Soal Nclex 2

NCLEX Practice Exam for Safety and Infection Control
1. A child is admitted to the pediatric unit with a diagnosis of suspected

meningococcal meningitis. Which of the following nursing measures should
the nurse do FIRST?
A.
Institute seizure precautions
B.
Assess neurologic status
C.
Place in respiratory isolation
D.
Assess vital signs

2. A client is diagnosed with methicillin resistant staphylococcus aureus
pneumonia. What type of isolation is MOST appropriate for this client?
A.
Reverse isolation
B.
Respiratory isolation
C.
Standard precautions
D.
Contact isolation
3. Several clients are admitted to an adult medical unit. The nurse would
ensure airborne precautions for a client with which of the following medical
conditions?
A.
A diagnosis of AIDS and cytomegalovirus
B.
A positive PPD with an abnormal chest x-ray
C.
A tentative diagnosis of viral pneumonia
D.
Advanced carcinoma of the lung

4. Which of the following is the FIRST priority in preventing infections when
providing care for a client?
A.
Handwashing
B.
Wearing gloves
C.
Using a barrier between clients furniture and nurses bag
D.
Wearing gowns and goggles
5. An adult woman is admitted to an isolation unit in the hospital after

tuberculosis was detected during a pre-employment physical. Although
frightened about her diagnosis, she is anxious to cooperate with the
therapeutic regimen. The teaching plan includes information regarding the
most common means of transmitting the tubercle bacillus from one
individual to another. Which contamination is usually responsible?
A.
Hands.
B.
Droplet nuclei.
C.
Milk products.
D.
Eating utensils.
6. A 2 year old is to be admitted in the pediatric unit. He is diagnosed with
febrile seizures. In preparing for his admission, which of the following is the
most important nursing action?
A.
Order a stat admission CBC.
B.
Place a urine collection bag and specimen cup at the bedside.
C.
Place a cooling mattress on his bed.
D.
Pad the side rails of his bed.

7. A young adult is being treated for second and third degree burns over 25%
of his body and is now ready for discharge. The nurse evaluates his
understanding of discharge instructions relating to wound care and is
satisfied that he is prepared for home care when he makes which statement?
A.
I will need to take sponge baths at home to avoid exposing the

wounds to unsterile bath water.
B.
If any healed areas break open I should first cover them with a sterile
dressing and then report it.
C.
I must wear my Jobst elastic garment all day and can only remove it
when Im going to bed.
D.
I can expect occasional periods of low-grade fever and can take

Tylenol every 4 hours.
8. An eighty five year old man was admitted for surgery for benign prostatic
hypertrophy. Preoperatively he was alert, oriented, cooperative, and
knowledgeable about his surgery. Several hours after surgery, the evening
nurse found him acutely confused, agitated, and trying to climb over the
protective side rails on his bed. The most appropriate nursing intervention
that will calm an agitated client is
A.
limit visits by staff.
B.
encourage family phone calls.
C.
position in a bright, busy area.
D.
speak soothingly and provide quiet music.

9. Ms. Smith is admitted for internal radiation for cancer of the cervix. The
nurse knows the client understands the procedure when she makes which of
the following remarks the night before the procedure?
A.
She says to her husband, Please bring me a hamburger and french

fries tomorrow when you come. I hate hospital food.
B.
I told my daughter who is pregnant to either come to see me tonight

or wait until I go home from the hospital.
C.
I understand it will be several weeks before all the radiation leaves

my body.
D.
I brought several craft projects to do while the radium is inserted.

10. The nurse in charge is evaluating the infection control procedures on the
unit. Which finding indicates a break in technique and the need for education
of staff?
A.
The nurse aide is not wearing gloves when feeding an elderly client.
B.
A client with active tuberculosis is asked to wear a mask when he

leaves his room to go to another department for testing.
C.
A nurse with open, weeping lesions of the hands puts on gloves before
giving direct client care.
D.
The nurse puts on a mask, a gown, and gloves before entering the
room of a client on strict isolation.
11. The charge nurse observes a new staff nurse who is changing a dressing
on a surgical wound. After carefully washing her hands the nurse dons sterile
gloves to remove the old dressing. After removing the dirty dressing, the
nurse removes the gloves and dons a new pair of sterile gloves in
preparation for cleaning and redressing the wound. The most appropriate
action for the charge nurse is to:
A.
interrupt the procedure to inform the staff nurse that sterile gloves are
not needed to remove the old dressing.
B.
congratulate the nurse on the use of good technique.
C.
discuss dressing change technique with the nurse at a later date.
D.
interrupt the procedure to inform the nurse of the need to wash her
hands after removal of the dirty dressing and gloves.
12. Nurse Jane is visiting a client at home and is assessing him for risk of a
fall. The most important factor to consider in this assessment is:
A.
Correct illumination of the environment.
B.
amount of regular exercise.
C.
the resting pulse rate.
D.
status of salt intake.

13. Mrs. Jones will have to change the dressing on her injured right leg twice
a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline
irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones
understands the importance of maintaining asepsis?
A.
If I drop the 4 X 4s on the floor, I can use them as long as they are not
soiled.
B.
If I drop the 4 X 4s on the floor, I can use them if I rinse them with
sterile normal saline.
C.
If I question the sterility of any dressing material, I should not use it.
D.
I should put on my sterile gloves, then open the bottle of saline to

soak the 4 X 4s.
14. A client has been placed in blood and body fluid isolation. The nurse is
instructing auxiliary personnel in the correct procedures. Which statement by
the nursing assistant indicates the best understanding of the correct protocol
for blood and body fluid isolation?
A.
Masks should be worn with all client contact.
B.
Gloves should be worn for contact with nonintact skin, mucous

membranes, or soiled items.
C.
Isolation gowns are not needed.
D.
A private room is always indicated.

15. A client has been placed in blood and body fluid isolation. The nurse is
instructing auxiliary personnel in the correct procedures. Which statement by
the nursing assistant indicates the best understanding of the correct protocol
for blood and body fluid isolation?
A.
Masks should be worn with all client contact.
B.
Gloves should be worn for contact with nonintact skin, mucous

membranes, or soiled items.
C.
Isolation gowns are not needed.
D.
A private room is always indicated.

16. The nurse is evaluating whether nonprofessional staff understand how to
prevent transmission of HIV. Which of the following behaviors indicates
correct application of universal precautions?
A.
A lab technician rests his hand on the desk to steady it while recapping
the needle after drawing blood.
B.
An aide wears gloves to feed a helpless client.
C.
An assistant puts on a mask and protective eye wear before assisting

the nurse to suction a tracheostomy.
D.
A pregnant worker refuses to care for a client known to have AIDS.
17. Jayson, 1 year old child has a staph skin infection. Her brother has also
developed the same infection. Which behavior by the children is most likely
to have caused the transmission of the organism?
A.
Bathing together.
B.
Coughing on each other.
C.
Sharing pacifiers.
D.
Eating off the same plate.

18. Jessie, a young man with newly diagnosed acquired immune deficiency
syndrome (AIDS) is being discharged from the hospital. The nurse knows that
teaching regarding prevention of AIDS transmission has been effective when
the client:
A.
verbalizes the role of sexual activity in spread of the disorder.
B.
states he will make arrangements to drop his college classes.
C.
acknowledges the need to avoid all contact sports.
D.
says he will avoid close contact with his three-year-old niece.

19. Which question is least useful in the assessment of a client with AIDS?
A.
Are you a drug user?
B.
Do you have many sex partners?
C.
What is your method of birth control?
D.
How old were you when you became sexually active?

20. Mrs. Parker, a 70-year-old woman with severe macular degeneration, is
admitted to the hospital the day before scheduled surgery. The nurses
preoperative goals for Mrs. M. would include:
A.
independently ambulating around the unit.
B.
reading the routine preoperative education materials.
C.
maneuvering safely after orientation to the room.
D.
using a bedpan for elimination needs.

Answers and Rationales
1.
Answer C. The initial therapeutic management of acute bacterial

meningitis includes isolation precautions, initiation of antimicrobial therapy
and maintenance of optimum hydration. Nurses should take necessary
precautions to protect themselves and others from possible infection.
2.
Answer D. Contact or Body Substance Isolation (BSI) involves the use

of barrier protection (e.g. gloves, mask, gown, or protective eyewear as
appropriate) whenever direct contact with any body fluid is expected. When
determining the type of isolation to use, one must consider the mode of
transmission. The hands of personnel continues to be the principal mode of
transmission for methicillin resistant staphylococcus aureus (MRSA). Because
the organism is limited to the sputum in this example, precautions are taken
if contact with the patients sputum is expected. A private room and BSI,
along with good hand washing techniques, are the best defense against the
spread of MRSA pneumonia.
3.
Answer B. The client who must be placed in airborne precautions is

the client with a positive PPD (purified protein derivative) who has a positive
x-ray for a suspicious tuberculin lesion.
4.
Answer A. Handwashing remains the most effective way to avoid

spreading infection. However, too often nurses do not practice good
handwashing techniques and do not teach families to do so. Nurses need to
wash their hands before and after touching the client and before entering the
nursing bag.
5.
Answer B. Hands are the primary method of transmission of the

common cold. The most frequent means of transmission of the tubercle
bacillus is by droplet nuclei. The bacillus is present in the air as a result of
coughing, sneezing, and expectoration of sputum by an infected person. The
tubercle bacillus is not transmitted by means of contaminated food. Contact
with contaminated food or water could cause outbreaks of salmonella,
infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not
transmitted by eating utensils. Some exogenous microbes can be
transmitted via reservoirs such as linens or eating utensils.
6.
Answer D. Preparing for routine laboratory studies is not as high a

priority as preventing injury and promoting safety. Preparing for routine
laboratory studies is not as high a priority as preventing injury and promoting
safety. A cooling blanket must be ordered by the physician and is usually not
used unless other methods for the reduction of fever have not been
successful. The child has a diagnosis of febrile seizures. Precautions to
prevent injury and promote safety should take precedence.
7.
Answer B. Bathing or showering in the usual manner is permitted,

using a mild detergent soap such as Ivory Snow. This cleanses the wounds,
especially those that are still open, and removes dead tissue. The client is
taught to report changes in wound healing such as blister formation, signs of
infection, and opening of a previously healed area. Sterile dressings are
applied until the wound is assessed and a plan of care developed. The Jobs
garment is designed to place constant pressure on the new healthy tissue
that is forming to promote adherence to the underlying structure in order to
prevent hypertrophic scarring. In order to be effective, the garment must be
worn for 23 hours daily. It is removed for wound assessment and wound care
and to permit bathing. The client must be aware that infection of the wound
may occur; signs of infection, including fever, redness, pain, warmth in and
around the wound and increased or foul smelling drainage must be reported
immediately.
8.
Answer D. The client needs frequent visits by the staff to orient him
and to assess his safety. Phone calls from his family will not help a client who
is trying to climb over the side rails and may even add to his danger. Putting
the client in a bright, busy area would probably add to his confusion. The
environment is an important factor in the prevention of injuries. Talking softly
and providing quiet music have a calming effect on the agitated client.
9.
Answer B. The client will be on a clear liquid or very low residue diet.
Hamburgers and french fries are not allowed. People who are pregnant
should not come in close contact with someone who has internal radiation
therapy. The radioactivity could possibly damage the fetus. This statement is
not true. As soon as the radiation source is removed (probably 36 to 72 hours

after insertion), the client is no longer contaminated with radioactivity. Craft
projects usually require the client to sit. The client must remain flat with very
little head elevation during the time the rods are in place.
10.
Answer C. There is no need to wear gloves when feeding a client.
However, universal precautions (treating all blood and body fluids as if they
are infectious) should be observed in all situations. A client with active
tuberculosis should be on respiratory precautions. Having the client wear a
mask when leaving his private room is appropriate. Persons with exudative
lesions or weeping dermatitis should not give direct client care or handle
client-care equipment until the condition resolves. Strict isolation requires
the use of mask, gown, and gloves.
11.
Answer D. Nonsterile gloves are adequate to remove the old dressing.
However, the use of sterile gloves does not put the client in danger so
discussion of this can wait until later. The staff nurse is doing two things
incorrectly. Nonsterile gloves are adequate to remove the old dressing. The
nurse should wash her hands after removing the soiled dressing and before
donning sterile gloves to clean and dress the wound. The nurse should wash
her hands after removing the soiled dressing and before donning the sterile
gloves to clean and dress the wound. Not doing this compromises client
safety and should be brought to the immediate attention of the nurse. The
staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to
remove the old dressing. However, the use of sterile gloves does not put the
client in danger so discussion of this can wait until later. However, the nurse
should wash her hands after removing the soiled dressing and before
donning sterile gloves to clean and dress the wound. Not doing this
compromises client safety and should be brought to the immediate attention
of the nurse.
12.
Answer A. To prevent falls, the environment should be well lighted.
Night lights should be used if necessary. Other factors to assess include

removing loose scatter rugs, removing spills, and installing handrails and
grab bars as appropriate. The amount of regular exercise is not the most
important factor to assess. It is only indirectly related. The resting pulse rate
is not related to preventing falls. The salt intake is not directly related to
preventing falls.
13.
Answer C. Anything dropped on the floor is no longer sterile and
should not be used. The statement indicates lack of understanding. Anything

dropped on the floor is no longer sterile and should not be used. The
statement indicates lack of understanding. If there is ever any doubt about
the sterility of an instrument or dressing, it should not be used. The 4 X 4s
should be soaked prior to donning the sterile gloves. Once the sterile gloves
touch the bottle of normal saline they are no longer sterile. This statement
indicates a need for further instruction.
14.
Answer B. Masks should only be worn during procedures that are
likely to cause splashes of blood or body fluid. Gloves should be worn for all
contact with blood and body fluids, nonintact skin and mucous membranes;
for handling soiled items; and for performing venipuncture. Gowns should be
worn during procedures that are likely to cause splashes of blood or body
fluids. A private room is only indicated if the clients hygiene is poor.
15.
Answer B. Masks should only be worn during procedures that are
likely to cause splashes of blood or body fluid. Gloves should be worn for all
contact with blood and body fluids, nonintact skin and mucous membranes;
for handling soiled items; and for performing venipuncture. Gowns should be
worn during procedures that are likely to cause splashes of blood or body
fluids. A private room is only indicated if the clients hygiene is poor.
16.
Answer C. Needles that have been used to draw blood should not be
recapped. If it is necessary to recap them, an instrument such as a hemostat

should be used to recap. The hand should never be used. Gloves are not
necessary when feeding, since there is no contact with mucus membranes.
Although saliva may have small amounts of HIV in it, the virus does not
invade through unbroken skin. There is no evidence in the question to
indicate broken skin. Masks and protective eye wear are indicated anytime
there is great potential for splashing of body fluids that may be

contaminated with blood. Suctioning of a tracheostomy almost always
stimulates coughing, which is likely to generate droplets that may splash the
health care worker. Clients who are suctioned frequently or have had an
invasive procedure like a tracheostomy are likely to have blood in the
sputum. There is no reason to restrict pregnant workers from caring for
persons with AIDS as long as they utilize universal precautions.
17.
Answer A. Direct contact is the mode of transmission for
staphylococcus. Staph is not spread by coughing. Staph is not spread

through oral secretions. Direct contact is required. Staph is not spread
through oral secretions.
18.
Answer A. The AIDS virus is spread through direct contact with body
fluids such as blood and through sexual intercourse. Casual contact with
other people does not pose a risk of transmission of AIDS. Unless the client is
feeling very ill, there is no need for him to drop his college classes. Contact
sports are not contraindicated unless there is a significant chance of bleeding
and direct contact with others. Casual contact with other people does not
pose a risk of transmission of AIDS. There is no need to limit casual contact
with children.
19.
Answer D. Drug use is a risk factor for AIDS. Multiple sex partners is a
risk factor for AIDS. Birth control methods are important to prevent a baby
from being born with the AIDS virus. The age at which sexual activity began
it not relevant as it does not usually provide information that identifies the
presence of risk factors for AIDS.
20.
Answer C. Independently ambulating around the unit is not
appropriate because the unit environment can change and injury could
result. Assistance is necessary because of the clients visual deficit. It is
unlikely the client can see well enough to read the materials. Maneuvering
safely after orientation to the room is a realistic goal for a person with
impaired vision. Orienting the client to the room should help the client to
move safely. Using the bedpan is an unnecessary restriction on the client as

she can be oriented to the bathroom or to call for assistance.
NCLEX Practice Exam for Health Promotion and Maintenance
1. What equipment would be necessary to complete an evaluation of cranial

nerves 9 and 10 during a physical assessment?
A.
A cotton ball
B.
A pen light
C.
An ophthalmoscope
D.
A tongue depressor and flashlight

2. Which technique would be best in caring for a client following receiving a
diagnosis of a state IV tumor in the brain?
A.
Offering the client pamphlets on support groups for brain cancer
B.
Asking the client if there is anything he or his family needs
C.
Reminding the client that advances in technology are occurring

everyday
D.
Providing accurate information about the disease and treatment

options
3. An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing
intervention would be implemented when the neonate becomes jittery and
lethargic?
A.
Administer insulin
B.
Administer oxygen
C.
Feed the infant glucose water (10%)
D.
Place infant in a warmer

4. What question would be most important to ask a male client who is in for a
digital rectal examination?
A.
Have you noticed a change in the force of the urinary system?
B.
Have you noticed a change in tolerance of certain foods in your diet?
C.
Do you notice polyuria in the AM?
D.
Do you notice any burning with urination or any odor to the urine?
5. The nurse assesses a prolonged late deceleration of the fetal heart rate
while the client is receiving oxytocin (Pitocin) IV to stimulate labor. The
priority nursing intervention would be to:
A.
Turn off the infusion
B.
Turn the client to the left
C.
Change the fluid to Ringers Lactate
D.
Increase mainline IV rate

6. Which nursing approach would be most appropriate to use while
administering an oral medication to a 4 month old?
A.
Place medication in 45cc of formula
B.
Place medication in an empty nipple
C.
Place medication in a full bottle of formula
D.
Place in supine position. Administer medication using a plastic syringe

7. Which nursing intervention would be a priority during the care of a 2
month old after surgery?
A.
Minimize stimuli for the infant
B.
Restrain all extremities
C.
Encourage stroking of the infant
D.
Demonstrate to the mother how she can assist with her infants care.
8. While performing a physical examination on a newborn, which assessment
should be reported to the physician?
A.
Head circumference of 40 cm
B.
Chest circumference of 32 cm
C.
Acrocyanosis and edema of the scalp
D.
Heart rate of 160 and respirations of 40
9. Which action by the mother of a preschooler would indicate a disturbed

family interaction?
A.
Tells her child that if he does not sit down and shut up she will leave
him there.
B.
Explains that the injection will burn like abee sting.
C.
Tells her child that the injection can be given while hes in her lap
D.
Reassures child that it is acceptable to cry.

10. During the history, which information from a 21 year old client would
indicate a risk for development of testicular cancer?
A.
Genital Herpes
B.
Hydrocele
C.
Measles
D.
Undescended testicle
11. While caring for a client, the nurse notes a pulsating mass in the clients
periumbilical area. Which of the following assessments is appropriate for the
nurse to perform?
A.
Measure the length of the mass
B.
Auscultate the mass
C.
Percuss the mass
D.
Palpate the mass

12. When observing 4 year-old children playing in the hospital playroom,
what activity would the nurse expect to see the children participating in?
A.
Competitive board games with older children
B.
Playing with their own toys along side with other children
C.
Playing alone with hand held computer games
D.
Playing cooperatively with other preschoolers

13. The nurse is teaching the parents of a 3 month-old infant about nutrition.
What is the main source of fluids for an infant until about 12 months of age?
A.
Formula or breast milk
B.
Dilute nonfat dry milk
C.
Warmed fruit juice
D.
Fluoridated tap water

14. While the nurse is administering medications to a client, the client states
I do not want to take that medicine today. Which of the following responses
by the nurse would be best?
A.
Thats OK, its all right to skip your medication now and then.
B.
I will have to call your doctor and report this.
C.
Is there a reason why you dont want to take your medicine?
D.
Do you understand the consequences of refusing your prescribed

treatment?
15. The nurse is assessing a 4 month-old infant. Which motor skill would the
nurse anticipate finding?
A.
Hold a rattle
B.
Bang two blocks
C.
Drink from a cup
D.
Wave bye-bye
16. The nurse should recognize that all of the following physical changes of
the head and face are associated with the aging client except:
A.
pronounced wrinkles on the face.
B.
decreased size of the nose and ears.
C.
increased growth of facial hair.
D.
neck wrinkles.
17. All of the following characteristics would indicate to the nurse that an
elder client might experience undesirable effects of medicines except:
A.
increased oxidative enzyme levels.
B.
alcohol taken with medication.
C.
medications containing magnesium.
D.
decreased serum albumin.

18. When assessing a newborn whose mother consumed alcohol during the
pregnancy, the nurse would assess for which of these clinical manifestations?
A.
wide-spaced eyes, smooth filtrum, flattened nose
B.
strong tongue thrust, short palpebral fissures, simean crease
C.
negative Babinski sign, hyperreflexia, deafness
D.
shortened limbs, increased jitteriness, constant sucking

19. Which of these statements, when made by the nurse, is most effective
when communicating with a 4-year-old?
A.
Tell me where you hurt.
B.
Other children like having their blood pressure taken.
C.
This will be like having a little stick in your arm.
D.
Anything you tell me is confidential.

20. A 64 year-old client scheduled for surgery with a general anesthetic
refuses to remove a set of dentures prior to leaving the unit for the operating
room. What would be the most appropriate intervention by the nurse?
A.
Explain to the client that the dentures must come out as they may get
lost or broken in the operating room
B.
Ask the client if there are second thoughts about having the procedure
C.
Notify the anesthesia department and the surgeon of the clients

refusal
D.
Ask the client if the preference would be to remove the dentures in the
operating room receiving area
21. The nurse is assessing a client who states her last menstrual period was
March 17, and she has missed one period. She reports episodes of nausea
and vomiting. Pregancy is confirmed by a urine test. What will the nurse
calculate as the estimated date of delivery (EDD)?
A.
November 8
B.
May 15
C.
February 21
D.
December 24
22. The family of a 6 year-old with a fractured femur asks the nurse if the
childs height will be affected by the injury. Which statement is true
concerning long bone fractures in children?
A.
Growth problems will occur if the fracture involves the periosteum
B.
Epiphyseal fractures often interrupt a childs normal growth pattern
C.
Children usually heal very quickly, so growth problems are rare
D.
Adequate blood supply to the bone prevents growth delay after

fractures
23. A client is admitted to the hospital with a history of confusion. The client
has difficulty remembering recent events and becomes disoriented when
away from home. Which statement would provide the bestreality orientation
for this client?
A.
Good morning. Do you remember where you are?
B.
Hello. My name is Elaine Jones and I am your nurse for today.
C.
How are you today? Remember, youre in the hospital.
D.
Good morning. Youre in the hospital. I am your nurse Elaine Jones.

24. When a client wishes to improve the appearance of their eyes by
removing excess skin from the face and neck, the nurse should provide
teaching regarding which of the following procedures?
A.
Dermabrasion
B.
Rhinoplasty
C.
Blepharoplasty
D.
Rhytidectomy
1.
Answer D. Cranial nerves 9 and 10 are the glossopharyngeal and

vagus nerves. The gag reflex would be evaluated.
2.
Answer D. Providing information for the client is the best technique for
a new diagnosis.
3.
Answer C. After birth, the infant of a diabetic mother is often

hypoglycemic.
4.
Answer A. This change would be most indicative of a potential

complication with (BPH) benign prostate hypertrophy.
5.
Answer A. Stopping the infusion will decrease contractions and

possibly remove uterine pressure on the fetus, which is a possible cause of
the deceleration.
6.
Answer B. This is a convenient method for administering medications

to an infant. Option D is partially correct however, the infant is never placed
in a reclining position during a procedure due to a potential aspiration.
7.
Answer C. Tactile stimulation is imperative for an infants normal

emotional development. After the trauma of surgery, sensory deprivation can
cause failure to thrive.
8.
Answer A. Average circumference of the head for a neonate ranges

between 32 to 36 cm. An increase in size may indicate hydrocephaly or
increased intracranial pressure.
9.
Answer A. Threatening a child with abandonment will destroy the

childs trust in his family.
10.
Answer D. Undescended testicles make the client high risk for
testicular cancer. Mumps, inguinal hernia in childhood, orchitis, and testicular

cancer in the contra lateral testis are other predisposing factors.
11.
Answer B. Auscultate the mass. Auscultation of the abdomen and
finding a bruit will confirm the presence of an abdominal aneurysm and will
form the basis of information given to the provider. The mass should not be
palpated because of the risk of rupture.
12.
Answer D. Playing cooperatively with other preschoolers. Cooperative
play is typical of the late preschool period.

13.
Answer A. Formula or breast milk are the perfect food and source of
nutrients and liquids up to 1 year of age.
14.
Answer C. When a new problem is identified, it is important for the
nurse to collect accurate assessment data. This is crucial to ensure that

client needs are adequately identified in order to select the best nursing care
approaches. The nurse should try to discover the reason for the refusal which
may be that the client has developed untoward side effects.
15.
Answer A. The age at which a baby will develop the skill of grasping
a toy with help is 4 to 6 months.

16.
Answer B. The nose and ears of the aging client actually become
longer and broader. The chin line is also altered. Wrinkles on the face
become more pronounced and tend to take on the general mood of the client
over the years. For example laugh or frown wrinkles about the eyebrows,
lips, cheeks, and outer edges of the eye orbit. The change in the androgenestrogen ration causes an increase in growth of facial hair in most elder
adults. The aging process shortens the platysma muscle, which contributes
to neck wrinkles.
17.
Answer A. Oxidative enzyme levels decrease in the elderly, which
affects the disposition of medication and can alter the therapeutic effects of
medication. Alcohol has a smaller water distribution level in the elderly,
resulting in higher blood alcohol levels. Alcohol also interacts with various
drugs to either potentate or interfere with their effects. Magnesium is
contained in a lot of medications elder clients routinely obtain over the
counter. Magnesium toxicity is a real concern. Albumin is the major drugbinding protein. Decreased levels of serum albumin mean that higher levels
of the drug remain free and that there are less therapeutic effects and
increased drug interactions.
18.
Answer A. The nurse should anticipate that the infant may have fetal
alcohol syndrome and should assess for signs and symptoms of it. These
include the characteristics listed in choice A.
19.
Answer A. Four-year-olds are egocentric and interested in having the
focus on themselves. They will not be interested in what it feels like to other
children. Preschoolers are concrete thinkers and would literally interpret any
analogies so they are not helpful in explaining procedures. Assurance of

confidential communication is most appropriate for the adolescent. In
addition, confidentiality is not maintained if the child plans to harm
themselves, harm someone else, or discloses abuse.
20.
Answer D. Clients anticipating surgery may experience a variety of
fears. This choice allows the client control over the situation and fosters the
clients sense of self-esteem and self-concept.
21.
Answer D. Naegeles rule: add 7 days and subtract 3 months from the
first day of the last regular menstrual period to calculate the estimated date
of delivery.
22.
Answer B. Epiphyseal fractures often interrupt a childs normal growth
pattern
23.
Answer is D. As cognitive ability declines, the nurse provides a calm,
predictable environment for the client. This response establishes time,

location and the caregivers name.
24.
Answer D. Rhytidectomy is the procedure for removing excess skin
from the face and neck. It is commonly called a face lift. Dermabrasion
involves the spraying of a chemical to cause light freezing of the skin, which
is then abraded with sandpaper or a revolving wire brush. It is used to
remove facial scars, severe acne, and pigment from tattoos. Rhinoplasty is
done to improve the appearance of the nose and involves reshaping the
nasal skeleton and overlying skin. Blepharoplasty is the procedure that
removes loose and protruding fat from the upper and lower eyelids.
NCLEX Practice Exam for Basic Care and Comfort
1. Nurse Jessie is caring for an elderly woman who has had a fractured hip
repaired. In the first few days following the surgical repair, which of the
following nursing measures will best facilitate the resumption of activities for
this client?
A.
arranging for the wheelchair
B.
asking her family to visit
C.
assisting her to sit out of bed in a chair qid
D.
encouraging the use of an overhead trapeze

2. What do you think is the most important nursing order in a client with
major head trauma who is about to receive bolus enteral feeding?
A.
measure intake and output.
B.
check albumin level.
C.
monitor glucose levels.
D.
increase enteral feeding.

3. What is the pathological process causing esophageal varices is
A.
ascites and edema.
B.
systemic hypertension.
C.
portal hypertension.
D.
dilated veins and varicesitis.

4. Which of the following interventions will help lessen the effect of GERD
(acid reflux)?
A.
Elevate the head of the bed on 4-6 inch blocks.
B.
Lie down after eating.
C.
Increase fluid intake just before bedtime.
D.
Wear a girdle.
5. What is the main benefit of therapeutic massages is:
A.
to help a person with swollen legs to decrease the fluid retention.
B.
to help a person with duodenal ulcers feel better.
C.
to help damaged tissue in a diabetic to heal.
D.
to improve circulation and muscles tone.

6. Which of the following foods should be avoided by clients who are prone to
develop heartburn as a result of gastroesophgeal reflux disease (GERD)?
A.
Lettuce
B.
Eggs
C.
Chocolate
D.
Butterscotch
7. Which of the following should be included in a plan of care for a client
receiving total parenteral nutrition (TPN)?
A.
Withhold medications while the TPN is infusing.
B.
Change TPN solution every 24 hours.
C.
Flush the TPN line with water prior to initiating nutritional support.
D.
Keep client on complete bed rest during TPN therapy.

8. Which of the following should be included in a plan of care for a client who
is lactose intolerant?
A.
Remove all dairy products from the diet.
B.
Frozen yogurt can be included in the diet.
C.
Drink small amounts of milk on an empty stomach.
D.
Spread out selection of dairy products throughout the day.

9. Pain tolerance in an elderly patient with cancer would:
A.
stay the same.
B.
be lowered.
C.
be increased.
D.
no effect on pain tolerance.

10. What is the main advantage of cutaneous stimulation in managing paint:
A.
costs less.
B.
restricts movement and decreases.
C.
gives client control over pain syndrome.
D.
allows the family to care for the patient at home.

11. The nurse is instructing a 65 year-old female client diagnosed with
osteoporosis. The most important instruction regarding exercise would be to
A.
exercise doing weight bearing activities
B.
exercise to reduce weight
C.
avoid exercise activities that increase the risk of fracture
D.
exercise to strengthen muscles and thereby protect bones

12. A client in a long term care facility complains of pain. The nurse collects
data about the clients pain. The first step in pain assessment is for the nurse
to
A.
have the client identify coping methods
B.
get the description of the location and intensity of the pain
C.
accept the clients report of pain
D.
determine the clients status of pain

13. Which statement best describes the effects of immobility in children?
A.
Immobility prevents the progression of language and fine motor

development
B.
Immobility in children has similar physical effects to those found in

adults
C.
Children are more susceptible to the effects of immobility than are

adults
D.
Children are likely to have prolonged immobility with subsequent

complications
14. After a myocardial infarction, a client is placed on a sodium restricted
diet. When the nurse is teaching the client about the diet, which meal plan
would be the most appropriate to suggest?
A.
3 oz. broiled fish, 1 baked potato, cup canned beets, 1 orange, and
milk
B.
3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C.
A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple

juice
D.
3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and
1 orange
15. A nurse is assessing several clients in a long term health care facility.
Which client is at highest risk for development of decubitus ulcers?
A.
A 79 year-old malnourished client on bed rest
B.
An obese client who uses a wheelchair
C.
An incontinent client who has had 3 diarrhea stools
D.
An 80 year-old ambulatory diabetic client

16. Ms. Kelly. has had a CVA (cerebrovascular accident) and has severe rightsided weakness. She has been taught to walk with a cane. The nurse is
evaluating her use of the cane prior to discharge. Which of the following
reflects correct use of the cane?
A.
Holding the cane in her left hand, Ms. Kelly. moves the cane forward
first, then her right leg, and finally her left leg
B.
Holding the cane in her right hand, Ms. Kelly. moves the cane forward
first, then her left leg, and finally her right leg
C.
Holding the cane in her right hand, Ms. Kelly. moves the cane and her
right leg forward, then moves her left leg forward.
D.
Holding the cane in her left hand, Ms. Kelly. moves the cane and her
left leg forward, then moves her right leg forward
17. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of
the following food choices, if selected by the client, indicate an
understanding of a low-fat, high-fiber diet?
A.
Tuna salad sandwich on whole wheat bread.
B.
Vegetable soup made with vegetable stock, carrots, celery, and

legumes served with toasted oat bread
C.
Chefs salad with hard boiled eggs and fat-free dressing
D.
Broiled chicken stuffed with chopped apples and walnuts
18. An 85-year-old male patient has been bedridden for two weeks. Which of
the following complaints by the patient indicates to the nurse that he is
developing a complication of immobility?
A.
Stiffness of the right ankle joint
B.
Soreness of the gums
C.
Short-term memory loss.
D.
Decreased appetite.
19. An eleven-month-old infant is brought to the pediatric clinic. The nurse
suspects that the child has iron deficiency anemia. Because iron deficiency
anemia is suspected, which of the following is the most important
information to obtain from the infants parents?
A.
Normal dietary intake.
B.
Relevant sociocultural, economic, and educational background of the

family.
C.
Any evidence of blood in the stools
D.
A history of maternal anemia during pregnancy

20. A 46-year-old female with chronic constipation is assessed by the nurse
for a bowel training regimen. Which factor indicates further information is
needed by the nurse?
A.
The clients dietary habits include foods high in bulk.
B.
The clients fluid intake is between 2500-3000 ml per day
C.
The client engages in moderate exercise each day
D.
The clients bowel habits were not discussed.

1.
Answer D. Exercise is important to keep the joints and muscles

functioning and to prevent secondary complications. Using the overhead
trapeze prevents hazards of immobility by permitting movement in bed and
strengthening of the upper extremities in preparation for ambulation. Sitting
in a wheelchair would require too great hip flexion initially. Asking her family
to visit would not facilitate the resumption of activities. Sitting in a chair

would cause too much hip flexion. The client initially needs to be in a low
Fowlers position or taking a few steps (as ordered) with the aid of a walker.
2.
Answer A. It is important to measure intake and output, which should

equal. Enteral feeding are hyperosmotic agents pulling fluid from cells into
vascular bed. Water given before feeding will present a hyperosmotic
diuresis. I and O measures assess fluid balance.
3.
Answer C. Esophageal varices results from increased portal

hypertension. In portal hypertension, the liver cannot accept all of the fluid
from the portal vein. The excess fluid will back flow to the vessels with lesser
pressure, such as esophageal veins or rectal veins causing esophageal
varices or hemorrhoids.
4.
Answer A. Elevation of the head of the bed allows gravity to assist in

decreasing the backflow of acid into the esophagus. Fluid does not flow
uphill. The other three options all increase fluid backflow into the esophagus
through position or increasing abdominal pressure.
5.
Answer D. Particularly in the elderly adults, therapeutic massage will

help improve circulation and muscle tone as well as the personal attention
and social interaction that a good massage provides. A massage is
contraindicated in any condition where massage to damaged tissue can
dislodge a blood clot.
6.
Answer C. Ingestion of chocolate can reduce lower esophageal

sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. All
of the other foods do not affect LES pressure.
7.
Answer B. TPN solutions should be changed every 24 hours in order

to prevent bacterial overgrowth due to hypertonicity of the solution. Option 1
is incorrect; medication therapy can continue during TPN therapy. Option 3 is
incorrect; flushing is not required because the initiation of TPN does not
require a client to remain on bed rest during therapy. However, other clinical
conditions of the client may affect mobility issues and warrant the clients
being on bed rest.
8.
Answer B. Clients who are lactose intolerant can digest frozen yogurt.
Yogurt products are formed by bacterial action, and this action assists in the
digestion of lactose. The freezing process further stops bacterial action so
that limited lactase activity remains. Option 1 is incorrect; elimination of all
dairy products can lead to significant clinical deficiencies of other nutrients.
Option 3 is incorrect because drinking milk on an empty stomach can
exacerbate clinical symptoms. Drinking milk with a meal may benefit the
client because other foods, (especially fat) may decrease transit time and
allow for increased lactase activity. Option 4 is incorrect because although
individual tolerance should be acknowledged, spreading out the use of
known dairy products will usually exacerbate clinical symptoms.
9.
Answer B. There is potential for a lowered pain tolerance to exist with

diminished adaptative capacity.
10.
Answer C. Cutaneous stimulation allows the patient to have control
over his pain and allows him to be in his own environment. Cutaneous
stimulation increases movement and decreases pain.
11.
Answer A. Weight bearing exercises are beneficial in the treatment of
osteoporosis. Although loss of bone cannot be substantially reversed, further

loss can be greatly reduced if the client includes weight bearing exercises
along with estrogen replacement and calcium supplements in their treatment
protocol.
12.
Answer C. Although all of the options above are correct, the first and
most important piece of information in this clients pain assessment is what

the client is telling you about the pain the clients report.
13.
Answer B. Care of the immobile child includes efforts to prevent
complications of muscle atrophy, contractures, skin breakdown, decreased

metabolism and bone demineralization. Secondary alterations also occur in
the cardiovascular, respiratory and renal systems. Similar effects and
alterations occur in adults.
14.
Answer D. Canned fish and vegetables and cured meats are high in
sodium. This meal does not contain any canned fish and/or vegetables or
cured meats
15.
Answer A. Weighing significantly less than ideal body weight
increases the number and surface area of bony prominences which are
susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for
decubiti, due in part to poor hydration and inadequate protein intake.
16.
Answer A. When a person with weakness on one side uses a cane,
there should always be two points of contact with the floor. When Ms. Kelly.
moves the cane forward, she has both feet on the floor, providing stability. As
she moves the weak leg, the cane and the strong leg provide support.
Finally, the cane, which is even with the weak leg, provides stability while
she moves the strong leg. She should not hold the cane with her weak arm.
The use of the cane requires arm strength to ensure that the cane provides
adequate stability when standing on the weak leg. The cane should be held
in the left hand, the hand opposite the affected leg. If Ms. Kelly. moved the
cane and her strong foot at the same time, she would be left standing on her
weak leg at one point. This would be unstable at best; at worse, impossible
17.
Answer B. Mayonnaise in tuna salad is high in fat. The whole wheat
bread has some fiber. This choice shows a low-fat soup (which would have
been higher in fat if made with chicken or beef stock) and high-fiber bread
and soup contents (both the vegetables and the legumes). Salad is high in
fiber, but hard boiled eggs are high in fat. There is some fiber in the apples
and walnuts. The walnuts are high in fat, as is the chicken.
18.
Answer A. Stiffness of a joint may indicate the beginning of a
contracture and/or early muscle atrophy. Soreness of the gums is not related
to immobility. Short-term memory loss is not related to immobility. Decreased
appetite is unlikely to be related to immobility.
19.
Answer A. Iron deficiency anemia occurs commonly in children 6 to
24 months of age. For the first 4 to 5 months of infancy iron stores laid down
for the baby during pregnancy are adequate. When fetal iron stores are
depleted, supplemental dietary iron needs to be supplied to meet the infants

rapid growth needs. Iron deficiency may occur in the infant who drinks
mostly milk, which contains no iron, and does not receive adequate dietary
iron or supplemental iron. Daily dietary intake is much more related to the
diagnosis of iron deficiency anemia than is sociocultural, economic, and
educational background of the family. Iron deficiency anemia in an infant is
very unlikely to be related to gastrointestinal bleeding. Anemia during
pregnancy is unlikely to be the cause of the infants iron deficiency anemia.
Fetal iron stores are drawn from the mother even if she is anemic.
20.
Answer D. Foods high in bulk are appropriate. Exercise should be a
part of a bowel training regimen. To assess the client for a bowel training
program the factors causing the bowel alteration should be assessed. A
routine for bowel elimination should be based on the clients previous bowel
habits and alterations in bowel habits that have occurred because of illness
or trauma. The client and the family should assist in the planning of the
program which should include foods high in bulk, adequate exercise, and
fluid intake of 2500-3000 ml.
NCLEX Practice Exam for Pharmacological and Parenteral Therapies
1. A 2 year-old child is receiving temporary total parental nutrition (TPN)

through a central venous line. This is the first day of TPN therapy. Although
all of the following nursing actions must be included in the plan of care of
this child, which one would be a priority at this time?
A.
Use aseptic technique during dressing changes
B.
Maintain central line catheter integrity
C.
Monitor serum glucose levels
D.
Check results of liver function tests
2. Nurse Jamie is administering the initial total parenteral nutrition solution to

a client. Which of the following assessments requires the nurses immediate
attention?
A.
Temperature of 37.5 degrees Celsius
B.
Urine output of 300 cc in 4 hours
C.
Poor skin turgor
D.
Blood glucose of 350 mg/dl

3. Nurse Susan administered intravenous gamma globulin to an 18 monthold child with AIDS. The parent asks why this medication is being given. What
is the nurses best response?
A.
It will slow down the replication of the virus.
B.
This medication will improve your childs overall health status.
C.
This medication is used to prevent bacterial infections.
D.
It will increase the effectiveness of the other medications your child

receives.
4. When caring for a client with total parenteral nutrition (TPN), what is the
most important action on the part of the nurse?
A.
Record the number of stools per day
B.
Maintain strict intake and output records
C.
Sterile technique for dressing change at IV site
D.
Monitor for cardiac arrhythmias

5. The nurse is administering an intravenous vesicant chemotherapeutic
agent to a client. Which assessment would require the nurses immediate
action?
A.
Stomatitis lesion in the mouth
B.
Severe nausea and vomiting
C.
Complaints of pain at site of infusion
D.
A rash on the clients extremities
6. Nurse Celine is caring for a client with clinical depression who is receiving
a MAO inhibitor. When providing instructions about precautions with this
medication, the nurse should instruct the client to:
A.
Avoid chocolate and cheese
B.
Take frequent naps
C.
Take the medication with milk
D.
Avoid walking without assistance

7. While providing home care to a client with congestive heart failure, the
nurse is asked how long diuretics must be taken. The BEST response to this
client should be:
A.
As you urinate more, you will need less medication to control fluid.
B.
You will have to take this medication for about a year.
C.
The medication must be continued so the fluid problem is controlled.
D.
Please talk to your physician about medications and treatments.

8. George, age 8, is admitted with rheumatic fever. Which clinical finding
indicates to the nurse that George needs to continue taking the salicylates
he had received at home?
A.
Chorea.
B.
Polyarthritis.
C.
Subcutaneous nodules.
D.
Erythema marginatum.
9. An order is written to start an IV on a 74-year-old client who is getting
ready to go to the operating room for a total hip replacement. What gauge of
catheter would best meet the needs of this client?
A.
18
B.
20
C.
21 butterfly
D.
25
10. A client with an acute exacerbation of rheumatoid arthritis is admitted to

the hospital for treatment. Which drug, used to treat clients with rheumatoid
arthritis, has both an anti-inflammatory and immunosuppressive effect?
A.
Gold sodium thiomalate (Myochrysine)
B.
Azathioprine (Imuran)
C.
Prednisone (Deltasone)
D.
Naproxen (Naprosyn)
11. Which of the following is least likely to influence the potential for a client
to comply with lithium therapy after discharge?
A.
The impact of lithium on the clients energy level and life-style.
B.
The need for consistent blood level monitoring.
C.
The potential side effects of lithium.
D.
What the clients friends think of his need to take medication

12. Which of the following is least likely to influence the potential for a client
to comply with lithium therapy after discharge?
A.
The impact of lithium on the clients energy level and life-style.
B.
The need for consistent blood level monitoring.
C.
The potential side effects of lithium.
D.
What the clients friends think of his need to take medication.

13. The nurse is caring for an elderly client who has been diagnosed as
having sundown syndrome. He is alert and oriented during the day but
becomes disoriented and disruptive around dinnertime. He is hospitalized for
evaluation. The nurse asks the client and his family to list all of the
medications, prescription and nonprescription, he is currently taking. What is
the primary reason for this action?
A.
Multiple medications can lead to dementia
B.
The medications can provide clues regarding his medical background
C.
Ability to recall medications is a good assessment of the clients level

of orientation.
D.
Medications taken by a client are part of every nursing assessment.

14. A 25-year-old woman is in her fifth month of pregnancy. She has been
taking 20 units of NPH insulin for diabetes mellitus daily for six years. Her
diabetes has been well controlled with this dosage. She has been coming for
routine prenatal visits, during which diabetic teaching has been
implemented. Which of the following statements indicates that the woman
understands the teaching regarding her insulin needs during her pregnancy?
A.
Are you sure all this insulin wont hurt my baby?
B.
Ill probably need my daily insulin dose raised.
C.
I will continue to take my regular dose of insulin.
D.
These finger sticks make my hand sore. Can I do them less

frequently?
15. Mrs. Johanson.s physician has prescribed tetracycline 500 mg po q6h.
While assessing Mrs. Johansons nursing history for allergies, the nurse notes
that Mrs. Johansons is also taking oral contraceptives. What is the most
appropriate initial nursing intervention?
A.
Administer the dose of tetracycline.
B.
Notify the physician that Mrs. Johanson is taking oral contraceptives.
C.
Tell Mrs. Johanson, she should stop taking oral contraceptives since
they are inactivated by tetracycline.
D.
Tell Mrs. Johanson, to use another form of birth control for at least two
months.
16. An adult clients insulin dosage is 10 units of regular insulin and 15 units
of NPH insulin in the morning. The client should be taught to expect the first
insulin peak:
A.
as soon as food is ingested.
B.
in two to four hours.
C.
in six hours.
D.
in ten to twelve hours.
17. An adult is hospitalized for treatment of deep electrical burns. Burn

wound sepsis develops and mafenide acetate 10% (Sulfamylon) is ordered
bid. While applying the Sulfamylon to the wound, it is important for the nurse
to prepare the client for expected responses to the topical application, which
include:
A.
severe burning pain for a few minutes following application.
B.
possible severe metabolic alkalosis with continued use.
C.
black discoloration of everything that comes in contact with this drug.
D.
chilling due to evaporation of solution from the moistened dressings.

18. Ms.Clark has hyperthyroidism and is scheduled for a thyroidectomy. The
physician has ordered Lugols solution for the client. The nurse understands
that the primary reason for giving Lugols solution preoperatively is to:
A.
decrease the risk of agranulocytosis postoperatively.
B.
prevent tetany while the client is under general anesthesia.
C.
reduce the size and vascularity of the thyroid and prevent hemorrhage.
D.
potentiate the effect of the other preoperative medication so less

medicine can be given while the client is under anesthesia.
19. A two-year-old child with congestive heart failure has been receiving
digoxin for one week. The nurse needs to recognize that an early sign of
digitalis toxicity is:
A.
bradypnea.
B.
failure to thrive.
C.
tachycardia.
D.
vomiting.
20. Mr. Bates is admitted to the surgical ICU following a left adrenalectomy.
He is sleepy but easily aroused. An IV containing hydrocortisone is running.
The nurse planning care for Mr. Bates knows it is essential to include which of
the following nursing interventions at this time?
A.
Monitor blood glucose levels every shift to detect development of

hypo- or hyperglycemia.
B.
Keep flat on back with minimal movement to reduce risk of

hemorrhage following surgery.
C.
Administer hydrocortisone until vital signs stabilize, then discontinue

the IV.
D.
Teach Mr. Bates how to care for his wound since he is at high risk for
developing postoperative infection.
1.
Answer C. Monitor serum glucose levels. Hyperglycemia may occur

during the first day or 2 as the child adapts to the high-glucose load of the
TPN solution. Thus, a chief nursing responsibility is blood glucose testing.
2.
Answer D. Total parenteral nutrition formulas contain dextrose in

concentrations of 10% or greater to supply 20% to 50% of the total calories.
Blood glucose levels should be checked every 4 to 6 hours. A sliding scale
dose of insulin may be ordered to maintain the blood glucose level below
200mg/dl.
3.
Answer C. Intravenous gamma globulin is given to help prevent as

well as to fight bacterial infections in young children with AIDS.
4.
Answer C. Clients receiving TPN are very susceptible to infection. The

concentrated glucose solutions are a good medium for bacterial growth.
Strict sterile
technique is crucial in preventing infection at IV infusion site.
5.
Answer C. A vesicant is a chemotherapeutic agent capable of causing

blistering of tissues and possible tissue necrosis if there is extravasation.
These agents are irritants which cause pain along the vein wall, with or
without inflammation.
6.
Answer A. Foods high in tryptophan, tyramine and caffeine, such as

chocolate and cheese may precipitate hypertensive crisis.
7.
Answer C. This is the most therapeutic response and gives the client
accurate information.
8.
Answer B. Chorea is the restless and sudden aimless and irregular

movements of the extremities suddenly seen in persons with rheumatic
fever, especially girls. Polyarthritis is characterized by swollen, painful, hot
joints that respond to salicylates. Subcutaneous nodules are nontender
swellings over bony prominences sometimes seen in persons with rheumatic
fever. Erythema marginatum is a skin condition characterized by nonpruritic
rash, affecting trunk and proximal extremities, seen in persons with
rheumatic fever.
9.
Answer A. Clients going to the operating room ideally should have an

18- gauge catheter. This is large enough to handle blood products safely and
to allow rapid administration of large amounts of fluid if indicated during the
perioperative period. An 18-gauge catheter is recommended. A 20-gauge
catheter is a second choice. A 21-gauge needle is too small and a butterfly
too unstable for a client going to surgery. A 25-gauge needle is too small.
10.
Answer C. Gold sodium thiomalate is usually used in combination with
aspirin and nonsteroidal anti-inflammatory drugs to relieve pain. Gold has an

immunosuppressive affect. Azathioprine is used for clients with lifethreatening rheumatoid arthritis for its immunosuppressive effects.
Prednisone is used to treat persons with acute exacerbations of rheumatoid
arthritis. This medication is given for its anti-inflammatory and
immunosuppressive effects. Naproxen is a nonsteroidal anti-inflammatory
drug. Immunosuppression does not occur.
11.
Answer D. The impact of lithium on the clients energy level and life
style are great determinants to compliance. The frequent blood level

monitoring required is difficult for clients to follow for a long period of time.
Potential side effects such as fine tremor, drowsiness, diarrhea, polyuria,
thirst, weight gain, and fatigue can be disturbing to the client. While the
clients social network can influence the client in terms of compliance, the
influence is typically secondary to that of the other factors listed.
12.
Answer D. The impact of lithium on the clients energy level and life
style are great determinants to compliance. The frequent blood level
monitoring required is difficult for clients to follow for a long period of time.
Potential side effects such as fine tremor, drowsiness, diarrhea, polyuria,
thirst, weight gain, and fatigue can be disturbing to the client. While the
clients social network can influence the client in terms of compliance, the
influence is typically secondary to that of the other factors listed.
13.
Answer A. Drugs commonly used by elderly people, especially in
combination, can lead to dementia. Assessment of the medication taken may

or may not provide information on the clients medical background. However,
this is not the primary reason for assessing medications in a client who is
exhibiting sundown syndrome. Ability to recall medications may indicate
short-term memory and recall. However, that is not the primary reason for
assessing medications in a client with sundown syndrome. Medication history
should be a part of the nursing assessment. In this client there is an even
more important reason for evaluating the medications taken.
14.
Answer B. The client starts to need increased insulin in the second
trimester. This statement indicates a lack of understanding. As a result of

placental maturation and placental production of lactogen, insulin
requirements begin increasing in the second trimester and may double or
quadruple by the end of pregnancy. The client starts to need increased
insulin in the second trimester. This statement indicates a lack of
understanding. Insulin doses depend on blood glucose levels. Finger sticks
for glucose levels must be continued.
15.
Answer B. The nurse should be aware that tetracyclines decrease the
effectiveness of oral contraceptives. The physician should be notified. The

physician should be notified. Tetracycline decreases the effectiveness of oral
contraceptives. There may be an equally effective antibiotic available that
can be prescribed. Note on the clients chart that the physician was notified.
The nurse should be aware that tetracyclines decrease the effectiveness of
oral contraceptives. The nurse should not tell the client to stop taking oral
contraceptives unless the physician orders this. The nurse should be aware
that tetracyclines decrease the effectiveness of oral contraceptives. If the
physician chooses to keep the client on tetracycline, the client should be

encouraged to use another form of birth control. The first intervention is to
notify the physician.
16.
Answer B. The first insulin peak will occur two to four hours after
administration of regular insulin. Regular insulin is classified as rapid acting

and will peak two to four hours after administration. The second peak will be
eight to twelve hours after the administration of NPH insulin. This is why a
snack must be eaten mid-morning and also three to four hours after the
evening meal. The first insulin peak will occur two to four hours after
administration of regular insulin. The first insulin peak will occur two to four
hours after administration of regular insulin. The second peak will occur eight
to twelve hours after the administration of NPH insulin.
17.
Answer A. Mafenide acetate 10% (Sulfamylon) does cause burning on
application. An analgesic may be required before the ointment is applied.

Mafenide acetate 10% (Sulfamylon) is a strong carbonic anhydrase inhibitor
that affects the renal tubular buffering system, resulting in metabolic
acidosis. Mafenide acetate 10% (Sulfamylon) does not cause discoloration.
Silver nitrate solution, another topical antibiotic used to treat burn sepsis,
has the disadvantage of turning everything it touches black. Mafenide
acetate 10% (Sulfamylon) is an ointment that is applied directly to the
wound. It has the ability to diffuse rapidly through the eschar. The wound
may be left open or dry dressing may be applied. Silver nitrate solution is
applied by soaking the wound dressings and keeping them constantly wet,
which may cause chilling and hypotension.
18.
Answer C. Doses of over 30 mg/day may increase the risk of
agranulocytosis. Lugols solution does not act to prevent tetany. Calcium is

used to treat tetany. The client may receive iodine solution (Lugols solution)
for 10 to 14 days before surgery to decrease vascularity of the thyroid and
thus prevent excess bleeding. Lugols solution does not potentiate any other
preoperative medication.
19.
Answer D. Bradypnea (slow breathing) is not associated with digitalis
toxicity. Bradycardia is associated with digitalis toxicity. Although children

with congestive heart failure often have a related condition of failure to
thrive, it is not directly related to digitalis administration. It is more related to
chronic hypoxia. Tachycardia is not a sign of digitalis toxicity. Bradycardia is a
sign of digitalis toxicity. The earliest sign of digitalis toxicity is vomiting,
although one episode does not warrant discontinuing medication.
20.
Answer A. Hydrocortisone promotes gluconeogenesis and elevates
blood glucose levels. Following adrenalectomy the normal supply of

hydrocortisone is interrupted and must be replaced to maintain the blood
glucose at normal levels. Care for the client following adrenalectomy is
similar to that for any abdominal operation. The client is encouraged to
change position, cough, and deep breathe to prevent postoperative
complications such as pneumonia or thrombophlebitis. Maintenance doses of
hydrocortisone will be administered IV until the client is able to take it by
mouth and will be necessary for six months to two years or until the
remaining gland recovers. The client undergoing an adrenalectomy is at
increased risk for infection and delayed wound healing and will need to learn
about wound care, but not at this time while he is in the ICU.
NCLEX Prep for Psychosocial Integrity

1. Jannah, a 15-year-old girl with anorexia has been admitted to a
mental health unit. She refuses to eat. Which of the following
statements is the best response from the nurse?
a. You dont have to eat. Its your choice
b. I hope youll eat your food by mouth. Tube feedings and I.V. lines can be
uncomfortable
c. Why do you think youre fat? Youre underweight. Here look in the mirror
d. You really look terrible at this weight. I hope youll eat
2. Nurse Sofia is assessing a 15-year-old female whos being

admitted for treatment of anorexia nervosa. Which clinical
manifestation is the nurse most likely to find?
a. Tachycardia
b. Warm, flushed extremities
c. Parotid gland tenderness
d. Coarse hair growth
3. A client whos at high risk for suicide needs close supervision. To
best ensure the clients safety, nurse Leslie should:
a. Check the client frequently at irregular intervals throughout the night
b. Assure the client that the nurse will hold in confidence anything the client
says
c. Repeatedly discuss previous suicide attempts with the client
d. Disregard decreased communication by the client because this is common
in suicidal clients
4. During which phase of alcoholism is loss of control and
physiologic dependence evident?
a. Prealcoholic phase
b. Early alcoholic phase
c. Crucial phase
d. Chronic phase
5. Nurse Tony is developing a plan of care for a client with anorexia
nervosa. Which action should the nurse include in the plan?
a. Restrict visits with the family until the client begins to eat
b. Provide privacy during meals
c. Set up a strict eating plan for the client

d. Encourage the client to exercise, which will reduce her anxiety
6. In a toddler, which of the following injuries is most likely the
result of child abuse?
a. A hematoma on the occipital region of the head
b. A 1-inch forehead laceration
c. Several small, dime-sized circular burns on the childs back
d. A small isolated bruise on the right lower extremity
7. A client begins to experience alcoholic hallucinosis. What is the
best nursing intervention at this time?
a. Keeping the client restrained in bed
b. Checking the clients blood pressure every 15 minutes and offering juices
c. Providing a quiet environment and administering medication as needed
and prescribed
d. Restraining the client and measuring blood pressure every 30 minutes
8. A client is admitted for an overdose of amphetamines. When
assessing this client, nurse Pauleen should expect to see:
a. Tension and irritability
b. Slow pulse
c. Hypotension
d. Constipation
9. A client is admitted to the emergency department after being
found unconscious. Her blood pressure is 82/50 mm Hg. She is 5 4
(1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and
emaciated. After regaining consciousness, she reports that she has
had trouble eating lately and cant remember what she ate in the
last 24 hours. She also states that she has had amenorrhea for the
past year. She is convinced she is fat and refuses food. Nurse Kisses
suspects that she has:
a. Bulimia nervosa
b. Anorexia nervosa
c. Depression
d. Schizophrenia
10. When planning care for a client who has ingested phencyclidine
(PCP), which of the following is the highest priority?
a. Clients physical needs
b. Clients safety needs
c. Clients psychosocial needs
d. Clients medical needs
11. A client is being admitted to the substance abuse unit for
alcohol detoxification. As part of the intake interview, the nurse
asks him when he had his last alcoholic drink. He says that he had
his last drink 6 hours before admission. Based on this response,
nurse Willy should expect early withdrawal symptoms to:
a. Not occur at all because the time period for their occurrence has passed
b. Begin anytime within the next 1 to 2 days
c. Begin within 2 to 7 days
d. Begin after 7 days
12. A client who reportedly consumes 1 qt of vodka daily is admitted
for alcohol detoxification. To try to prevent alcohol withdrawal
symptoms, Dr. Smith is most likely to prescribe which drug?
a. Clozapine (Clozaril)
b. Thiothixene (Navane)
c. Lorazepam (Ativan)
d. Lithium carbonate (Eskalith)
13. When monitoring a client recently admitted for treatment of
cocaine addiction, nurse Gem notes sudden increases in the arterial
blood pressure and heart rate. To correct these problems, the nurse
expects the physician to prescribe:
a. Norepinephrine (Levophed) and lidocaine (Xylocaine)
b. Nifedipine (Procardia) and lidocaine
c. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc)
d. Nifedipine and nitroglycerin
14. A client with a history of substance abuse has been attending
Alcoholics Anonymous meetings regularly in the psychiatric unit.
One afternoon, the client tells the nurse, Im not going to those
meetings anymore. Im not like the rest of those people. Im not a
drunk. What is the most appropriate response?
a. If you arent an alcoholic, why do you keep drinking and ending up in the
hospital?
b. Its your decision. If you dont want to go, you dont have to
c. You seem upset about the meetings
d. You have to go to the meetings. Its part of your treatment plan
15. A client with anorexia nervosa describes herself as a whale.
However, nurse Melissas assessment reveals that the client is 5 8
(1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the clients
unrealistic body image, which intervention should be included in the
plan of care?
a. Asking the client to compare her figure with magazine photographs of

women her age
b. Assigning the client to group therapy in which participants provide realistic
feedback about her weight
c. Confronting the client about her actual appearance during one-on-one
sessions, scheduled during each shift
d. Telling the client of the nurses concern for her health and desire to help
her make decisions to keep her healthy
16. Which of the following is important when restraining a violent
client?
a. Have three staff members present, one for each side of the body and one
for the head
b. Always tie restraints to side rails
c. Have an organized, efficient team approach after the decision is made to
restrain the client
d. Secure restraints to the gurney with knots to prevent escape
17. Nurse Dennis in the substance abuse unit is trying to encourage
a client to attend Alcoholics Anonymous meetings. When the client
asks the nurse what he must do to become a member, the nurse
should respond:
a. You must first stop drinking
b. Your physician must refer you to this program
c. Admit youre powerless over alcohol and that you need help
d. You must bring along a friend who will support you
18. Nurse Betty is assigned to care for a client with anorexia
nervosa. Initially, which nursing intervention is most appropriate for
this client?
a. Providing one-on-one supervision during meals and for 1 hour afterward

b. Letting the client eat with other clients to create a normal mealtime
atmosphere
c. Trying to persuade the client to eat and thus restore nutritional balance
d. Giving the client as much time to eat as desired
19. A client whos actively hallucinating is brought to the hospital by
friends. They say that the client used either lysergic acid
diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert.
Which of the following common assessment findings indicates that
the client may have ingested PCP?
a. Dilated pupils
b. Nystagmus
c. Paranoia
d. Altered mood
20. A parent brings a preschooler to the emergency department for
treatment of a dislocated shoulder, which allegedly happened when
the child fell down the stairs. Which action should nurse Joy make to
suspect that the child was abused?
a. The child cries uncontrollably throughout the examination
b. The child pulls away from contact with the physician
c. The child doesnt cry when the shoulder is examined
d. The child doesnt make eye contact with the nurse
21. In the emergency department, a client with facial lacerations
states that her husband beat her with a shoe. After the health care
team repairs her lacerations, she waits to be seen by the crisis
intake nurse, who will evaluate the continued threat of violence.
Suddenly the clients husband arrives, shouting that he wants to
finish the job. What is the first priority of the health care worker
who witnesses this scene?
a. Remaining with the client and staying calm
b. Calling a security guard and another staff member for assistance
c. Telling the clients husband that he must leave at once
d. Determining why the husband feels so angry
22. An attorney who throws books and furniture around the office
after losing a case is referred to the psychiatric nurse in the law
firms employee assistance program. Nurse Lyn knows that the
clients behavior most likely represents the use of which defense
mechanism?
a. Regression
b. Projection
c. Reaction-formation
d. Intellectualization
23. A client with borderline personality disorder is admitted to the
psychiatric unit. Initial nursing assessment reveals that the clients
wrists are scratched from a recent suicide attempt. Based on this
finding, nurse Lika should formulate a nursing diagnosis of:
a. Ineffective individual coping related to feelings of guilt
b. Situational low self-esteem related to feelings of loss of control
c. Risk for violence: Self-directed related to impulsive mutilating acts
d. Risk for violence: Directed toward others related to verbal threats
24. A client is admitted for detoxification after a cocaine overdose.
The client tells nurse Mercy that he frequently uses cocaine but he
can control his use if he chooses. Which coping mechanism is he
using?
a. Withdrawal
b. Logical thinking
c. Repression
d. Denial
25. Which of the following groups are considered to be at highest
risk for suicide?
a. Adolescents, men over age 45, and persons who have made previous
suicide attempts
b. Teachers, divorced persons, and substance abusers
c. Alcohol abusers, widows, and young married men
d. Depressed persons, physicians, and persons living in rural areas
ANSWERS & RATIONALE

1. B. Clients with anorexia can refuse food to the point of cardiac damage.
Tube feedings and I.V. infusions are ordered to prevent such damage. The
nurse is informing her of her treatment options
2. C. Frequent vomiting causes tenderness and swelling of the parotid
glands. The reduced metabolism that occurs with severe weight loss
produces bradycardia and cold extremities. Soft, downlike hair (called
lanugo) may cover the extremities, shoulders, and face of an anorexic client.
3. A. Checking the client frequently but at irregular intervals prevents the
client from predicting when observation will take place and altering behavior
in a misleading way at these times.
4. C. The crucial phase is marked by physical dependence. The prealcoholic
phase is characterized by drinking to medicate feelings and for relief from
stress. The early phase is characterized by sneaking drinks, blackouts,
rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is
characterized by emotional and physical deterioration.
5. C. Establishing a consistent eating plan and monitoring the clients weight
are important for this disorder. The family should be included in the clients
care. The client should be monitored during meals not given privacy.
Exercise must be limited and supervised.
6. C. Small circular burns on a childs back are no accident and may be from
cigarettes. Toddlers are injury prone because of their developmental stage,
and falls are frequent because of their unsteady gait; head injuries arent
uncommon. A small area of ecchymosis isnt suspicious in this age-group.
7. C. Manifestations of alcoholic hallucinosis are best treated by providing a
quiet environment to reduce stimulation and administering prescribed
central nervous system depressants in dosages that control symptoms
without causing oversedation. Although bed rest is indicated, restraints are
unnecessary unless the client poses a danger to himself or others. Also,
restraints may increase agitation and make the client feel trapped and
helpless when hallucinating. Offering juice is appropriate, but measuring
blood pressure every 15 minutes would interrupt the clients rest. To avoid
overstimulating the client, the nurse should check blood pressure every 2
hours.
8. A. An amphetamine is a nervous system stimulant that is subject to abuse
because of its ability to produce wakefulness and euphoria. An overdose
increases tension and irritability.
9. B. Anorexia nervosa is an eating disorder characterized by self-imposed
starvation with subsequent emaciation, nutritional deficiencies, and atrophic
and metabolic changes. Typically, the client is hypotensive and dehydrated.
Depending on the severity of the disorder, anorexic clients are at risk for
circulatory collapse (indicated by hypotension), dehydration, and death.

Bulimia nervosa is an eating disorder characterized by binge eating followed
by self-induced vomiting. Although depression may be accompanied by
weight loss, it isnt characterized by a body image disturbance or the intense
fear of obesity seen in anorexia nervosa. Schizophrenia may cause bizarre
eating patterns, but it rarely causes the full syndrome of anorexia nervosa.
10. B. The highest priority for a client who has ingested PCP is meeting
safety needs of the client as well as the staff. Drug effects are unpredictable
and prolonged, and the client may lose control easily. After safety needs
have been met, the clients physical, psychosocial, and medical needs can be
met.
11. B. Acute withdrawal symptoms from alcohol may begin 6 hours after the
client has stopped drinking and peak 1 to 2 days later. Delirium tremens may
occur 2 to 4 days even up to 7 days after the last drink.
12. C. The best choice for preventing or treating alcohol withdrawal
symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are
antipsychotic agents, and lithium carbonate is an antimanic agent; these
drugs arent used to manage alcohol withdrawal syndrome.
13. D. This client requires a vasodilator, such as nifedipine, to treat
hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the
heart rate. Lidocaine, an antiarrhythmic, isnt indicated because the client
doesnt have an arrhythmia. Although nitroglycerin may be used to treat
coronary vasospasm, it isnt the drug of choice in hypertension.
14. C. The substance abuser uses the substance to cope with feelings and
may deny the abuse. Asking if the client is upset about the meetings
encourages the client to identify and deal with feelings instead of covering
them up.
15. D. A client with anorexia nervosa has an unrealistic body image that
causes consumption of little or no food. Therefore, the client needs
assistance with making decisions about health. Instead of protecting the
clients health, options A, B, and C may serve to make the client defensive
and more entrenched in her unrealistic body image.
16. C. Emergency department personnel should use an organized, team
approach when restraining violent clients so that no one is injured in the
process. The leader, located at the clients head, should take charge; four
staff members are required to hold and restrain the limbs. For safety reasons,
restraints should be fastened to the bed frame instead of the side rails. For
quick release, loops should be used instead of knots.
17. C. The first of the Twelve Steps of Alcoholics Anonymous is admitting
that an individual is powerless over alcohol and that life has become
unmanageable. Although Alcoholics Anonymous promotes total abstinence, a
client will still be accepted if he drinks. A physician referral isnt necessary to
join. New members are assigned a support person who may be called upon
when the client has the urge to drink.
18. A. Because the client with anorexia nervosa may discard food or induce
vomiting in the bathroom, the nurse should provide one-on-one supervision
during meals and for 1 hour afterward. The nurse should set limits and let
the client know what is expected.
19. B. Phencyclidine is an anesthetic with severe psychological effects. It
blocks the reuptake of dopamine and directly affects the midbrain and
thalamus. Nystagmus and ataxia are common physical findings of PCP use.
Dilated pupils are evidence of LSD ingestion. Paranoia and altered mood
occur with both PCP and LSD ingestion.
20. C. A characteristic behavior of abused children is lack of crying when

they undergo a painful procedure or are examined by a health care
professional. Therefore, the nurse should suspect child abuse. Crying
throughout the examination, pulling away from the physician, and not
making eye contact with the nurse are normal behaviors for preschoolers.
21. B. The health care worker who witnesses this scene must take
precautions to ensure personal as well as client safety, but shouldnt attempt
to manage a physically aggressive person alone. Therefore, the first priority
is to call a security guard and another staff member. After doing this, the
health care worker should inform the husband what is expected, speaking in
concise statements and maintaining a firm but calm demeanor. This
approach makes it clear that the health care worker is in control and may
diffuse the situation until the security guard arrives. Telling the husband to
leave would probably be ineffective because of his agitated and irrational
state. Exploring his anger doesnt take precedence over safeguarding the
client and staff.
22. A. An adult who throws temper tantrums, such as this one, is displaying
regressive behavior, or behavior that is appropriate at a younger age. In
projection, the client blames someone or something other than the source. In
reaction formation, the client acts in opposition to his feelings. In
intellectualization, the client overuses rational explanations or abstract
thinking to decrease the significance of a feeling or event.
23. C. The predominant behavioral characteristic of the client with borderline
personality disorder is impulsiveness, especially of a physically selfdestructive sort. The observation that the client has scratched wrists doesnt
substantiate the other options.
24. D. Denial is an unconscious defense mechanism in which emotional
conflict and anxiety are avoided by refusing to acknowledge feelings,
desires, impulses, or external facts that are consciously intolerable.

Withdrawal is a common response to stress, characterized by apathy. Logical
thinking IS the ability to think rationally and make responsible decisions,
which would lead the client to admitting the problem and seeking help.
Repression is suppressing past events from the consciousness because of
guilty association.
25. A. Studies of those who commit suicide reveal the following high-risk
groups: adolescents; men over age 45; persons who have made previous
suicide attempts; divorced, widowed, and separated persons; professionals,
such as physicians, dentists, and attorneys; students; unemployed persons;
persons who are depressed, delusional, or hallucinating; alcohol or substance
abusers; and persons who live in urban areas. Although more women
attempt suicide than men, they typically choose less lethal means and
therefore are less likely to succeed in their attempts

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NCLEX Practice Exam for Safety and Infection Control

1. A child is admitted to the pediatric unit with a diagnosis of suspected

Institute seizure precautions

Assess neurologic status

Place in respiratory isolation

Assess vital signs

A diagnosis of AIDS and cytomegalovirus

A positive PPD with an abnormal chest x-ray

A tentative diagnosis of viral pneumonia

Advanced carcinoma of the lung

Using a barrier between clients furniture and nurses bag

Wearing gowns and goggles

5. An adult woman is admitted to an isolation unit in the hospital after

Order a stat admission CBC.

Place a urine collection bag and specimen cup at the bedside.

Place a cooling mattress on his bed.

Pad the side rails of his bed.

I will need to take sponge baths at home to avoid exposing the

I can expect occasional periods of low-grade fever and can take

limit visits by staff.

encourage family phone calls.

position in a bright, busy area.

speak soothingly and provide quiet music.

She says to her husband, Please bring me a hamburger and french

I told my daughter who is pregnant to either come to see me tonight

I understand it will be several weeks before all the radiation leaves

I brought several craft projects to do while the radium is inserted.

A client with active tuberculosis is asked to wear a mask when he

congratulate the nurse on the use of good technique.

discuss dressing change technique with the nurse at a later date.

Correct illumination of the environment.

amount of regular exercise.

the resting pulse rate.

status of salt intake.

I should put on my sterile gloves, then open the bottle of saline to

Masks should be worn with all client contact.

Gloves should be worn for contact with nonintact skin, mucous

Isolation gowns are not needed.

A private room is always indicated.

Masks should be worn with all client contact.

Gloves should be worn for contact with nonintact skin, mucous

Isolation gowns are not needed.

A private room is always indicated.

An aide wears gloves to feed a helpless client.

An assistant puts on a mask and protective eye wear before assisting

A pregnant worker refuses to care for a client known to have AIDS.

Coughing on each other.

Eating off the same plate.

verbalizes the role of sexual activity in spread of the disorder.

states he will make arrangements to drop his college classes.

acknowledges the need to avoid all contact sports.

says he will avoid close contact with his three-year-old niece.

Are you a drug user?

Do you have many sex partners?

What is your method of birth control?

How old were you when you became sexually active?

independently ambulating around the unit.

reading the routine preoperative education materials.

maneuvering safely after orientation to the room.

using a bedpan for elimination needs.

Answer C. The initial therapeutic management of acute bacterial

Answer D. Contact or Body Substance Isolation (BSI) involves the use