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Section 1: Safety & Infection Control (Q1-18)
Q1. A nurse enters a client's room and prepares to perform wound care. Before donning
gloves, which action is the priority?
A. Apply a mask and face shield
B. Perform hand hygiene using soap and water or alcohol-based hand rub
C. Place the client in contact precautions
D. Open the sterile dressing kit on the overbed table
Correct Answer: B. Perform hand hygiene using soap and water or alcohol-based hand
rub [CORRECT]
Rationale: Hand hygiene is always the first step before any client contact or donning
PPE to prevent transmission of microorganisms. Gloves do not replace hand hygiene,
and other PPE is selected based on the procedure and expected exposure.
Q2. A nurse is caring for a client with Clostridioides difficile. Which hand hygiene method
is required?
A. Alcohol-based hand rub only
B. Soap and water only
C. Either alcohol-based hand rub or soap and water
D. Antiseptic hand wipes only
Correct Answer: B. Soap and water only [CORRECT]
Rationale: C. difficile spores are not killed by alcohol-based hand rubs; vigorous
mechanical washing with soap and water is required to remove spores from hands.
Alcohol-based products are ineffective against spore-forming organisms.
Q3. A nurse delegates tasks to the assistive personnel (AP) on a medical-surgical unit.
Which task is appropriate to delegate to the AP?
A. Inserting an indwelling urinary catheter
,B. Performing non-sterile wound irrigation
C. Assessing a client's postoperative pain level
D. Evaluating a client's response to physical therapy
Correct Answer: B. Performing non-sterile wound irrigation [CORRECT]
Rationale: Non-sterile wound irrigation is within the scope of assistive personnel under
RN supervision; catheter insertion, assessment, and evaluation require nursing
judgment and remain the RN's responsibility. Delegation must follow the five rights and
ensure client safety.
Q4. A nurse is donning PPE to enter the room of a client with influenza. Which sequence
is correct?
A. Gown, mask, goggles, gloves
B. Mask, goggles, gown, gloves
C. Gloves, gown, mask, goggles
D. Gown, gloves, mask, goggles
Correct Answer: B. Mask, goggles, gown, gloves [CORRECT]
Rationale: The correct donning sequence for droplet precautions is mask first
(respiratory protection), then eye protection (goggles), then gown, and gloves last to
cover gown sleeves and ensure all exposed areas are protected. Gloves are always
donned last.
Q5. A nurse is preparing to administer morning medications to multiple clients. Which
action is essential to reduce the risk of medication errors? (Select all that apply
concept)
A. Prepare medications for all clients simultaneously to save time
B. Verify the client's identity using two unique identifiers before administration
C. Leave medications at the bedside if the client is in the bathroom
D. Check the medication against the MAR three times during the process
Correct Answer: B. Verify the client's identity using two unique identifiers before
administration [CORRECT]
Rationale: The Joint Commission requires two identifiers (name, birth date, medical
record number) to verify the right patient and prevent wrong-client errors. Preparing
,meds for multiple clients simultaneously (option A) increases error risk, and leaving
meds unattended (option C) violates the right patient and right documentation.
Q6. A client is admitted with a history of falls. Which intervention is the priority to
maintain safety?
A. Place the client in a room near the nurses' station
B. Keep the bed in the lowest position with wheels locked
C. Apply a vest restraint during all hours
D. Dim the hallway lights to promote sleep
Correct Answer: B. Keep the bed in the lowest position with wheels locked [CORRECT]
Rationale: Keeping the bed low and locked reduces fall injury severity and is the priority
environmental intervention; restraints (option C) are last resort and require a provider
order. While room placement (option A) helps, it does not directly prevent injury during a
fall.
Q7. A fire starts in a client's room. Which action should the nurse take first?
A. Activate the fire alarm and call the operator
B. Remove all clients in immediate danger
C. Close doors and windows to contain the fire
D. Extinguish the fire using the nearest appropriate extinguisher
Correct Answer: B. Remove all clients in immediate danger [CORRECT]
Rationale: The RACE acronym prioritizes Rescue/Remove clients in immediate danger
first, then Alarm, Contain, and Extinguish. Client safety is always the first priority in any
emergency before property or environmental concerns.
Q8. A client is confused and attempts to pull out an IV line. Which is the first nursing
action?
A. Apply bilateral wrist restraints immediately
B. Offer diversion activities and request a sitter
C. Administer a sedative medication
D. Move the client to a private room at the end of the hall
Correct Answer: B. Offer diversion activities and request a sitter [CORRECT]
, Rationale: The least restrictive intervention is always attempted first; diversion and a
sitter address the underlying confusion without the risks of restraints. Restraints (option
A) require a provider order and are only used after less restrictive measures fail and the
client is at risk of harming themselves.
Q9. A nurse sustains a needlestick from a client with unknown HIV status. Which is the
priority action?
A. Complete an incident report at the end of the shift
B. Wash the area with soap and water and report to employee health immediately
C. Wait for the client's HIV test results before taking action
D. Apply pressure to the wound and place a bandage
Correct Answer: B. Wash the area with soap and water and report to employee health
immediately [CORRECT]
Rationale: Immediate washing and reporting allow for prompt post-exposure
prophylaxis (PEP) within hours if indicated; PEP is most effective when started within 2
hours. Delaying for incident reports (option A) or test results (option C) could
compromise prophylaxis efficacy.
Q10. A client is diagnosed with pulmonary tuberculosis. Which precautions are
required?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions only
Correct Answer: C. Airborne precautions [CORRECT]
Rationale: Tuberculosis is transmitted via airborne droplet nuclei that remain suspended
in air; airborne precautions (negative pressure room, N95 respirator) are required.
Droplet precautions (option A) are for larger particles that travel short distances, and
standard precautions (option D) are insufficient for TB.
Q11. A nurse is caring for a client with pertussis. Which PPE is required before entering
the room?