Infection Control
NCLEX® practice.

Free practice set · 8 questions

8 more free infection control NCLEX-RN® practice questions

Real questions from the same bank the app serves. Pick an answer in your head, then open the rationale to see why the correct option holds and why each other option falls short. No account needed for these.

1. Question 1 of 8 · Infection Prevention & Patient Safety

   A 68-year-old client with a 40-pack-year smoking history presents to the respiratory unit with a productive cough, night sweats, and low-grade fever for 3 weeks. Acid-fast bacilli (AFB) are suspected on sputum smear. The health care provider has written an order for airborne precautions. The client's room is an airborne infection isolation room (AIIR) with proper air handling. Standard precautions signage is posted on the door, and a clear plastic mask is at the bedside. The nurse is about to enter the room to assess vital signs and listen to breath sounds. What should the nurse do?

   1. AEnter the room and apply the clear plastic mask provided at the bedside to protect against respiratory droplets.
   2. BDon an N95 respirator before entering the room, ensuring a proper fit check, and remove it after exiting the room.
   3. CDon gloves and a surgical mask before entering, since the client has respiratory symptoms and is febrile.
   4. DDon appropriate PPE only after assessing the client to determine whether AFB isolation is truly necessary.
   Show the answer and rationale

   Correct answer: B. Don an N95 respirator before entering the room, ensuring a proper fit check, and remove it after exiting the room.

   Per the CDC 2007 Guideline for Isolation Precautions (updated 2024), suspected or confirmed tuberculosis (Mycobacterium tuberculosis transmitted via airborne route) requires airborne precautions, not droplet or standard precautions. Airborne precautions mandate use of an N95 respirator (or PAPR if contraindicated) for all personnel entering the room. The respirator must be donned BEFORE entering the room and doffed only after exiting. The client is in an AIIR, which provides engineering control, but the N95 is the critical personal protective barrier against AFB-laden air particles. Standard precautions also apply and include hand hygiene at all WHO Five Moments. A clear plastic mask (surgical/droplet mask) does not provide the 0.3-micron filtration needed to prevent inhalation of airborne particles. Delaying PPE selection until after assessment violates the principle that precaution tier must be established and PPE donned before room entry to protect both nurse and client during the assessment window.

   A. Enter the room and apply the clear plastic mask provided at the bedside to protect against respiratory droplets.

   Incorrect, wrong precaution tier. A clear plastic mask provides droplet precaution-level protection, appropriate for large respiratory droplets. AFB spreads via smaller airborne particles requiring N95/PAPR filtration, not surgical masks. This violates the rule to match precaution tier to organism route.

   B. Don an N95 respirator before entering the room, ensuring a proper fit check, and remove it after exiting the room.

   Correct. The N95 respirator (or equivalent PAPR) is required per CDC airborne precautions for AFB/tuberculosis. Donning before entry and doffing after exit are nonnegotiable steps that match the organism's airborne transmission route.

   C. Don gloves and a surgical mask before entering, since the client has respiratory symptoms and is febrile.

   Incorrect, wrong precaution tier. Surgical mask and gloves correspond to droplet or contact precautions. AFB requires airborne precautions with N95 or PAPR because tuberculosis is transmitted via airborne route, not large droplets or direct contact. Surgical mask is insufficient filtration.

   D. Don appropriate PPE only after assessing the client to determine whether AFB isolation is truly necessary.

   Incorrect, premature-or-late action. PPE selection and donning must occur BEFORE entering the room, not after assessment. AFB isolation is already ordered; delaying PPE donning exposes the nurse and compromises the safety window. Precaution tier is determined by the organism and transmission route, not by end-of-assessment reassessment.

2. Question 2 of 8 · Infection Prevention & Patient Safety

   A 62-year-old client with suspected tuberculosis (TB) is admitted to a respiratory isolation room. Chest X-ray findings are pending, and sputum smears are being processed. The room is equipped with negative-pressure ventilation and HEPA filtration. Posted signage indicates airborne precautions are in effect. Standard precautions supplies and an N95 respirator are available at the bedside. The nurse is preparing to enter the room to perform an initial assessment and obtain vital signs. Which action demonstrates correct application of infection prevention principles for this client's suspected transmission route?

   1. ADon the N95 respirator before entering the room, perform hand hygiene upon entry, conduct the assessment, and remove the respirator only after exiting the room and closing the door.
   2. BPut on gloves and a gown upon entering the room, perform hand hygiene with alcohol-based rub before the assessment, and remove PPE before exiting.
   3. CEnter the room first to observe the client's respiratory status, then don personal protective equipment, perform hand hygiene, and complete the assessment.
   4. DWash hands with soap and water before entry, put on a surgical mask upon entering the room, complete the assessment, and remove the mask before leaving.
   Show the answer and rationale

   Correct answer: A. Don the N95 respirator before entering the room, perform hand hygiene upon entry, conduct the assessment, and remove the respirator only after exiting the room and closing the door.

   According to the CDC 2007 Guideline for Isolation Precautions (updated 2024), tuberculosis is transmitted by airborne nuclei and requires airborne precautions, which mandate an N95 respirator or PAPR, not a surgical mask or contact-based gown/gloves. The critical sequence is: donning PPE BEFORE entering the room, performing hand hygiene at the appropriate moment (after donning PPE, before client contact per WHO Five Moments), conducting the assessment, and doffing PPE before exiting (in the sequence: gloves → goggles/face shield → gown → mask/respirator → hand hygiene). This client's airborne route (suspected TB with sputum processing pending) necessitates respiratory isolation with negative-pressure room and N95 equipment. Standard precautions are the foundation for all clients; airborne precautions are the add-on tier for this organism. Entering the room unprotected or using a surgical mask violates the precaution-tier match rule and exposes the nurse to airborne nuclei. Hand hygiene with alcohol-based rub (rather than soap-and-water) is appropriate for routine hygiene after donning PPE and before client contact in this non-spore scenario.

   A. Don the N95 respirator before entering the room, perform hand hygiene upon entry, conduct the assessment, and remove the respirator only after exiting the room and closing the door.

   Correct. This sequence matches TB's airborne transmission route to the airborne precaution tier per CDC guidelines. Donning N95 BEFORE entry prevents exposure to airborne nuclei; hand hygiene after donning and before assessment follows the WHO Five Moments; doffing only after exiting prevents contamination of the environment outside the room. This client's confirmed isolation signage and negative-pressure room reinforce airborne tier appropriateness.

   B. Put on gloves and a gown upon entering the room, perform hand hygiene with alcohol-based rub before the assessment, and remove PPE before exiting.

   Wrong precaution tier. Gloves and gown are components of contact precautions, not airborne precautions. TB is not transmitted by direct or indirect contact; it requires respiratory protection (N95/PAPR). This option confuses the precaution tiers. While hand hygiene with alcohol-based rub is appropriate for routine non-spore hygiene, the absence of an N95 respirator is the critical omission. This violates the rule to match precaution tier to TB's airborne route.

   C. Enter the room first to observe the client's respiratory status, then don personal protective equipment, perform hand hygiene, and complete the assessment.

   Wrong timing (premature action). Donning PPE AFTER entering the room exposes the nurse to airborne nuclei before respiratory protection is in place. CDC guidelines mandate PPE donning before room entry. Entering unprotected to 'observe' the client violates the safety window; by then, TB transmission risk is already present. This action prioritizes assessment over immediate protection, contradicting the principle that exposure prevention precedes clinical data gathering in a confirmed or suspected airborne scenario.

   D. Wash hands with soap and water before entry, put on a surgical mask upon entering the room, complete the assessment, and remove the mask before leaving.

   Wrong precaution tier. Surgical masks are appropriate for droplet precautions (e.g., influenza, pertussis) but are ineffective against airborne nuclei from TB. TB requires N95 or PAPR, not surgical mask. This violates the key rule to match precaution tier to organism transmission route. Soap-and-water handwash is unnecessary here because there is no visible soiling or spore-forming organism (C. difficile, norovirus); alcohol-based rub after donning PPE would be standard.

3. Question 3 of 8 · Infection Prevention & Patient Safety

   A registered nurse is caring for a client with a positive methicillin-resistant Staphylococcus aureus (MRSA) wound infection who is on contact precautions. The client's isolation signage is posted at the bedside, and personal protective equipment (PPE), including gloves, gown, and face shield, is available in the anteroom. The nurse has just finished a blood draw from the client's intravenous line and is holding the used needle and syringe. What is the nurse's priority action?

   1. AContinue client education about wound care before disposing of the needle to ensure comprehension before leaving.
   2. BFinish doffing the gown and mask in the client's room, perform hand hygiene, then dispose of the syringe at the exit.
   3. CRecap the needle with one hand using a scoop technique, then place the syringe in a biohazard waste bag.
   4. DDispose of the needle directly into a puncture-resistant sharps container at the bedside without recapping.
   Show the answer and rationale

   Correct answer: D. Dispose of the needle directly into a puncture-resistant sharps container at the bedside without recapping.

   Per OSHA 29 CFR 1910.1030 (Bloodborne Pathogens standard), sharps contaminated with blood or body fluids must be disposed immediately at the point of use in a puncture-resistant, biohazard-labeled container without recapping. This client's MRSA-positive wound poses a bloodborne pathogen risk; the needle, freshly exposed to wound drainage, requires immediate safe containment to prevent needlestick injury and cross-contamination. The nurse must prioritize the sharps disposal before any other activity in or outside the room. Recapping the needle violates the OSHA standard and significantly increases needlestick injury risk; even a scoop technique is inferior to direct point-of-use disposal without recapping. Finishing PPE removal in the client's room violates the correct PPE doffing sequence, because gloves must be removed first, before the gown and mask, and it involves transitioning away from the sharps hazard before disposal is complete. Continuing client education delays the critical safety action of sharps containment and inappropriately prioritizes a non-urgent educational task over immediate biohazard management. Disposing of the needle directly into a puncture-resistant sharps container at the bedside without recapping directly aligns with OSHA Bloodborne Pathogens requirements and protects the nurse, the client, and subsequent care workers from needlestick and exposure risk.

   A. Continue client education about wound care before disposing of the needle to ensure comprehension before leaving.

   Delays the time-sensitive sharps disposal action by prioritizing a non-urgent client education task. Per OSHA and institutional safety protocols, biohazardous sharps must be disposed immediately at point of use; educational activities are secondary to acute contamination control and must not defer safe needle handling.

   B. Finish doffing the gown and mask in the client's room, perform hand hygiene, then dispose of the syringe at the exit.

   Violates correct PPE doffing sequence (gloves first, then gown, then mask) and delays sharps disposal. Leaving the sharps in hand while managing PPE transitions prolongs exposure risk and fails to address the immediate biohazard. The sharp must be safely contained before any doffing sequence begins.

   C. Recap the needle with one hand using a scoop technique, then place the syringe in a biohazard waste bag.

   Violates OSHA Bloodborne Pathogens standard by recapping, which substantially increases needlestick injury risk. Even a scoop technique does not negate the requirement for point-of-use, no-recapping disposal. This dangerous practice is explicitly prohibited by the standard and constitutes a likely preventable occupational injury.

   D. Dispose of the needle directly into a puncture-resistant sharps container at the bedside without recapping.

   Correct. OSHA 29 CFR 1910.1030 requires sharps to be disposed at the point of use in a puncture-resistant container without recapping. This MRSA-contaminated needle must be contained immediately to prevent needlestick injury and bloodborne pathogen transmission. Immediate sharps disposal is the nurse's priority before any other activity.

4. Question 4 of 8 · Infection Prevention & Patient Safety

   A nurse is caring for a client in contact precaution isolation with a known gastrointestinal infection. As the nurse prepares to perform wound care on the client, she observes the following at the bedside: a gown and non-sterile gloves are available; the "Contact Precaution" sign is posted on the door; a sharps container is present but the lid is partially open; and there is a sterile field set up on the over-bed table. Before entering the room, the nurse notes there are several used syringes on the bedside table with capped needles. Which action should the nurse take first?

   1. AReposition the client every 2 hours and then address the sharps disposal as time permits.
   2. BEnter the room, recap all remaining needles using two hands, and place them in a closed biohazard bag.
   3. CDefer PPE donning until after you assess the client's wound, then dispose of sharps at the end of the shift.
   4. DDon the gown and gloves before entering the room, then dispose of the capped needles in the open sharps container.
   Show the answer and rationale

   Correct answer: D. Don the gown and gloves before entering the room, then dispose of the capped needles in the open sharps container.

   Donning the gown and gloves before entering the room follows OSHA 29 CFR 1910.1030 (Bloodborne Pathogens Standard) and protects against contact transmission. The "Contact Precaution" sign signals the need for this layered defense. Once properly protected, the nurse immediately addresses the sharps safety hazard: capped needles and an open sharps container represent a point-of-use disposal failure. OSHA requires that sharps be placed directly into puncture-resistant, labeled containers at the point of care without recapping, breaking, or manual manipulation. Securing the sharps container lid after safe disposal completes the engineering control. Recapping needles with two hands violates OSHA's needle-safety directive and dramatically increases needlestick injury risk. The standard explicitly prohibits manual recapping and requires single-handed scoop technique only when absolutely necessary; point-of-use disposal is the gold standard. Routine repositioning addresses an unrelated and non-urgent finding instead of the immediate contamination and injury risk posed by exposed, capped needles and an open sharps container. This diverts attention from the safety threat. Delaying critical PPE donning until after room entry violates the principle of source control and contact-precaution compliance. Deferring sharps disposal until end-of-shift also leaves a needlestick hazard and biohazard exposure uncontrolled throughout the shift. Sharps safety is time-sensitive and must be addressed at point-of-use, not postponed.

   A. Reposition the client every 2 hours and then address the sharps disposal as time permits.

   Addresses an unrelated, routine care finding (repositioning every 2 hours) instead of the acute contamination and needlestick hazard presented by exposed capped needles and an open sharps container. Does not mitigate the safety risk and delays essential biohazardous-material management.

   B. Enter the room, recap all remaining needles using two hands, and place them in a closed biohazard bag.

   Violates OSHA Bloodborne Pathogens Standard by manually recapping needles with two hands. The standard prohibits this practice because it significantly increases needlestick injury risk. Point-of-use disposal directly into a puncture-resistant container, without recapping, is the required engineering control.

   C. Defer PPE donning until after you assess the client's wound, then dispose of sharps at the end of the shift.

   Wrong timing: defers PPE donning until after room entry, breaking contact-precaution protocol before source control is established. Also postpones sharps disposal until end-of-shift, leaving a documented needlestick hazard unmanaged. OSHA and CDC require immediate, point-of-use sharps disposal and pre-entry PPE.

   D. Don the gown and gloves before entering the room, then dispose of the capped needles in the open sharps container.

   Correct per OSHA 29 CFR 1910.1030: Don PPE (gown, gloves) before entering the contact-precaution room to establish source control, then immediately dispose of sharps at point-of-use in a puncture-resistant container with a secure lid. This sequence protects the nurse and ensures biohazardous material handling compliance.

5. Question 5 of 8 · Infection Prevention & Patient Safety

   An 82-year-old client is admitted to the medical-surgical unit with acute confusion related to a urinary tract infection. The client's Morse Fall Risk Score is 90 (high risk). On assessment, the nurse notes the client is cognitively impaired, oriented only to person, and has a documented history of syncopal episodes with orthostasis. The client has attempted to get out of bed twice without calling for assistance. The health care provider has written a PRN restraint order. Which action should the nurse take first?

   1. ACall the provider for direction on restraint application before implementing any fall-prevention measures.
   2. BReorient the client to the current date and time, then document the confusion in the medical record.
   3. CApply a four-sided bed rail and wrist restraint per the PRN order to prevent further fall attempts.
   4. DLower the bed to its lowest position, place the call light within reach, apply non-skid footwear, and schedule toileting every 2 hours before considering restraint.
   Show the answer and rationale

   Correct answer: D. Lower the bed to its lowest position, place the call light within reach, apply non-skid footwear, and schedule toileting every 2 hours before considering restraint.

   Joint Commission NPSG.09.02.01 requires the nurse to use a validated fall-risk assessment (Morse Score ≥45 = high risk) and implement a tiered fall-prevention bundle before considering restraint. For this high-risk, acutely confused 82-year-old with orthostatic history and two fall attempts, the evidence-based bundle includes: lowering the bed to its lowest position with two side rails up (four rails constitute a restraint), placing the call light within reach, ensuring non-skid footwear, and scheduling frequent toileting, all of which address this client's specific risk factors (confusion, orthostasis, toileting urgency). Only after attempting these least-restrictive alternatives and documented reassessment should restraint be considered. The client's delirium from UTI and orthostatic episodes make environmental controls and supervision more effective and safer than chemical or physical restraint. The PRN restraint order itself is problematic: CMS 42 CFR 482.13 prohibits PRN restraint orders; restraint requires a face-to-face provider evaluation and documented justification when less-restrictive measures have failed.

   A. Call the provider for direction on restraint application before implementing any fall-prevention measures.

   Wrong priority: the "calls the provider for direction instead of taking the indicated independent nursing action" error pattern. Initiating the fall-prevention bundle is an independent nursing action required by Joint Commission standards; the nurse implements the bundle first, then notifies the provider if restraint ultimately becomes necessary after least-restrictive alternatives fail. Calling before placing the bed low and establishing safe toileting delays essential safety interventions.

   B. Reorient the client to the current date and time, then document the confusion in the medical record.

   Irrelevant finding: the "selects an action that addresses an unrelated finding instead of the safety risk" error pattern. Reorientation and documentation of confusion are important but do not address the immediate fall safety risk. The client's altered cognition is the root cause of the risk; the bundle interventions (bed position, call light, toileting, footwear) mitigate that risk by removing environmental hazards and ensuring close staff proximity, whereas reorientation alone does not prevent falls.

   C. Apply a four-sided bed rail and wrist restraint per the PRN order to prevent further fall attempts.

   Wrong approach: the "applies restraint as PRN order or without trying less-restrictive alternatives" error pattern. CMS prohibits PRN restraint orders; four-sided bed rails are classified as a restraint. Applying restraint without first attempting and documenting the failure of less-restrictive alternatives (bed position, toileting, supervision) violates CMS 42 CFR 482.13 and Joint Commission standards. The client's delirium and orthostasis are better managed through environmental controls and staff proximity.

   D. Lower the bed to its lowest position, place the call light within reach, apply non-skid footwear, and schedule toileting every 2 hours before considering restraint.

   Correct. This implements the Joint Commission fall-prevention bundle anchored on the validated Morse assessment and tailored to this client's specific risk factors (confusion, orthostasis, attempted self-mobilization). The bundle, bed position, call-light access, footwear, scheduled toileting, are independent nursing actions that must precede any restraint consideration and directly address the safety risk.

6. Question 6 of 8 · Infection Prevention & Patient Safety

   A 68-year-old client with a history of severe anaphylaxis to iodinated contrast media (reported reaction: throat tightness, urticaria, hypotension requiring epinephrine) is admitted for acute coronary syndrome. The health care provider writes an order for a cardiac catheterization with contrast angiography. The client's allergy alert is prominently documented in the electronic health record. The client has mild cognitive impairment and lives alone; hearing is intact. The primary RN is preparing the client for the procedure. What is the priority action?

   1. AProceed to the catheterization lab and ensure the contrast is administered slowly to minimize the anaphylaxis risk.
   2. BReposition the client and ensure fall precautions are in place because the client has mild cognitive impairment.
   3. CPage the health care provider to ask if the cardiac catheterization should be performed before verifying the allergy status yourself.
   4. DClarify the order with the health care provider; discuss contrast-free alternatives or premedication protocol per institutional IPC and patient safety guidelines before proceeding.
   Show the answer and rationale

   Correct answer: D. Clarify the order with the health care provider; discuss contrast-free alternatives or premedication protocol per institutional IPC and patient safety guidelines before proceeding.

   The nurse must verify treatment orders for clarity, indication, dose, and client-specific safety before implementation, a core principle of the "verify appropriateness and accuracy of a treatment order" activity and alignment with Joint Commission NPSG standards for patient safety and error prevention. In this scenario, a severe anaphylaxis allergy to iodinated contrast (documented reaction: throat tightness, urticaria, hypotension requiring epinephrine) represents a direct conflict with the proposed cardiac catheterization with contrast angiography. Per the CDC Injection Safety guidelines and institutional safety protocols, the nurse must not initiate or allow a treatment that exposes the client to a known, severe allergen. Instead, the nurse independently recognizes this safety hazard, contacts the prescriber with the allergy data in hand, and explores alternatives (contrast-free imaging, premedication protocols per cardiology guidelines if available, or substitute procedures). This action honors the client's autonomy and comorbidity status while preventing iatrogenic harm. The nurse documents the clarification and any resulting order modification in the medical record. Option A violates the key rule by attempting to proceed with contrast exposure despite a documented severe anaphylaxis allergy; no dose-adjustment strategy eliminates anaphylaxis risk in a client with prior anaphylaxis. Option C incorrectly defers an independent nursing safety check to the provider; the nurse must first verify the allergy status against the treatment order before any provider notification, placing the verification within the nurse's scope and responsibility. Option B addresses an unrelated fall-prevention concern (cognitive impairment and room placement) rather than the immediate, safety-critical allergy-treatment conflict; repositioning and fall precautions do not resolve the contrast-anaphylaxis hazard and distract from the primary verification task.

   A. Proceed to the catheterization lab and ensure the contrast is administered slowly to minimize the anaphylaxis risk.

   Violates the "verify treatment orders for clarity, indication, dose, and client-specific safety" rule and expands the "administers/initiates a treatment despite a documented allergy" error pattern. Proceeding with contrast despite documented severe anaphylaxis is contraindicated regardless of infusion rate; the allergy must block exposure and trigger substitution or premedication discussions with the provider first.

   B. Reposition the client and ensure fall precautions are in place because the client has mild cognitive impairment.

   Expands the "selects an action that addresses an unrelated finding instead of the safety risk" error pattern. Although the client has mild cognitive impairment, reordering fall precautions does not address the immediate safety threat (contrast anaphylaxis). The irrelevant finding diverts from the critical allergy-treatment order conflict.

   C. Page the health care provider to ask if the cardiac catheterization should be performed before verifying the allergy status yourself.

   Violates the "verify treatment orders for clarity, indication, dose, and client-specific safety" rule and expands the "calls the provider for direction instead of taking the indicated independent nursing action" error pattern. The nurse must independently cross-check the documented allergy against the proposed order before calling the provider; this is a foundational nurse responsibility, not a task to defer. Verification precedes provider contact.

   D. Clarify the order with the health care provider; discuss contrast-free alternatives or premedication protocol per institutional IPC and patient safety guidelines before proceeding.

   Correct. The nurse recognizes the documented severe anaphylaxis allergy to iodinated contrast and must independently verify that the treatment order is safe for this client before implementation, per the "verify treatment orders for clarity, indication, dose, and client-specific safety" rule. Contacting the provider to clarify alternatives or premedication aligns with Joint Commission patient safety standards and prevents iatrogenic anaphylaxis.

7. Question 7 of 8 · Infection Prevention & Patient Safety

   A 73-year-old client with a history of moderate cognitive impairment and a documented severe latex allergy (reaction: urticaria and angioedema) is admitted to the orthopedic unit following a hip fracture. The client has a high fall risk (score 8/10) and remains confused about place and time. The health care provider's order reads: "Soft restraints to bilateral wrists for fall prevention, PRN. Reassess q2h for continued need." The client's allergy alert is flagged in the electronic health record. The nurse is preparing to implement the restraint order. Which action should the nurse take before applying the restraints?

   1. AApply the soft restraints immediately to both wrists to prevent a fall, as the high fall-risk score and PRN order authorize restraint use without delay.
   2. BPage the health care provider for explicit approval before placing the client on any fall-prevention measures, including bed positioning or monitoring.
   3. CVerify the order's type, site, time limit, and reassessment plan; confirm restraints are latex-free; and try least-restrictive alternatives, such as a low bed, alarm, or 1:1 supervision.
   4. DDocument the client's cognitive impairment in the chart and reassess the client's orientation status every 2 hours as a routine measure for confused clients.
   Show the answer and rationale

   Correct answer: C. Verify the order's type, site, time limit, and reassessment plan; confirm restraints are latex-free; and try least-restrictive alternatives, such as a low bed, alarm, or 1:1 supervision.

   Before implementing a non-medication treatment order, including restraints, the nurse must verify the order is complete, appropriate, and safe for the individual client (NCSBN activity: Verify Appropriateness and Accuracy of a Treatment Order; CMS 42 CFR 482.13 requires restraint orders to specify type, duration, rationale, and reassessment schedule; ANA Scope and Standards require least-restrictive alternatives be explored first). In this case, the restraint order meets the basic criteria (bilateral wrists, PRN, q2h reassessment), but the nurse must confirm that the restraint material is latex-free given the client's documented severe latex allergy with a history of angioedema, a contraindication to latex-containing products. Additionally, the nurse is obligated to explore and document why less-restrictive options (e.g., low bed, bed alarm, sitter, frequent rounds) are insufficient before applying physical restraints to a cognitively impaired client. This verification step protects both the client's safety (preventing anaphylaxis from latex exposure) and their rights (ensuring restraint is truly the last resort). Option A violates the "verify treatment orders for clarity, indication, dose, and client-specific safety" rule: it applies restraints without confirming the material is latex-free, creating a direct allergy hazard. The high fall-risk score does not override the requirement to check for unsafe materials or skip least-restrictive alternatives. Option B violates the "verify treatment orders for clarity, indication, dose, and client-specific safety" rule by deferring independent nursing verification to the provider. The nurse must independently assess the order's safety and completeness (including allergy compatibility and material selection) before implementation; routine bed positioning and monitoring are independent nursing actions that do not require provider authorization. Option D violates the "verify treatment orders for clarity, indication, dose, and client-specific safety" rule by addressing an unrelated (though documented) finding, the client's cognitive impairment and orientation, rather than the immediate safety issue: verifying the restraint order is safe and appropriate before application. Reassessing orientation every 2 hours does not address the latex allergy risk or the requirement to document least-restrictive alternative exploration.

   A. Apply the soft restraints immediately to both wrists to prevent a fall, as the high fall-risk score and PRN order authorize restraint use without delay.

   Incorrect. Expands the "administers/initiates a treatment despite a documented allergy" error pattern: proceeding with restraint application without confirming the material is latex-free violates the key rule by exposing a client with a documented severe latex allergy (urticaria, angioedema) to a potential anaphylaxis risk. A high fall-risk score does not override allergy safety checks.

   B. Page the health care provider for explicit approval before placing the client on any fall-prevention measures, including bed positioning or monitoring.

   Incorrect. Expands the "calls the provider for direction instead of taking the indicated independent nursing action" error pattern: paging the provider for approval of fall-prevention measures violates the key rule by delegating independent nursing verification of order safety and completeness to the provider. The nurse must assess allergy compatibility and material safety before implementation; these are independent nursing responsibilities, not provider-directed actions.

   C. Verify the order's type, site, time limit, and reassessment plan; confirm restraints are latex-free; and try least-restrictive alternatives, such as a low bed, alarm, or 1:1 supervision.

   Correct. The nurse verifies the restraint order's required details, confirms that the equipment is latex-free for a client with a severe latex allergy, and attempts less-restrictive safety measures first. These steps support safe order implementation and comply with the requirement to use restraints only when necessary and after less-restrictive alternatives are considered.

   D. Document the client's cognitive impairment in the chart and reassess the client's orientation status every 2 hours as a routine measure for confused clients.

   Incorrect. Expands the "selects an action that addresses an unrelated finding instead of the safety risk" error pattern: documenting cognitive impairment and reassessing orientation every 2 hours addresses a descriptive finding (the client's confusion) rather than the immediate safety verification required before restraint application. This action does not verify the order's safety (latex-free material), completeness, or least-restrictive alternative exploration.

8. Question 8 of 8 · Infection Prevention & Patient Safety

   A nurse is performing dressing changes for a client with a stage 3 pressure injury on the sacrum. The client is on contact precautions due to methicillin-resistant Staphylococcus aureus (MRSA) colonization. The bedside signage clearly displays the contact precautions requirement, and a gown and gloves are available at the room entrance. During the procedure, the nurse must handle contaminated dressings and sterile supplies. After completing the dressing change, which action should the nurse take first?

   1. ADocument the wound assessment findings and plan to doff all PPE at the unit desk before hand hygiene.
   2. BReassess the pressure injury stage and reorder topical antibiotics before removing any PPE.
   3. CRemove the gown first, then the gloves, and proceed directly to the next client without hand hygiene.
   4. DRemove gloves first, then remove the gown, and perform hand hygiene before leaving the client's room.
   Show the answer and rationale

   Correct answer: D. Remove gloves first, then remove the gown, and perform hand hygiene before leaving the client's room.

   The correct action is to remove gloves first, then the gown, and perform hand hygiene before leaving the room. This sequence aligns with the CDC contact precautions protocol and WHO Five Moments for hand hygiene. According to OSHA Bloodborne Pathogens and CDC Guidelines for Isolation Precautions, PPE doffing must follow a specific order to prevent self-contamination: gloves (most contaminated) are removed first by peeling from the wrist, followed by the gown (turning it inside-out as it is removed from the shoulders), and then immediate hand hygiene with alcohol-based hand rub or soap and water before exiting the room. This client has MRSA colonization on a contaminated pressure-injury site; improper doffing sequence risks transferring the organism to the nurse's hands or face and then to other clients or surfaces. Option C violates the correct doffing sequence and omits hand hygiene between client care, both violations of CDC isolation precautions and the WHO Five Moments. Option A delays doffing PPE and performs hand hygiene outside the client's room, which violates the principle that hand hygiene must occur at the point of care (before exiting) to prevent contamination of common areas. Option B addresses documentation and medication review, which are unrelated to the immediate post-procedure PPE and hand-hygiene action required for infection control.

   A. Document the wound assessment findings and plan to doff all PPE at the unit desk before hand hygiene.

   Incorrect. This action delays doffing PPE and moves hand hygiene outside the client's room, violating the WHO Five Moments (hand hygiene must occur at the point of care before exiting). Walking through common areas in contaminated PPE and without hand hygiene between the client room and the unit desk increases the risk of transmitting MRSA to high-touch surfaces and other clients.

   B. Reassess the pressure injury stage and reorder topical antibiotics before removing any PPE.

   Incorrect. Reassessing the pressure-injury stage and reviewing medications are clinical assessments unrelated to the immediate post-procedure safety action of PPE doffing and hand hygiene. This option addresses an irrelevant finding and delays the infection-control action required after contact-precaution procedures, failing to prioritize the safety risk of MRSA transmission.

   C. Remove the gown first, then the gloves, and proceed directly to the next client without hand hygiene.

   Incorrect. This option violates the correct PPE doffing sequence (gown before gloves) and omits hand hygiene at the point of care. Removing the gown first, when gloves are still contaminated, risks transferring MRSA to exposed skin. Skipping hand hygiene before leaving the room violates CDC Guidelines for Isolation Precautions and the WHO Five Moments, increasing risk of cross-contamination.

   D. Remove gloves first, then remove the gown, and perform hand hygiene before leaving the client's room.

   Correct. Gloves are removed first (peeling from the wrist inward to avoid contact with the contaminated exterior), followed by the gown, and then immediate hand hygiene within the room before exiting. This sequence and timing prevent self-contamination and comply with CDC isolation precautions and the WHO Five Moments for hand hygiene, protecting both the nurse and other clients from MRSA transmission.