Exam (elaborations)
Archer Safety/Infection Control
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Archer Safety/Infection Control
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ARCHER SAFETY/INFECTIONI
CONTROL QUESTIONS WITH CORRECT
ANSWERS
The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior
to entering the room, the nurse should do which of the following?
A. Wear gloves and a gown.
B. Perform hand hygiene.
C. Review the client's viral load.
D. Obtain a disposable stethoscope. - Explanation
Choice B is correct. When caring for a client who has AIDS, the nurse should maintain standard
precautions. Applying PPE such as a gown, pair of gloves, and mask would be inappropriate. Standard
precautions require appropriate hand hygiene and other PPE as needed.
Choices A, C, and D are incorrect. The diagnosis of AIDS requires standard precautions which mandate
appropriate hand hygiene. It would be inappropriate for gowns or gloves to be worn during client care.
Assessing the client's viral load prior to obtaining vital signs would not change the fact that this client
requires standard precautions. A disposable stethoscope and blood pressure cuff may be useful for a
client with contact precautions, but it would not be necessary for a client with AIDS.
Additional Info
For a client with standard precautions, hand hygiene is required before and after client care. The nurse
may use alcohol-based hand sanitizers only if the hands are not visibly soiled. Another exception to the
use of alcohol-based hand sanitizers is if the client has a pathogen such as C. difficile, which requires that
the hands be washed with soap and water. Gloves should only be worn when contact with mucous
membranes, blood, or non-intact skin will be anticipated. This type of contact is not expected during the
collection of vital signs.
Last Updated - 15, Jan 2022
,Which of the following vaccines contains a live virus?
Correct
A. IPV
B. DTaP
C. Varicella
D. Hepatitis B - Explanation
Choice C is correct. Varicella is a live virus. Currently, the available live attenuated viral vaccines are
measles, mumps, rubella, vaccinia, varicella, zoster (which contains the same virus as varicella vaccine
but in a much higher amount), yellow fever, rotavirus, and influenza (intranasal).
Choice A is incorrect. IPV is an inactivated polio vaccine.
Choice B is incorrect. DTaP contains inactivated forms of the toxin produced by the bacteria that cause
the three diseases Diphtheria, Tetanus, and Pertussis.
Choice D is incorrect. Hepatitis B vaccine is a genetically engineered (human-made in the laboratory)
piece of the virus. It does not contain a live virus.
NCSBN Client Need, Topic: Health Promotion and Maintenance, Subtopic: Immunizations
Last Updated - 03, Dec 2021
The nurse is caring for a client with a sacral wound infected with Methicillin-resistant staphylococcus
aureus. Which personal protective equipment (PPE) is necessary to care for this client?
Select all that apply.
A. Gloves
B. N95 respirator
C. Surgical Mask
D. Goggles
E. Gown - Explanation
,Choices A and E are correct. A gown and gloves should be used when coming into contact with an MRSA
wound. This prevents secretions from the wound from infecting the nurse.
Choices B, C, and D are incorrect. MRSA in the wound requires contact precautions. A mask is not
necessary, nor is goggles or a respirator.
Additional Info
MRSA is a gram-positive bacteria that is found frequently in healthcare facilities. MRSA is spread by
direct contact and affects most older adults through indwelling urinary catheters, vascular access
devices, open wounds, and endotracheal tubes. It is susceptible to only a few antibiotics, such as IV
vancomycin and oral linezolid.
For a client on contact precautions, the door may remain open. During client transport, the wound
should be covered with a dry dressing.
The nurse has just given an intradermal injection of PPD to a client in the clinic when she accidentally
sticks herself in the finger with the used needle. What is the initial action of the nurse?
A. Fill out an incidence occurrence report.
B. Wash the area with soap and water right away.
C. Ask the client if he has HIV or hepatitis.
D. Put an antibiotic cream and bandage over the site.
Submit Answer - Explanation
Choice B is correct. The initial action of the nurse should be to wash the area with soap and water first
then try to squeeze the area to make it bleed.
Choice A is incorrect. The incident should be documented entirely; however, the nurse should care for
the wound first.
Choice C is incorrect. The nurse should not directly ask the client. The nurse may refer to the client's
chart or ask the client to have his blood drawn for testing.
Choice D is incorrect. The first puncture site would not need an antibiotic ointment.
Additional Info
, Last Updated - 17, Oct 2021
The charge nurse is performing safety rounds on clients in the nursing unit. Which observation requires
follow-up? A client with
A. an indwelling urinary catheter hanging from the bed frame.
B. right-sided weakness with their cane on the left side of the bed.
C. a history of falling given a bedside commode.
D. a belt restraint was applied and secured over the chest. - Explanation
Choice D is correct This observation requires follow-up because a belt restraint should be applied to the
client's waist - not the chest. It is inappropriate to have a belt restraint secured over the client's
abdomen or chest.
Choices A, B, and C are incorrect. These observations do not require follow-up. An indwelling catheter
tubing should hang freely from the bed frame. The tubing should be without any kinks or loops. If a
client has right-sided weakness, their ambulation device (cane, walker, etc.) should be placed on their
stronger side. A client with a history of falling is at an increased risk for future falls and placing a bedside
commode is a measure to reduce falls (by decreasing the client's distance to ambulate to the bathroom).
Additional Info
Belt restraints may be warranted for confused or impulsive clients who are continually trying to get out
of bed or a chair after repeated redirection, when it's unsafe for them to get up unassisted. Belt
restraints should be applied over clothing and secured over the client's waist. The restraint should be
anchored to an immovable part of the bed or the chair.
Last Updated - 22, Jun 2022
The nurse conducts safety rounds within the nursing unit. Which observation requires follow-up? Select
all that apply.
A. The client's armband was affixed to the bedside table.
B. The client's telephone number and name were used as identifiers.
C. Multiple blood specimen tubes are labeled before specimen collection.
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