Module 6: Safety and Infection Control
EXAM 2025 QUESTIONS AND ANSWERS
After discussing the use of restraints with a client and family, a physician has written a
prescription for wrist restraints to be applied to a client. The nurse instructs the nursing
assistant to apply the restraints. Which of the following observations by the nurse indicates that
the nursing assistant is using the restraints safely and correctly? Select all that apply. - ANS -
The restraints are being released every 2 hours.
- A safety knot has been used to secure the restraints.
- The call light has been placed within reach of the client.
Rationale: Restraints should never be applied tightly, because this could impair circulation. They
should be tied to the bed frame (not the siderail) with the use of a safety knot. The client could
sustain injury if the siderail were lowered with a restraint attached to it. A safety knot is used
because it can easily be released in an emergency. Restraints must be released every 2 hours to
facilitate inspection of the skin, help ensure good circulation, and permit movement of the joint
through its range of motion. The call light must always be within reach of the client in case he
or she needs assistance.
A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All
victims are alert. Which of these clients does the nurse assign to the emergent category? Select
all that apply. - ANS -A victim with respiratory distress
-A victim with partial amputation of the foot
Rationale: One rating system commonly used in the ED consists of three tiers — emergent,
urgent, and nonurgent — with the categories sometimes identified with color coding or
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Page
numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life-
@COPYRIGHT BRAINBARTER 2025/2026
, threatening injuries (here, the clients with respiratory distress [airway] and partial amputation
of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation
but have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a.
yellow or priority 2) classification is given to clients whose injuries and complications are not
life threatening (here, the client with the fractured humerus), provided that they are treated
within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The
nonurgent (a.k.a. green or priority 3) classification is given to clients with local injuries (here,
the clients with the forehead laceration and bruises of the arms and legs) who do not have
immediate complications and can wait several hours for medical treatment; these clients
require evaluation every 1 to 2 hours thereafter.
A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a
blood tube containing a specimen from the client broke. What steps should the nurse take to
clean up the blood spill? Select all that apply. - ANS - Using tongs to collect any broken glass
- Wearing gloves for the cleanup procedure
- Disinfecting the area of the blood spill with a dilute bleach solution
Rationale: The nurse should blot the spill with an absorbent disposable material such as
disposable paper towels or terry wipes, not a face cloth or towel. Tongs are used to pick up any
broken glass, and gloves are worn for the procedure. The broken glass is disposed of in a
puncture-resistant container. The area is disinfected with a dilute bleach solution or other
agency-accepted product.
A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape
on the overbed table. Which of these actions on the part of the nurse indicate correct
understanding of the principles of aseptic technique? Select all that apply. - ANS - Positioning
the sterile field so that it remains in full view
- Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand
- Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves
Rationale: The principles of surgical asepsis must be followed in the preparation of a sterile
field. Among these principles: A sterile object remains sterile only when touched by other
sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of
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Page
the range of vision or an object held below the nurse's waist is to be considered contaminated;
@COPYRIGHT BRAINBARTER 2025/2026
, a sterile object or field becomes contaminated with prolonged exposure to air; when a sterile
surface comes in contact with a wet, contaminated surface, the sterile object or field becomes
contaminated by way of capillary action; fluid flows in the direction of gravity; a 1-inch edge of
a sterile field or container is to be considered contaminated.
In which of the following situations would the nurse use this type of restraint (mitten restraint)?
Select all that apply. - ANS - To prevent dislodgment of an intravenous line
- To prevent the use of the hands while allowing free arm movement
Rationale: A mitten restraint is a thumbless device used to restrain the hands. It prevents the
use of the hands while allowing free arm movement. Mitten restraints are useful for the client
who must be prevented from dislodging an intravenous line, indwelling urinary catheter,
nasogastric tube, other types of tubes, or wound dressings. A belt restraint prevents the client
from falling out of a bed, a chair, or a stretcher. A mitten restraint does not secure the
shoulders and the waist and is not used to prevent the client from turning side to side.
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank
some window cleaner that had been stored in a cabinet. The nurse should instruct the mother
to immediately: - ANS Call a poison control center
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting
should not be induced if the victim is unconscious or if the substance ingested was a strong
corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare
provider has given specific instructions to induce vomiting. Neither calling an ambulance nor
calling the physician's answering service is the immediate action, because either would delay
treatment. Additionally, the physician would immediately make a referral to the poison control
center. The poison control center may advise the mother to bring the child to the emergency
department; if this is the case, the mother should then call an ambulance.
A home care nurse is visiting an older client who has been recovering from a mild brain attack
(stroke) affecting her left side. The client lives alone but receives regular assistance from her
daughter and son, who both live within 10 miles. Which of the following actions should the
nurse take to assess the client's safety risk? Select all that apply. - ANS - Assessing the client's
3
visual acuity
Page
@COPYRIGHT BRAINBARTER 2025/2026
, - Observing the client's gait and posture
- Evaluating the client's muscle strength
- Looking for any hazards in the home environment
Rationale: To conduct a thorough client assessment, the nurse looks for risk factors related to
safety. The assessment should include the assessment of visual acuity, gait and posture, and
muscle strength, because alterations in these areas increase the client's risk for falls and injury.
The nurse should also assess the home environment, looking for any hazards or obstacles that
might affect safety. Asking a family member to move in with the client until recovery is
complete and requesting that the client transfer to an assisted living environment for at least 1
month are not assessment activities. Additionally, nothing in the question indicates that these
actions are necessary; therefore, these options are unrealistic and unreasonable.
A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to
climb out of bed. Which of these safety devices that the nurse might suggest is the least
restrictive? - ANS Ambularm
Rationale: The Ambularm device, worn on the leg, signals when the client's leg is in a
dependent position. It is used for clients who climb out of bed and are at risk for falling.
Ambularm devices that may be attached to the bed or chair or to the client's mattress or
nightgown are also available. A belt restraint is a device that is wrapped around the client's
waist to secure the client to bed or to a stretcher. A wrist restraint is a device used to
immobilize an arm. An elbow restraint consists of a piece of fabric with slots into which tongue
blades are inserted, after which the device is wrapped around the elbow area to immobilize it.
Of the options provided, the Ambularm is the least restrictive safety device.
A home health nurse has instructed a client about safety measures during the use of an oxygen
concentrator in the home. Which statement by the client indicates to the nurse that the client
has understood the directions? Select all that apply. - ANS - "I need to follow the oxygen
prescription exactly."
- "I have to keep the oxygen concentrator out of direct sunlight."
- "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the
oxygen concentrator."
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Page
@COPYRIGHT BRAINBARTER 2025/2026
EXAM 2025 QUESTIONS AND ANSWERS
After discussing the use of restraints with a client and family, a physician has written a
prescription for wrist restraints to be applied to a client. The nurse instructs the nursing
assistant to apply the restraints. Which of the following observations by the nurse indicates that
the nursing assistant is using the restraints safely and correctly? Select all that apply. - ANS -
The restraints are being released every 2 hours.
- A safety knot has been used to secure the restraints.
- The call light has been placed within reach of the client.
Rationale: Restraints should never be applied tightly, because this could impair circulation. They
should be tied to the bed frame (not the siderail) with the use of a safety knot. The client could
sustain injury if the siderail were lowered with a restraint attached to it. A safety knot is used
because it can easily be released in an emergency. Restraints must be released every 2 hours to
facilitate inspection of the skin, help ensure good circulation, and permit movement of the joint
through its range of motion. The call light must always be within reach of the client in case he
or she needs assistance.
A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All
victims are alert. Which of these clients does the nurse assign to the emergent category? Select
all that apply. - ANS -A victim with respiratory distress
-A victim with partial amputation of the foot
Rationale: One rating system commonly used in the ED consists of three tiers — emergent,
urgent, and nonurgent — with the categories sometimes identified with color coding or
1
Page
numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life-
@COPYRIGHT BRAINBARTER 2025/2026
, threatening injuries (here, the clients with respiratory distress [airway] and partial amputation
of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation
but have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a.
yellow or priority 2) classification is given to clients whose injuries and complications are not
life threatening (here, the client with the fractured humerus), provided that they are treated
within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The
nonurgent (a.k.a. green or priority 3) classification is given to clients with local injuries (here,
the clients with the forehead laceration and bruises of the arms and legs) who do not have
immediate complications and can wait several hours for medical treatment; these clients
require evaluation every 1 to 2 hours thereafter.
A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a
blood tube containing a specimen from the client broke. What steps should the nurse take to
clean up the blood spill? Select all that apply. - ANS - Using tongs to collect any broken glass
- Wearing gloves for the cleanup procedure
- Disinfecting the area of the blood spill with a dilute bleach solution
Rationale: The nurse should blot the spill with an absorbent disposable material such as
disposable paper towels or terry wipes, not a face cloth or towel. Tongs are used to pick up any
broken glass, and gloves are worn for the procedure. The broken glass is disposed of in a
puncture-resistant container. The area is disinfected with a dilute bleach solution or other
agency-accepted product.
A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape
on the overbed table. Which of these actions on the part of the nurse indicate correct
understanding of the principles of aseptic technique? Select all that apply. - ANS - Positioning
the sterile field so that it remains in full view
- Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand
- Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves
Rationale: The principles of surgical asepsis must be followed in the preparation of a sterile
field. Among these principles: A sterile object remains sterile only when touched by other
sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of
2
Page
the range of vision or an object held below the nurse's waist is to be considered contaminated;
@COPYRIGHT BRAINBARTER 2025/2026
, a sterile object or field becomes contaminated with prolonged exposure to air; when a sterile
surface comes in contact with a wet, contaminated surface, the sterile object or field becomes
contaminated by way of capillary action; fluid flows in the direction of gravity; a 1-inch edge of
a sterile field or container is to be considered contaminated.
In which of the following situations would the nurse use this type of restraint (mitten restraint)?
Select all that apply. - ANS - To prevent dislodgment of an intravenous line
- To prevent the use of the hands while allowing free arm movement
Rationale: A mitten restraint is a thumbless device used to restrain the hands. It prevents the
use of the hands while allowing free arm movement. Mitten restraints are useful for the client
who must be prevented from dislodging an intravenous line, indwelling urinary catheter,
nasogastric tube, other types of tubes, or wound dressings. A belt restraint prevents the client
from falling out of a bed, a chair, or a stretcher. A mitten restraint does not secure the
shoulders and the waist and is not used to prevent the client from turning side to side.
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank
some window cleaner that had been stored in a cabinet. The nurse should instruct the mother
to immediately: - ANS Call a poison control center
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting
should not be induced if the victim is unconscious or if the substance ingested was a strong
corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare
provider has given specific instructions to induce vomiting. Neither calling an ambulance nor
calling the physician's answering service is the immediate action, because either would delay
treatment. Additionally, the physician would immediately make a referral to the poison control
center. The poison control center may advise the mother to bring the child to the emergency
department; if this is the case, the mother should then call an ambulance.
A home care nurse is visiting an older client who has been recovering from a mild brain attack
(stroke) affecting her left side. The client lives alone but receives regular assistance from her
daughter and son, who both live within 10 miles. Which of the following actions should the
nurse take to assess the client's safety risk? Select all that apply. - ANS - Assessing the client's
3
visual acuity
Page
@COPYRIGHT BRAINBARTER 2025/2026
, - Observing the client's gait and posture
- Evaluating the client's muscle strength
- Looking for any hazards in the home environment
Rationale: To conduct a thorough client assessment, the nurse looks for risk factors related to
safety. The assessment should include the assessment of visual acuity, gait and posture, and
muscle strength, because alterations in these areas increase the client's risk for falls and injury.
The nurse should also assess the home environment, looking for any hazards or obstacles that
might affect safety. Asking a family member to move in with the client until recovery is
complete and requesting that the client transfer to an assisted living environment for at least 1
month are not assessment activities. Additionally, nothing in the question indicates that these
actions are necessary; therefore, these options are unrealistic and unreasonable.
A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to
climb out of bed. Which of these safety devices that the nurse might suggest is the least
restrictive? - ANS Ambularm
Rationale: The Ambularm device, worn on the leg, signals when the client's leg is in a
dependent position. It is used for clients who climb out of bed and are at risk for falling.
Ambularm devices that may be attached to the bed or chair or to the client's mattress or
nightgown are also available. A belt restraint is a device that is wrapped around the client's
waist to secure the client to bed or to a stretcher. A wrist restraint is a device used to
immobilize an arm. An elbow restraint consists of a piece of fabric with slots into which tongue
blades are inserted, after which the device is wrapped around the elbow area to immobilize it.
Of the options provided, the Ambularm is the least restrictive safety device.
A home health nurse has instructed a client about safety measures during the use of an oxygen
concentrator in the home. Which statement by the client indicates to the nurse that the client
has understood the directions? Select all that apply. - ANS - "I need to follow the oxygen
prescription exactly."
- "I have to keep the oxygen concentrator out of direct sunlight."
- "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the
oxygen concentrator."
4
Page
@COPYRIGHT BRAINBARTER 2025/2026
