NCLEX RN Safety & Infection Control
Practice Exam 4 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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1. A client is admitted with a diagnosis of pulmonary tuberculosis. The nurse
implements airborne precautions. Which personal protective equipment
(PPE) is essential for the nurse to wear when entering the client's room?
Answer: N95 respirator
Rationale: Tuberculosis is transmitted via airborne droplet nuclei, which
remain suspended in the air. An N95 respirator, which filters out 95% of
airborne particles, is required for respiratory protection. A standard
surgical mask does not provide an adequate seal for airborne pathogens.
Gloves and a gown are indicated for contact precautions, but the
respiratory protection is the critical element for airborne diseases.
2. The nurse is preparing to administer a blood transfusion. Which action is
most important to prevent a transfusion-related infection?
Answer: Verify the client's identity using two identifiers before initiating
the transfusion
Rationale: Although blood products are screened, the most critical nursing
action to prevent wrong-patient transfusion errors is to verify the client's
identity using two identifiers (e.g., name and date of birth) against the
blood product label. This prevents administering blood to the wrong
client, which could lead to acute hemolytic reactions or transmission of
bloodborne pathogens due to mismatched blood. Blood tubing and filters
do not prevent infections from contaminated units or mismatched
administration.
,3. A client with methicillin-resistant Staphylococcus aureus (MRSA) is placed
on contact precautions. The nurse enters the room to perform a wound
dressing change. Which sequence of actions for removing PPE is correct?
Answer: Remove gloves, perform hand hygiene, remove gown, perform
hand hygiene
Rationale: According to CDC guidelines, for contact precautions, the gown
and gloves are both considered contaminated. The proper sequence is to
first remove the gloves (which are most heavily contaminated), perform
hand hygiene, then untie and remove the gown, followed by another hand
hygiene. Removing the gown first would risk contaminating the nurse's
clothing and hands. The mask and goggles, if worn, would be removed
last outside the room.
4. The nurse is caring for a client with a Clostridium difficile infection. Which
hand hygiene product is most appropriate for use after providing care?
Answer: Soap and water
Rationale: Clostridium difficile forms spores that are resistant to alcohol-
based hand sanitizers. Alcohol does not kill the spores, and they remain
viable on the hands. Washing with soap and water physically removes the
spores through friction and running water. This is the only acceptable
hand hygiene method after caring for a client with C. difficile.
5. A fire breaks out in a client's room on the medical-surgical unit. The nurse
enters the room and sees a fire in the trash can. Which action should the
nurse take first?
Answer: Remove the client from immediate danger
Rationale: According to the RACE mnemonic (Rescue, Alarm, Confine,
Extinguish), the first action is to Rescue/Remove the client from the
immediate fire area. Client safety is the highest priority. The nurse must
ensure the client is moved to a safe location before activating the alarm or
attempting to extinguish the fire.
6. The nurse is preparing to use a physical restraint on a client who is at risk
for falling. Which action demonstrates safe and legal use of restraints?
Answer: Obtain a written provider order within the designated time frame
, (e.g., 24 hours)
Rationale: Restraints require a provider's order. In acute care, a written
order must be obtained within a specific time frame (often 24 hours,
depending on facility policy). Restraints should not be applied solely based
on nursing judgment, and they must be the least restrictive option. Tying
them to the bed frame is incorrect, as they should be tied to the movable
bed frame part. Restraints must be removed frequently for assessment
and range-of-motion exercises.
7. A client is receiving continuous oxygen via a nasal cannula at 4 L/min. The
nurse observes a small grease fire in a kitchen area adjacent to the client's
room. What is the nurse's priority action?
Answer: Turn off the oxygen source at the wall
Rationale: Oxygen supports combustion. In the presence of a fire, the
immediate priority is to remove the fire triangle component of oxygen.
Turning off the oxygen source reduces the risk of the fire spreading to the
client and the equipment. Removing the client would be the next step
(RACE), but turning off the oxygen is a critical first action specific to
oxygen use. Using a fire extinguisher is important but secondary to
removing the fuel/oxidizer.
8. The nurse is performing a sterile dressing change. The nurse opens a sterile
package and the sterile field becomes contaminated when the nurse
reaches over the field. What is the correct nursing action?
Answer: Discard the supplies and restart the procedure with new sterile
supplies
Rationale: Once a sterile field is compromised, it is considered
contaminated. The nurse must not attempt to rearrange supplies or use
them. The only safe action is to discard the contaminated supplies and
prepare a new sterile field with new supplies to prevent introducing
pathogens into the client's wound.
9. A client with a tracheostomy is coughing and producing copious secretions.
The nurse wears a mask and gloves. Which additional PPE is indicated for
this procedure?
, Answer: Goggles or face shield
Rationale: When performing procedures that generate aerosolized
secretions, such as suctioning a tracheostomy, the nurse must protect the
mucous membranes of the eyes, nose, and mouth. While a mask covers
the nose and mouth, goggles or a face shield are required to protect the
eyes from splash and droplet exposure. A gown is also needed if splashing
is anticipated, but goggles are specifically indicated for eye protection.
10.The nurse is instructing a nursing assistant on proper hand hygiene. Which
statement indicates a need for further teaching?
Answer: "I will use alcohol-based hand sanitizer if my hands are visibly
soiled."
Rationale: Alcohol-based hand sanitizers are not effective when hands are
visibly soiled, gritty, or contaminated with blood or body fluids. In these
situations, soap and water must be used. The other statements are
correct: hand hygiene is required before and after client contact, and hand
sanitizer is appropriate when hands are not visibly soiled.
11.The nurse is teaching a client about cough etiquette. Which instruction
should be included?
Answer: "Cover your mouth and nose with a tissue or your elbow when
coughing."
Rationale: Standard precautions include respiratory hygiene/cough
etiquette. The client should use a tissue to cover the mouth and nose,
dispose of it immediately, and perform hand hygiene. If a tissue is
unavailable, the client should use the inner aspect of their elbow to
prevent the spread of droplets. Using the hands is discouraged unless
immediate hand hygiene is performed.
12.A client has been diagnosed with a herpes simplex virus infection. The nurse
implements standard precautions. Which task can the nurse safely perform
without gloves?
Answer: Taking the client's oral temperature
Rationale: Standard precautions require gloves for contact with non-intact
skin, mucous membranes, blood, and body fluids. Taking an oral
Practice Exam 4 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A client is admitted with a diagnosis of pulmonary tuberculosis. The nurse
implements airborne precautions. Which personal protective equipment
(PPE) is essential for the nurse to wear when entering the client's room?
Answer: N95 respirator
Rationale: Tuberculosis is transmitted via airborne droplet nuclei, which
remain suspended in the air. An N95 respirator, which filters out 95% of
airborne particles, is required for respiratory protection. A standard
surgical mask does not provide an adequate seal for airborne pathogens.
Gloves and a gown are indicated for contact precautions, but the
respiratory protection is the critical element for airborne diseases.
2. The nurse is preparing to administer a blood transfusion. Which action is
most important to prevent a transfusion-related infection?
Answer: Verify the client's identity using two identifiers before initiating
the transfusion
Rationale: Although blood products are screened, the most critical nursing
action to prevent wrong-patient transfusion errors is to verify the client's
identity using two identifiers (e.g., name and date of birth) against the
blood product label. This prevents administering blood to the wrong
client, which could lead to acute hemolytic reactions or transmission of
bloodborne pathogens due to mismatched blood. Blood tubing and filters
do not prevent infections from contaminated units or mismatched
administration.
,3. A client with methicillin-resistant Staphylococcus aureus (MRSA) is placed
on contact precautions. The nurse enters the room to perform a wound
dressing change. Which sequence of actions for removing PPE is correct?
Answer: Remove gloves, perform hand hygiene, remove gown, perform
hand hygiene
Rationale: According to CDC guidelines, for contact precautions, the gown
and gloves are both considered contaminated. The proper sequence is to
first remove the gloves (which are most heavily contaminated), perform
hand hygiene, then untie and remove the gown, followed by another hand
hygiene. Removing the gown first would risk contaminating the nurse's
clothing and hands. The mask and goggles, if worn, would be removed
last outside the room.
4. The nurse is caring for a client with a Clostridium difficile infection. Which
hand hygiene product is most appropriate for use after providing care?
Answer: Soap and water
Rationale: Clostridium difficile forms spores that are resistant to alcohol-
based hand sanitizers. Alcohol does not kill the spores, and they remain
viable on the hands. Washing with soap and water physically removes the
spores through friction and running water. This is the only acceptable
hand hygiene method after caring for a client with C. difficile.
5. A fire breaks out in a client's room on the medical-surgical unit. The nurse
enters the room and sees a fire in the trash can. Which action should the
nurse take first?
Answer: Remove the client from immediate danger
Rationale: According to the RACE mnemonic (Rescue, Alarm, Confine,
Extinguish), the first action is to Rescue/Remove the client from the
immediate fire area. Client safety is the highest priority. The nurse must
ensure the client is moved to a safe location before activating the alarm or
attempting to extinguish the fire.
6. The nurse is preparing to use a physical restraint on a client who is at risk
for falling. Which action demonstrates safe and legal use of restraints?
Answer: Obtain a written provider order within the designated time frame
, (e.g., 24 hours)
Rationale: Restraints require a provider's order. In acute care, a written
order must be obtained within a specific time frame (often 24 hours,
depending on facility policy). Restraints should not be applied solely based
on nursing judgment, and they must be the least restrictive option. Tying
them to the bed frame is incorrect, as they should be tied to the movable
bed frame part. Restraints must be removed frequently for assessment
and range-of-motion exercises.
7. A client is receiving continuous oxygen via a nasal cannula at 4 L/min. The
nurse observes a small grease fire in a kitchen area adjacent to the client's
room. What is the nurse's priority action?
Answer: Turn off the oxygen source at the wall
Rationale: Oxygen supports combustion. In the presence of a fire, the
immediate priority is to remove the fire triangle component of oxygen.
Turning off the oxygen source reduces the risk of the fire spreading to the
client and the equipment. Removing the client would be the next step
(RACE), but turning off the oxygen is a critical first action specific to
oxygen use. Using a fire extinguisher is important but secondary to
removing the fuel/oxidizer.
8. The nurse is performing a sterile dressing change. The nurse opens a sterile
package and the sterile field becomes contaminated when the nurse
reaches over the field. What is the correct nursing action?
Answer: Discard the supplies and restart the procedure with new sterile
supplies
Rationale: Once a sterile field is compromised, it is considered
contaminated. The nurse must not attempt to rearrange supplies or use
them. The only safe action is to discard the contaminated supplies and
prepare a new sterile field with new supplies to prevent introducing
pathogens into the client's wound.
9. A client with a tracheostomy is coughing and producing copious secretions.
The nurse wears a mask and gloves. Which additional PPE is indicated for
this procedure?
, Answer: Goggles or face shield
Rationale: When performing procedures that generate aerosolized
secretions, such as suctioning a tracheostomy, the nurse must protect the
mucous membranes of the eyes, nose, and mouth. While a mask covers
the nose and mouth, goggles or a face shield are required to protect the
eyes from splash and droplet exposure. A gown is also needed if splashing
is anticipated, but goggles are specifically indicated for eye protection.
10.The nurse is instructing a nursing assistant on proper hand hygiene. Which
statement indicates a need for further teaching?
Answer: "I will use alcohol-based hand sanitizer if my hands are visibly
soiled."
Rationale: Alcohol-based hand sanitizers are not effective when hands are
visibly soiled, gritty, or contaminated with blood or body fluids. In these
situations, soap and water must be used. The other statements are
correct: hand hygiene is required before and after client contact, and hand
sanitizer is appropriate when hands are not visibly soiled.
11.The nurse is teaching a client about cough etiquette. Which instruction
should be included?
Answer: "Cover your mouth and nose with a tissue or your elbow when
coughing."
Rationale: Standard precautions include respiratory hygiene/cough
etiquette. The client should use a tissue to cover the mouth and nose,
dispose of it immediately, and perform hand hygiene. If a tissue is
unavailable, the client should use the inner aspect of their elbow to
prevent the spread of droplets. Using the hands is discouraged unless
immediate hand hygiene is performed.
12.A client has been diagnosed with a herpes simplex virus infection. The nurse
implements standard precautions. Which task can the nurse safely perform
without gloves?
Answer: Taking the client's oral temperature
Rationale: Standard precautions require gloves for contact with non-intact
skin, mucous membranes, blood, and body fluids. Taking an oral
