Standards ATI NCLEX 50 Questions and Answers with Rationale on Medical and Surgical Asepsis

Free preview · Original latest version

Sample questions from Standards ATI NCLEX 50 Questions and Answers with Rationale on Medical and Surgical Asepsis

This material has 150 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, a nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 68-year-old client with a draining wound whose dressing is due to be changed using sterile technique
   • B.A 54-year-old client receiving chemotherapy who has an oral temperature of 38.3 C and an absolute neutrophil count of 400/mm3
   • C.A 79-year-old client with a chronic pressure injury whose wound-care consult is scheduled for later today
   • D.A 43-year-old client with a urinary catheter who needs assistance with perineal care

   Rationale: The client with fever and severe neutropenia is at immediate risk for life-threatening infection and requires prompt assessment and protective infection-control measures. The draining wound needs timely sterile care, but no instability is described. Catheter care and a scheduled wound-care consult are important but can wait until the highest-risk client is assessed. Prioritize signs of systemic infection in an immunocompromised client.

2. 2.During a home visit, a 72-year-old client with diabetes has a shallow foot ulcer and a home glucose reading of 198 mg/dL. Which actions should the nurse take while changing the dressing to reduce contamination risk? Select all that apply.

   • A.Cleanse the wound from the least contaminated area toward the most contaminated area, using a fresh gauze pad for each stroke.
   • B.Reuse the gloves worn while removing the old dressing to apply the new dressing if they appear clean.
   • C.Place the sterile dressing directly on the bedside table after opening its package.
   • D.Perform hand hygiene before setting up the clean work surface.
   • E.Use clean gloves to remove the soiled dressing, then discard them.
   • F.Put on sterile gloves before cleansing the wound and applying the new dressing.

   Rationale: Hand hygiene, clean gloves for removing the soiled dressing, and sterile gloves for a sterile dressing change help prevent transfer of microorganisms. Cleansing from the least contaminated area toward the most contaminated area with a fresh pad for each stroke also limits cross-contamination. A bedside table is not a sterile field, so the sterile dressing must not be placed directly on it. Gloves used to remove the old dressing are contaminated and must not be reused for the clean procedure.

3. 3.A parent brings a 3-year-old child to a community clinic with a new prescription for an oral antibiotic. The child has a draining ear and a temperature of 38.0 C. Which instruction is most important for preventing transmission at the clinic?

   • A.Clean the child's ears with an antiseptic before allowing the child to leave the clinic.
   • B.Keep the child in the waiting area until the prescription is ready so the nurse can reassess the temperature.
   • C.Ask the parent to wear sterile gloves when helping the child take the first dose.
   • D.Use standard precautions and place the child in a private examination room while awaiting evaluation.

   Rationale: A private room and standard precautions reduce exposure to other clients while the cause of the drainage and fever is assessed. Keeping the child in a shared waiting area increases exposure risk. Sterile gloves are not needed for oral medication administration, and cleaning the ear is not a transmission-control measure and could cause harm. Use precautions appropriate to the suspected infection rather than adding unnecessary sterile procedures.

4. 4.The provider prescribes a medication through a central venous catheter for a 16-year-old client with leukemia. The client is afebrile but has an absolute neutrophil count of 300/mm3. Which action should the nurse take before accessing the catheter?

   • A.Scrub the catheter hub with the agency-approved antiseptic for the specified contact time and allow it to dry.
   • B.Flush the catheter first, then disinfect the hub before attaching the medication.
   • C.Swab the hub briefly with alcohol and access it while the hub is still wet.
   • D.Apply sterile gloves and omit hub disinfection because the gloves protect the catheter.

   Answer and rationale are in the full material.

5. 5.In a long-term care facility, a 90-year-old resident with dementia has new watery diarrhea and abdominal cramping after completing clindamycin. Which action should the nurse take first?

   • A.Give an antidiarrheal medication from the as-needed supply and reassess in 4 hours.
   • B.Use alcohol-based hand rub after providing care and return to the medication cart.
   • C.Place the resident on contact precautions and notify the provider of the new symptoms.
   • D.Transfer the resident to a shared bathroom to keep the room available for observation.

   Answer and rationale are in the full material.