Answer: 2, 3, 6
A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate? 1. "I have a vase in the utility room, and I will get it for you." 2. "I will get the vase and wash it well before you put the flowers in it." 3. "The flowers from your garden are beautiful, but they should not be placed in the child's room at this time." 4. "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."
Correct Answer: 3
Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive? 1. Instruct the mother to check the anterior fontanel for bulging and sutures for widening each day. 2. Instruct the mother to feed the newborn in an upright position with the head and chest tilted slightly back to avoid aspiration. 3. Instruct the mother to feed the newborn with a special nipple and burp the newborn frequently to decrease the tendency to swallow air. 4. Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.
Correct Answer: 4
