NCLEX-PN Test #11 1 — Questions and Answers
Question 1: A nurse is caring for a patient admitted with active pulmonary tuberculosis. Which type of isolation precautions should the nurse implement?
- Contact precautions with gloves and gown
- Droplet precautions with a surgical mask
- Airborne precautions with a negative-pressure room and N95 respirator (Correct answer)
- Standard precautions only
Correct answer: Airborne precautions with a negative-pressure room and N95 respirator
Pulmonary tuberculosis is transmitted via airborne droplet nuclei (particles smaller than 5 microns that remain suspended in air). Airborne precautions require placement in a negative-pressure room and use of an N95 or higher-level respirator by healthcare workers.
Question 2: A nurse prepares to perform a sterile dressing change. After opening the sterile field, the nurse turns away momentarily. What is the correct action?
- Continue with the dressing change since the field was only unattended briefly
- Discard the sterile field and set up a new one (Correct answer)
- Cover the sterile field with a sterile drape and proceed
- Ask a colleague to confirm the field is still sterile
Correct answer: Discard the sterile field and set up a new one
A sterile field is considered contaminated if it is out of the nurse's direct line of vision, even briefly. The nurse must discard the compromised sterile field and open a new sterile setup to prevent infection.
Question 3: A nurse caring for a patient with Clostridium difficile (C. diff) diarrhea should use which hand hygiene method?
- Alcohol-based hand rub for at least 30 seconds
- Soap and water handwashing for at least 20 seconds (Correct answer)
- Either alcohol rub or soap and water — both are equally effective
- Chlorhexidine wipe followed by alcohol rub
Correct answer: Soap and water handwashing for at least 20 seconds
C. difficile produces spores that are not destroyed by alcohol-based hand sanitizers. Soap and water handwashing with friction for at least 20 seconds is required to mechanically remove spores from the hands.
Question 4: A client is placed on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). When entering the room, the nurse should don PPE in which order?
- Gloves, then gown
- Gown, then gloves (Correct answer)
- Mask, then gown, then gloves
- Gloves, then gown, then mask
Correct answer: Gown, then gloves
For contact precautions, the gown should be donned first to protect clothing and skin, followed by gloves. This sequence ensures the gown cuffs are covered by the gloves, reducing contamination risk.
Question 5: A nurse notes that a Foley catheter drainage bag is resting on the floor. What is the priority action?
- Empty the bag and document the finding
- Replace the entire catheter system immediately (Correct answer)
- Lift the bag off the floor, clean the drainage port, and document
- Leave it as is and report to the charge nurse
Correct answer: Replace the entire catheter system immediately
The closed urinary drainage system has been contaminated by contact with the floor. To prevent a catheter-associated urinary tract infection (CAUTI), the entire catheter and drainage system must be replaced per infection control standards.
Question 6: After removing gloves following patient care, a nurse notices a small tear in one glove. What is the most appropriate next action?
- Apply hand lotion to protect any skin breaks
- Perform hand hygiene immediately and assess the skin for breaks (Correct answer)
- Report the incident only if the patient has a known infection
- No action is needed since gloves were worn throughout
Correct answer: Perform hand hygiene immediately and assess the skin for breaks
A torn glove is a potential exposure risk. The nurse should perform hand hygiene immediately and inspect the skin for cuts or abrasions. If the patient has a bloodborne pathogen or the skin is broken, the incident must be reported and an exposure protocol followed.
NCLEX-PN Test #11 1
A nurse is caring for a patient admitted with active pulmonary tuberculosis.
Which type of isolation precautions should the nurse implement?