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CNA Medical-Surgical LPN (MSPNC(C)) study materials
CNA Medical-Surgical LPN (MSPNC(C)) study resources

CNA Medical-Surgical LPN (MSPNC(C)) practice questions

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Question 1Safe and Effective Care Environment: Coordinated Care

An LPN is assigned four clients on a medical-surgical unit. Which client should the LPN assess first?

  1. A client awaiting a routine dressing change on a healing surgical wound
  2. A client with new-onset confusion and a heart rate of 118 beats per minute Correct answer.
  3. A client scheduled for discharge teaching in one hour
  4. A client requesting pain medication for chronic back pain rated 6 out of 10

Explanation

Priority assessment goes to the client with signs of physiologic deterioration, because new confusion with tachycardia may signal hypoxia, infection, or hemorrhage and can deteriorate rapidly. Stable clients with routine or chronic needs can safely wait while the unstable client is evaluated.

Question 2Safe and Effective Care Environment: Coordinated Care

During shift report, which information is most important for the LPN to communicate to the oncoming nurse?

  1. The client's family visiting schedule for the weekend
  2. The client's new oxygen requirement and falling urine output Correct answer.
  3. The client's preferred television channel and daily routine
  4. The client's occupation before hospital admission

Explanation

Handoff report must emphasize changes in condition and abnormal findings that affect safety and immediate care, such as increasing oxygen needs and decreasing urine output. Social and background details matter for holistic care but do not take priority over deteriorating clinical status.

Question 3Safe and Effective Care Environment: Coordinated Care

A client who speaks limited English is scheduled for a procedure requiring informed consent. Which action by the LPN best supports the client's rights?

  1. Ask the client's adult child to interpret the consent discussion
  2. Rely on written materials printed only in English
  3. Have the client sign the form and explain details afterward
  4. Use a qualified medical interpreter for the consent discussion Correct answer.

Explanation

Informed consent requires that the client understand the information in a language they comprehend, so a qualified medical interpreter should be used rather than family members. Using family to interpret risks errors and breaches confidentiality, and consent must be understood before signing.

Question 4Safe and Effective Care Environment: Coordinated Care

The LPN is preparing to delegate a task to an unlicensed assistive personnel (UAP). Which task is appropriate to delegate?

  1. Teaching a client how to use an incentive spirometer
  2. Obtaining vital signs on a stable postoperative client Correct answer.
  3. Evaluating whether a client's pain intervention was effective
  4. Performing the initial assessment of a newly admitted client

Explanation

Delegation to UAP is limited to tasks with predictable outcomes that do not require nursing judgment, such as routine vital signs on a stable client. Assessment, teaching, and evaluation are nursing process responsibilities that cannot be delegated.

Question 5Safe and Effective Care Environment: Coordinated Care

A client reports a fall in the bathroom and is found on the floor with a possible hip fracture. Which action should the LPN take first?

  1. Assess the client and keep them still while calling for help Correct answer.
  2. Help the client to stand and walk back to bed
  3. Return the client to bed using a mechanical lift alone
  4. Document the incident before notifying the provider

Explanation

After a fall with suspected fracture, the priority is to assess the client and prevent further injury by immobilizing and summoning assistance. Moving the client before assessment can worsen a fracture or cause additional harm.

Question 6Safe and Effective Care Environment: Coordinated Care

The LPN receives a telephone order from a provider for a new medication. What is the correct action?

  1. Write the order, read it back to the provider, and document it per policy Correct answer.
  2. Ask the unit clerk to transcribe the order into the record
  3. Administer the medication and document the order afterward
  4. Wait until the provider makes rounds to obtain a written order

Explanation

Telephone orders must be written down, read back verbatim to the prescriber for verification, and documented according to facility policy to prevent medication errors. Transcription by non-nursing staff and administering before verification create serious safety risks.

Question 7Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client with suspected active pulmonary tuberculosis. Which action best reflects appropriate infection control coordination?

  1. Use standard precautions only and keep the door open
  2. Place the client in a negative-pressure room with airborne precautions Correct answer.
  3. Place the client in a room with another client who has pneumonia
  4. Wear gloves but no respiratory protection when entering the room

Explanation

Suspected active pulmonary tuberculosis requires airborne precautions, including a negative-pressure room and fitted N95 or higher respirator. Standard precautions alone do not prevent transmission of airborne droplet nuclei.

Question 8Safe and Effective Care Environment: Coordinated Care

A client is being transferred from the emergency department to the medical-surgical unit. Which information is essential for the LPN to receive during the transfer report?

  1. The names of the client's outpatient physicians only
  2. The client's insurance provider and billing status
  3. Allergies, current medications, and code status Correct answer.
  4. The client's food and activity preferences

Explanation

Transfer communication must include high-risk safety information such as allergies, current medications, and resuscitation status so the receiving nurse can provide safe care. Financial and preference data are useful but not essential to immediate safety.

Question 9Safe and Effective Care Environment: Coordinated Care

The LPN is assigned to a client whose plan of care includes a new intervention. Which action demonstrates appropriate use of the nursing care plan?

  1. Follow the plan and document evaluation of the client's response Correct answer.
  2. Delegate revision of the plan to the unlicensed assistive personnel
  3. Change the plan independently without notifying the team
  4. Ignore the plan if the client seems stable that day

Explanation

The care plan guides individualized nursing actions and requires ongoing evaluation of the client's response, which the LPN documents. Revising the plan is a collaborative nursing responsibility, not a task for unlicensed staff.

Question 10Safe and Effective Care Environment: Coordinated Care

A client with a do-not-resuscitate order becomes unresponsive and pulseless. Which action should the LPN take?

  1. Call a code and start rescue breathing
  2. Begin chest compressions immediately
  3. Honor the DNR order and notify the provider and family per policy Correct answer.
  4. Wait for the family to arrive before taking any action

Explanation

A valid do-not-resuscitate order directs staff to withhold cardiopulmonary resuscitation and instead provide comfort-focused care while notifying the provider and following facility policy. Starting resuscitation would violate the client's documented wishes.

Question 11Safe and Effective Care Environment: Coordinated Care

The LPN is coordinating care for a client who needs a blood transfusion. Which action is most important before the transfusion begins?

  1. Obtain the client's consent for the transfusion after it starts
  2. Start the transfusion rapidly to finish before shift change
  3. Premedicate the client with an antihistamine without an order
  4. Verify the client's identity and blood product with a second licensed nurse Correct answer.

Explanation

Two qualified staff must independently verify client identity and blood product compatibility at the bedside to prevent a transfusion reaction from misidentification. Consent should be obtained before the procedure, and premedication requires a provider order.

Question 12Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client who is at risk for pressure injuries. Which action should be coordinated with the interdisciplinary team?

  1. Reposition the client every two hours and consult the wound care nurse Correct answer.
  2. Massage bony prominences vigorously twice a day
  3. Limit fluid intake to reduce moisture on the skin
  4. Apply a heating pad to reddened areas each shift

Explanation

Pressure injury prevention requires scheduled repositioning and collaboration with wound care specialists for individualized interventions. Heat, vigorous massage, and fluid restriction can worsen tissue damage or cause dehydration.

Question 13Safe and Effective Care Environment: Coordinated Care

A client is scheduled for surgery in the morning and reports taking warfarin at home. Which action should the LPN take?

  1. Notify the surgeon and document the reported medication Correct answer.
  2. Reassure the client that warfarin does not affect surgery
  3. Administer the usual warfarin dose from the home supply
  4. Wait until after surgery to mention the medication

Explanation

Anticoagulant use increases bleeding risk during surgery, so the LPN must promptly notify the surgeon and document the report so the plan can be adjusted. Withholding or giving the medication without an order is outside nursing scope.

Question 14Safe and Effective Care Environment: Coordinated Care

The LPN is reviewing a client's discharge instructions after abdominal surgery. Which statement by the client indicates a need for further teaching?

  1. I can resume driving as soon as I feel like it Correct answer.
  2. I will avoid lifting heavy objects for several weeks
  3. I will keep my follow-up appointment next week
  4. I will call my provider if my incision becomes red or drains pus

Explanation

Resuming driving depends on the procedure, medications, and provider clearance, so assuming it is safe once the client feels able indicates a knowledge gap. Wound infection signs, lifting restrictions, and follow-up appointments reflect correct understanding.

Question 15Safe and Effective Care Environment: Coordinated Care

The LPN is coordinating care with a physical therapist for a client recovering from a stroke. Which action best supports collaborative care?

  1. Cancel therapy when the client reports fatigue
  2. Perform therapy exercises instead of the therapist
  3. Share the client's current mobility status and goals with the therapist Correct answer.
  4. Schedule therapy only when the nurse is available

Explanation

Effective collaboration requires sharing current assessment data and client goals so the team can coordinate a consistent plan. Canceling therapy or substituting nursing exercises undermines the therapist's expertise and the client's progress.

Question 16Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client who reports chest pain. Which action should be taken first?

  1. Wait to see if the pain resolves on its own
  2. Finish documenting the previous client's care before responding
  3. Obtain vital signs and a focused assessment, then notify the provider Correct answer.
  4. Ask the UAP to assess the chest pain

Explanation

New chest pain requires immediate assessment of vital signs and pain characteristics followed by prompt provider notification, because it may indicate a life-threatening cardiac event. Delaying assessment or delegating it to unlicensed staff is unsafe.

Question 17Safe and Effective Care Environment: Coordinated Care

A client is admitted with a new diagnosis of diabetes and needs teaching about insulin administration. Which action by the LPN is most appropriate?

  1. Provide a printed handout and assume the client understands
  2. Assess the client's readiness to learn and coordinate teaching with the diabetes educator Correct answer.
  3. Delay all teaching until the day of discharge
  4. Delegate the teaching to the UAP

Explanation

Teaching should begin with an assessment of the client's readiness, barriers, and learning needs, then be coordinated with specialists such as a diabetes educator. Handouts alone and last-minute discharge teaching are ineffective.

Question 18Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client who requires a signed consent for a procedure. Which element is essential for valid informed consent?

  1. The client signs the form before speaking with the provider
  2. A family member signs because the client is anxious
  3. The client receives information about risks, benefits, and alternatives Correct answer.
  4. The consent is obtained after sedation is administered

Explanation

Valid informed consent requires that the client receive complete information about the procedure, including risks, benefits, and alternatives, and voluntarily agree. Signing before discussion or after sedation does not reflect informed, voluntary consent.

Question 19Safe and Effective Care Environment: Coordinated Care

During a shift, the LPN must complete several tasks. Which task should be performed first?

  1. Calling the dietary department about a menu preference
  2. Providing a bed bath to a stable client
  3. Administering a scheduled oral medication due 30 minutes ago Correct answer.
  4. Reordering supplies for the unit

Explanation

Time-sensitive medications that are overdue take priority because delays can affect therapeutic levels and client safety. Comfort care and administrative tasks can be completed after essential medications are given.

Question 20Safe and Effective Care Environment: Coordinated Care

The LPN observes an unlicensed assistive personnel (UAP) about to feed a client who has dysphagia. Which action should the LPN take?

  1. Allow the feeding to continue since UAPs routinely feed clients
  2. Stop the feeding and verify the client's swallowing precautions and diet order Correct answer.
  3. Leave the room and document the observation later
  4. Ask the UAP to feed the client faster to save time

Explanation

Clients with dysphagia require specific feeding precautions and often a modified diet, and the nurse must ensure delegated care matches the client's needs. Intervening immediately prevents aspiration and allows reeducation of the UAP.

Question 21Safe and Effective Care Environment: Coordinated Care

A client with an advance directive naming a health care proxy becomes incapacitated. Who should make health care decisions for this client?

  1. The attending provider alone
  2. The client's closest available relative regardless of the document
  3. The nurse caring for the client that shift
  4. The health care proxy designated in the advance directive Correct answer.

Explanation

When a client loses decision-making capacity, the person legally designated in the advance directive, such as a health care proxy, makes decisions according to the client's documented wishes. Nurses and providers provide information but do not assume that authority.

Question 22Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client who is confused and repeatedly attempts to get out of bed. Which action is the best initial approach?

  1. Apply soft wrist restraints without an order
  2. Identify the cause of agitation and implement fall precautions Correct answer.
  3. Raise all four side rails and leave the room
  4. Ask the UAP to sit with the client for the entire shift

Explanation

The least restrictive and most appropriate initial step is to assess for causes of agitation such as pain, hypoxia, or urinary retention and to implement fall precautions. Restraints require a provider order and are used only after less restrictive measures fail.

Question 23Safe and Effective Care Environment: Coordinated Care

The LPN receives a report that a client's potassium level is 6.8 mEq/L. Which action should the LPN take first?

  1. Notify the provider immediately and place the client on a cardiac monitor Correct answer.
  2. Document the result and recheck it the next shift
  3. Encourage the client to eat foods high in potassium
  4. Administer the next scheduled dose of potassium supplement

Explanation

A potassium level of 6.8 mEq/L is critically high and can cause life-threatening dysrhythmias, so the provider must be notified immediately and cardiac monitoring initiated. Continuing potassium intake or delaying notification could be fatal.

Question 24Safe and Effective Care Environment: Coordinated Care

The LPN is coordinating care for a client being discharged home with a new ostomy. Which referral is most important to arrange before discharge?

  1. Dietary for menu preferences
  2. Physical therapy for gait training
  3. Wound, ostomy, and continence nurse for ostomy education Correct answer.
  4. Social work for transportation vouchers only

Explanation

A new ostomy requires teaching about pouching, skin care, and recognizing complications, which is the specialty of the wound, ostomy, and continence nurse. Other referrals may be useful but do not address the essential self-care skill.

Question 25Safe and Effective Care Environment: Coordinated Care

The LPN is assigned to care for a client who is scheduled for a procedure requiring conscious sedation. Which action best reflects safe coordination?

  1. Confirm the consent, NPO status, and baseline vital signs before the procedure Correct answer.
  2. Allow the client to eat a light breakfast before the procedure
  3. Skip baseline vital signs to save time
  4. Administer the sedating medication without a provider order

Explanation

Before conscious sedation, the nurse verifies informed consent, NPO status, allergies, and baseline vital signs so the procedure can proceed safely and responses can be compared afterward. Sedating medications require a provider order and are given under monitoring.

Question 26Safe and Effective Care Environment: Coordinated Care

An LPN is preparing to give a client a medication that the pharmacist flagged as having a similar-sounding name to another drug on the unit. Which action best supports safe medication administration?

  1. Ask the unlicensed assistive personnel to confirm the drug name on the label
  2. Hold the medication without notifying the provider or pharmacist
  3. Verify the order against the client's identification band and the original prescription before giving Correct answer.
  4. Administer the medication and document the similarity in the nurses' notes

Explanation

Look-alike/sound-alike medications require independent verification of the order, the label, and the client identity before administration. This two-source check reduces the risk of a wrong-drug error. Documentation of a concern does not prevent the error, and holding a dose requires communication with the prescriber.

Question 27Safe and Effective Care Environment: Coordinated Care

A client tells the LPN that she does not understand why she is receiving a blood thinner and wants to stop taking it. Which response by the LPN best reflects the principle of informed participation in care?

  1. Document the refusal and take no further action because the client has that right
  2. Tell the client that the provider ordered it and the decision is not hers to make
  3. Ask another nurse to give the medication so the client does not associate it with you
  4. Explain the purpose in plain language and notify the provider of the client's concern Correct answer.

Explanation

Clients have the right to understand and participate in decisions about their care, so the nurse should clarify in understandable terms and involve the provider. Dismissing the concern undermines autonomy and informed consent. Simply documenting a refusal without exploring the reason fails to advocate for the client.

Question 28Safe and Effective Care Environment: Coordinated Care

An LPN is delegating a task to unlicensed assistive personnel (UAP). Which factor is most important for the LPN to consider when deciding whether the task can be delegated?

  1. The number of years the UAP has worked on the unit
  2. Whether the UAP volunteers to perform the task
  3. The time remaining in the shift
  4. The stability of the client and the predictability of the task outcome Correct answer.

Explanation

Delegation decisions rest on client stability, task complexity, and the predictability of the outcome, which determine whether the task requires a licensed nurse. Experience and willingness are helpful but do not replace this clinical judgment. Shift timing should not drive delegation of nursing tasks.

Question 29Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client who speaks limited English and is about to sign a consent form for a procedure. Which action is most appropriate?

  1. Have a family member who speaks both languages interpret the conversation
  2. Use gestures and simple words to convey the information
  3. Ask the client to sign now and answer questions after the procedure
  4. Arrange for a qualified medical interpreter to explain the procedure before the client signs Correct answer.

Explanation

Valid informed consent requires that the client understand the information, which depends on accurate interpretation by a qualified medical interpreter. Family members may misinterpret or filter information and are not appropriate for consent discussions. Signing before understanding the procedure invalidates consent.

Question 30Safe and Effective Care Environment: Coordinated Care

An LPN notices that a client's intravenous site is red and swollen and the infusion has slowed. Which action should the LPN take first?

  1. Document the finding and reassess at the end of the shift
  2. Stop the infusion and assess the site Correct answer.
  3. Slow the rate and continue to monitor
  4. Apply a warm compress and continue the infusion

Explanation

Redness, swelling, and slowed flow suggest infiltration or phlebitis, so the infusion should be stopped and the site assessed before further action. Continuing the infusion risks tissue damage and fluid extravasation. Ongoing monitoring or delayed reassessment allows the complication to worsen.

Question 31Safe and Effective Care Environment: Coordinated Care

An LPN is preparing to discharge a client who will need wound care at home. Which action best demonstrates coordination of care across settings?

  1. Contact the home health agency to arrange a visit and send the wound care plan Correct answer.
  2. Ask the client's neighbor to check the wound daily
  3. Tell the client to call the clinic if the wound looks worse
  4. Give the client written instructions and schedule a follow-up appointment

Explanation

Coordinating care across settings involves arranging follow-up services and transmitting the plan of care to the receiving provider. Written instructions and follow-up appointments alone do not ensure continuity of skilled wound care. Relying on a neighbor does not provide appropriate clinical oversight.

Question 32Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client who is at risk for falls and is receiving a new sedating medication. Which action best reflects appropriate collaboration with the interprofessional team?

  1. Place the client in a room near the nurses' station and continue the medication as ordered
  2. Ask the UAP to check on the client every hour
  3. Document the fall risk and reassess the client at the next shift
  4. Notify the provider of the increased fall risk and request a review of the medication regimen Correct answer.

Explanation

When a new medication increases a client's risk, the nurse should communicate the concern to the prescriber and participate in reviewing the regimen. Environmental measures are useful but do not address the medication-related risk. Delaying communication or reassessment leaves the client vulnerable.

Question 33Safe and Effective Care Environment: Coordinated Care

A client is being discharged with a new prescription for a medication that requires prior authorization from the insurance company. Which action by the LPN best supports continuity of care?

  1. Instruct the client to return to the emergency department if the medication is not covered
  2. Discharge the client and let the pharmacy resolve the issue later
  3. Tell the client to pay out of pocket for the medication
  4. Notify the provider and pharmacy so an alternative or authorization can be arranged before discharge Correct answer.

Explanation

Unresolved coverage issues can prevent the client from obtaining needed medication, so the nurse should communicate with the provider and pharmacy before discharge. Advising self-payment or later resolution risks an interruption in therapy. Returning to the emergency department is not an appropriate plan for a prescription problem.

Question 34Safe and Effective Care Environment: Coordinated Care

The LPN is caring for a client who has just returned from surgery and is reporting pain. The provider's orders include a PRN opioid. Which action should the LPN take first?

  1. Assess the client's pain, vital signs, and level of consciousness before giving the medication Correct answer.
  2. Administer the opioid immediately because the client reports pain
  3. Encourage the client to use nonpharmacologic measures only
  4. Wait until the client's next scheduled assessment to give the medication

Explanation

Before giving a PRN opioid, the nurse should assess pain and baseline vital signs and level of consciousness to determine appropriateness and safety. Administering without assessment risks oversedation or respiratory depression. Delaying or withholding analgesia without assessment does not meet the client's needs.

Question 35Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to suction a client with a new tracheostomy. Which action best reduces the risk of introducing infection during the procedure?

  1. Suctioning for at least 30 seconds each pass
  2. Wearing clean gloves and using sterile suction technique Correct answer.
  3. Instilling tap water into the airway before suctioning
  4. Reusing the same catheter for the entire shift

Explanation

Suctioning the artificial airway is a sterile procedure because the catheter enters the lower respiratory tract directly. Clean gloves alone are not sufficient; sterile gloves and a sterile catheter prevent pathogens from being carried into the lungs. Limiting each pass to about 10 to 15 seconds and avoiding routine instillation further reduce risk.

Question 36Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with an active pulmonary tuberculosis infection. Which type of precautions should the nurse initiate?

  1. Standard precautions only
  2. Airborne precautions Correct answer.
  3. Contact precautions
  4. Droplet precautions

Explanation

Tuberculosis spreads through airborne droplet nuclei that remain suspended in the air and travel on air currents. Airborne precautions require a fit-tested N95 respirator and a negative-pressure room with the door closed. Standard precautions alone do not address the airborne route.

Question 37Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to insert a urinary catheter. Which action is most important for preventing a catheter-associated urinary tract infection?

  1. Cleaning the meatus with alcohol
  2. Irrigating the bladder after insertion
  3. Leaving the drainage bag on the floor
  4. Using sterile technique throughout insertion Correct answer.

Explanation

Maintaining sterile technique during insertion is the single most effective step in preventing catheter-associated infection. Breaks in sterility allow organisms to enter the bladder directly. Additional measures include keeping the drainage bag below bladder level and avoiding unnecessary irrigation.

Question 38Safe and Effective Care Environment: Safety and Infection Control

A nurse is teaching a client about hand hygiene. Which statement by the client indicates correct understanding?

  1. I should rub my hands until they are dry after using alcohol gel. Correct answer.
  2. Artificial nails are acceptable if kept short.
  3. I only need to wash my hands after client contact.
  4. Alcohol rub is best when hands are visibly soiled.

Explanation

Alcohol-based hand rub must be rubbed into the skin until completely dry so that it achieves full antimicrobial effect. Handwashing with soap and water is required when hands are visibly soiled. Hand hygiene is performed both before and after client contact, and artificial nails are discouraged for direct-care staff.

Question 39Safe and Effective Care Environment: Safety and Infection Control

A client is placed on contact precautions for a wound infection with methicillin-resistant Staphylococcus aureus. Which action should the nurse take?

  1. Use only standard precautions for wound care
  2. Assign the client to a room with a roommate who has a clean wound
  3. Remove the gown before leaving the room and reuse it later
  4. Wear a gown and gloves for all contact with the client Correct answer.

Explanation

Contact precautions require gown and gloves for every entry into the room because the organism spreads through direct and indirect contact. Dedicated equipment and hand hygiene before and after care are also essential. Cohorting with a noninfected client is inappropriate.

Question 40Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client who is at risk for falls. Which action is most appropriate for preventing injury?

  1. Leaving the side rails down at all times
  2. Keeping the bed in the highest position
  3. Placing the call light within reach Correct answer.
  4. Using a bed with wheels unlocked

Explanation

Placing the call light within the client's reach allows prompt assistance and reduces the likelihood that the client will attempt unsafe independent movement. Beds should be kept low and locked, and side rails used per policy. These measures together reduce fall-related injury.

Question 41Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to administer a blood transfusion. Which action should be completed before starting the transfusion?

  1. Warm the blood in a microwave
  2. Start the transfusion with lactated Ringer's solution
  3. Verify the unit with a second qualified staff member at the bedside Correct answer.
  4. Add medications to the blood bag

Explanation

Bedside verification of the client identity and blood product compatibility by two qualified staff members prevents a hemolytic transfusion reaction. Blood must be infused with normal saline only, and no medications are added to the bag. Rapid warming or microwave use can hemolyze red cells.

Question 42Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with a new colostomy. Which action is appropriate for infection control when changing the pouch?

  1. Apply the new pouch without cleaning the skin
  2. Wear gloves and wash hands before and after the procedure Correct answer.
  3. Place the used pouch on the bedside table
  4. Empty and reuse the pouch without cleaning

Explanation

Gloves protect the nurse from exposure to stool, and hand hygiene before and after the procedure prevents organism transmission. The skin should be cleansed and dried before applying a new pouch. Contaminated supplies belong in the appropriate waste container.

Question 43Safe and Effective Care Environment: Safety and Infection Control

A nurse is reviewing the chart of a client with Clostridioides difficile diarrhea. Which action is essential?

  1. Use alcohol gel as the only hand hygiene method
  2. Place the client in airborne precautions
  3. Wash hands with soap and water after care Correct answer.
  4. Clean surfaces with a quaternary ammonium wipe only

Explanation

C. difficile spores are not reliably killed by alcohol, so soap-and-water handwashing is required after contact. Contact precautions and sporicidal cleaning agents such as bleach are used. Airborne precautions are not indicated for C. difficile.

Question 44Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client receiving oxygen therapy. Which action reduces the risk of fire?

  1. Allowing petroleum jelly on the nares
  2. Storing oxygen tanks upright but uncapped
  3. Using a wool blanket near the oxygen source
  4. Posting a no-smoking sign and removing ignition sources Correct answer.

Explanation

Oxygen supports combustion, so ignition sources such as smoking and open flames must be eliminated and signage posted. Petroleum-based products are flammable and should be avoided near oxygen. Cylinders should be secured and capped when not in use.

Question 45Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to administer a medication through a central venous catheter. Which action best prevents a central line-associated bloodstream infection?

  1. Scrubbing the hub with an antiseptic and allowing it to dry Correct answer.
  2. Changing the dressing only when it falls off
  3. Using the line for routine blood draws without cleaning
  4. Flushing the line with tap water

Explanation

Disinfecting the catheter hub with an appropriate antiseptic and letting it dry before access reduces contamination of the line. Dressings are changed per policy, and only sterile normal saline is used for flushing. Consistent hub care is a core prevention bundle element.

Question 46Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client on droplet precautions. Which action is correct?

  1. Wear an N95 respirator for all client contact
  2. Keep the door open for air circulation
  3. Place the client in a negative-pressure room
  4. Wear a surgical mask when within 3 to 6 feet of the client Correct answer.

Explanation

Droplet precautions require a surgical mask when working within about 3 to 6 feet of the client because large droplets travel short distances. A private room is preferred, and the door may remain open. Negative-pressure rooms and N95 respirators are reserved for airborne precautions.

Question 47Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client who becomes agitated and attempts to climb out of bed. Which action should the nurse take first?

  1. Stay with the client and call for assistance Correct answer.
  2. Administer a sedative without an order
  3. Apply wrist restraints immediately
  4. Raise all four side rails and leave the room

Explanation

The least restrictive intervention is to remain with the client and summon help to prevent injury. Restraints require a provider order and are used only after less restrictive measures fail. Raising all four side rails is considered a restraint and increases injury risk.

Question 48Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to administer an intramuscular injection. Which action prevents a needlestick injury?

  1. Placing the used needle on the bedside table
  2. Recapping the needle with two hands
  3. Bending the needle before disposal
  4. Activating the safety device and discarding the needle in a sharps container Correct answer.

Explanation

Activating the safety device immediately after use and disposing of the needle in a puncture-resistant sharps container prevents needlestick injuries. Recapping, bending, and leaving needles unattended all increase risk. Needles should never be handled with both hands.

Question 49Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client who is postoperative and has a drain in place. Which action supports surgical site infection prevention?

  1. Perform hand hygiene before and after drain care Correct answer.
  2. Cleanse the drain site with the same gauze used for the wound
  3. Change the dressing only when saturated through
  4. Keep the drain tubing looped above the insertion site

Explanation

Hand hygiene before and after drain care prevents transfer of organisms to the site. Drain tubing should be kept below the insertion site so that fluid does not flow back toward the wound. Dressings are changed per policy and when soiled, and clean supplies are used for each step.

Question 50Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with a latex allergy. Which action is most important?

  1. Use powdered latex gloves for brief procedures
  2. Place the client in a room near the supply closet
  3. Allow family to bring latex balloons
  4. Provide a latex-free environment and check all supplies Correct answer.

Explanation

Clients with latex allergy require a latex-free environment because reactions can occur with minimal exposure. All supplies, including gloves, tubing, and tourniquets, must be verified as latex-free. Powdered latex gloves disperse allergens into the air and are especially hazardous.