Employee/Occupational Health

Question 1

1. The infection preventionist (IP) is assisting Employee Health with
   personnel tuberculosis (TB) skin testing. Which of the following
   represents a known tuberculin skin test (TST) conversion in a
   healthcare worker?
   a. Prior tuberculin test results are not available, but the current
   result is 16 mm after 48 hours
   b. Tuberculin reaction 1 year ago was 9 mm, and the current
   results are 13 mm
   c. A prior tuberculin reaction was not measured, but
   the employee states it was dime-sized. The current
   result is 11 mm
   d. Tuberculin reaction 1 year ago was 3 mm, and the current
   result is 18 mm

Answer 1

D Tuberculin reaction 1 year ago was 3 mm, and the current result
is 18 mm
Rationale: Interpretation of the TST depends on measured TST induration in
millimeters, the person’s risk for being infected with M. tuberculosis, and risk
for progression to active TB if infected. The TST test should be interpreted
according to the CDC guidelines. A healthcare worker without known
exposure who demonstrates an increase of ≥10 mm is considered a positive
result. (

Question 2

A food service worker is diagnosed with Hepatitis A. How long
should this employee be on work restrictions?
a. Until 14 days after symptoms resolve
b. Until 7 days after onset of jaundice
c. Until 14 days after onset of jaundice
d. Until 10 days after symptoms resolve

Answer 2

B Until 7 days after onset of jaundice
Rationale: According to the ACIP, food service workers who are diagnosed
with Hepatitis A must be restricted from food handling until 7 days after the
onset of jaundice.

Question 3

Because there is no vaccine for Hepatitis C, there have been
national recommendations for prevention and control of
Hepatitis C virus (HCV) infections. These include all but which
recommendation?
a. Screening and testing of blood donors
b. Risk-reduction counseling and screening of persons
at risk for Hepatitis C infection
c. A national registry for all healthcare personnel known
to be Hepatitis C antibody positive
d. Adherence to Standard Precautions and safe work
practices in healthcare settings

Answer 3

C A national registry for all healthcare personnel known to be NOTES
Hepatitis C antibody positive
Rationale: No vaccine against HCV infection exists. National recommendations
for prevention and control of HCV infection, issued in 1998, emphasize primary
prevention activities to reduce the risk for HCV transmission. These activities
include screening and testing of blood donors, viral inactivation of plasmaderived
products, risk-reduction counseling and screening of persons at risk
for HCV infection, and adherence to Standard Precautions and safe work
practices in healthcare settings

Question 4

The U.S. Public Health Service’s Advisory Committee on NOTES
Immunization Practices (ACIP) recommends all of the following
immunizations be provided to healthcare personnel except:
a. Hepatitis A and B vaccines
b. Influenza vaccine
c. Measles, mumps, and rubella (MMR) and varicella-zoster
vaccines (if not immune)
d. Bacillus Calmette–Guérin (BCG)

Answer 4

D Bacillus Calmette–Guérin (BCG)
Rationale: Immunization programs provide protection from vaccinepreventable
diseases for both the workers and those under their care.
The infectious diseases for which vaccines are available for pre-exposure
intervention include Hepatitis A and B, influenza, measles, mumps, rubella,
tetanus, pertussis, and varicella-zoster (chickenpox).

Question 5

Which of the following statements is true regarding storage
of vaccines?
a. Vaccines should be taken out of the original packaging
b. Vaccines should be stored in a labeled container/bin on the
middle shelf a few inches from the wall
c. Vaccines should be packed tightly into the fridge
d. Vaccines should be stored in the top of the refrigerator

Answer 5

B Vaccines should be stored in a labeled container/bin on the
middle shelf a few inches from the wall
Rationale: Vaccine storage and handling errors can reduce vaccine potency
and result in inadequate immune responses and protection against disease.
The CDC recommends the following regarding vaccine storage:
• Vaccines need to be placed in the central area of the unit, away from
walls, vents, and coils
• Avoid placing vaccines on the top shelf
• There must be enough room to store the year’s largest inventory
without crowding
• A calibrated thermometer should be placed inside each storage unit
• The storage unit must be dedicated to the storage of vaccines

Question 6

An employee is exposed to a patient known to have chronic
Hepatitis B. The employee is a known responder to the Hepatitis B
vaccine, which was given to him as a student 5 years ago. What is
the recommended postexposure treatment for the employee?
a. Test the employee and all close personal contacts for
Hepatitis B
b. Start the Hepatitis B series on the employee because
of the length of time since vaccination
c. No treatment is recommended for a known responder
d. Recommend giving the employee the Hepatitis A vaccine

Answer 6

C No treatment is recommended for a known responder
Rationale: According to the CDC guidelines, when the employee is known
to have responded (converted) to positive Hepatitis B antibody following
immunization series, no treatment is recommended.

Question 7

An employee who is not immune to varicella-zoster was exposed
to a patient with active chickenpox. How long must the employee
remain on work restrictions?
a. Until evaluated by a physician
b. From day 10 after exposure to day 21 after exposure
c. No work restriction is necessary if no signs and symptoms
are present
d. At the discretion of the hospital infectious disease physician

Answer 7

B F rom day 10 after exposure to day 21 after exposure NOTES
Rationale: According to the ACIP guidelines, a nonimmune healthcare worker
who has direct contact with a patient with varicella zoster should be excluded
from work duty from the 10th day after the first day of exposure through the
21st days after the last exposure.

Question 8

Which of the following are acceptable methods for follow-up
testing among healthcare personnel with unprotected exposure
to TB?
1) QuantiFERON-TB Gold testing (QFT-G) of sputum at
the time of exposure and 12 weeks after exposure
2) QFT-G testing of blood at the time of exposure and
12 weeks after exposure
3) TST via tine tests at the time of exposure and 12 weeks
after exposure
4) TST via the intradermal method at the time of exposure
and 12 weeks after exposure
5) Chest radiograph for personnel with prior positive TST
or QFT-G results
6) Chest radiograph for symptomatic personnel with positive
TST or QFT-G results
a. 1, 3, 6
b. 2, 3, 5
c. 1, 4, 6
d. 2, 4, 6

Answer 8

D 2, 4, 6
Rationale: QFT-G is a blood assay. Intradermal rather than tine testing
methods should be used for TST. Testing should be administered at the
time of exposure and repeated at 12 week postexposure to look for possible
converters. Chest radiographs are performed only on those with prior
positive screening results who are currently symptomatic.

Question 9

What is the appropriate temperature for vaccines that require
refrigeration?
a. 46°F to 55°F (8°C to 13°C)
b. 25°F to 35°F (-4°C to 2°C)
c. 25°F to 45°F (-4°C to 7°C)
d. 35°F to 46°F (2°C to 8°C)

Answer 9

D 35°F to 46°F (2°C to 8°C)
Rationale: Most routinely recommended vaccines should be stored in a
refrigerator between 35°F and 46°F (2°C and 8°C), with a desired average
temperature of 40°F (5°C). Exposure to temperatures outside this range
may result in reduced vaccine potency and increased risk of vaccinepreventable
diseases.

Question 10

The IP is reviewing the immunization records of healthcare
personnel at their facility and discovers that employees born
before 1957 do not have any record of receiving MMR vaccine.
What should she recommend to the Human Resources Director
regarding employees born before 1957?
a. They are considered immune and do not require follow-up
b. They should receive two doses of the vaccine 4 weeks apart
c. They are only required to provide proof of immunity
to measles
d. They are required to provide proof of immunity to measles,
mumps, and rubella

Answer 10

D They are required to provide proof of immunity to measles,
mumps, and rubella
Rationale: All persons working in healthcare facilities should be immune to
measles, mumps, and rubella. It is reasonable to require proof of immunization.
Proof of immunity consists of documented vaccination with one or more
doses of live vaccine on or after the first birthday, laboratory evidence of
immunity to these diseases, or history of these diseases based on a healthcare
worker diagnosis. Although birth before 1957 is considered acceptable
evidence of measles, rubella, and mumps immunity, ACIP recommends
that healthcare facilities consider vaccinating unvaccinated personnel born
before 1957 who do not have laboratory evidence of measles, rubella, and
mumps immunity; laboratory confirmation of disease; or vaccination with two
appropriately spaced doses of MMR vaccine for measles and mumps and one
dose of MMR vaccine for rubella.

Question 11

Staff assisting with bronchoscopy of a patient with suspected NOTES
TB must wear which type of respiratory protection?
a. Surgical/procedure mask
b. Face shield
c. Protection is not required
d. A fit-tested respirator or powered air purifying
respirator (PAPR)

Answer 11

D A fit-tested respirator or powered air purifying respirator (PAPR)
Rationale: Healthcare personnel assisting with bronchoscopy should wear
appropriate personal protective equipment including a fit-tested respirator
or a PAPR.

Question 12

An employee has sustained a needlestick injury from a bloodcontaminated
needle. The source patient was Hepatitis B virus
(HBV) positive, and the employee had completed one of the
three vaccinations in the Hepatitis B series. Which of the following
is the correct postexposure prophylaxis (PEP) for this patient?
a. Complete the Hepatitis B vaccine series
b. Complete the Hepatitis B vaccine series and provide
Hepatitis B immunoglobulin
c. Provide Hepatitis B immunoglobulin and begin
interferon therapy
d. No PEP is needed

Answer 12

B Complete the Hepatitis B vaccine series and provide Hepatitis B
immunoglobulin
Rationale: HBV is transmitted by percutaneous or mucosal exposure to
infectious blood or body fluids. The risk of HBV seroconversion after a
percutaneous injury ranges from 23 to 62 percent depending on the Hepatitis
B e antigen (HBeAg) status of the source person. For exposed persons who
are in the process of being vaccinated but have not completed the vaccination
series, vaccination should be completed as scheduled, and Hepatitis B immune
globulin (HBIG) should be added as indicated. Both HBIG and the Hepatitis B
vaccine should be administered as soon as possible after exposure (preferably
within 24 hours)

Question 13

The IP is developing a seasonal influenza immunization promotion
program and decides to survey some healthcare personnel to
determine their knowledge and attitude about influenza vaccines.
Several healthcare personnel state that they do not want to be
immunized because they believe that the vaccine can give them
the flu. What is the best response the IP can give to alleviate
this fear?
a. The symptoms of the flu from the vaccine are much
milder than actually getting the flu, so they are better
off being immunized
b. There are no known reactions or side effects to the
flu vaccine
c. Any symptoms they experience are due to allergies to
components of the vaccine, so they will not get the flu
from the vaccine
d. They might experience symptoms that are due to the
immune response to the vaccine, but they cannot get
the flu from the vaccine

Answer 13

D They might experience symptoms that are due to the immune
response to the vaccine, but they cannot get the flu from the vaccine
Rationale: Vaccination is the primary method for preventing influenza and
its complications. Healthcare personnel compliance with annual influenza
vaccination is an expected behavior to protect patients, staff, and families.
There are two forms of vaccination available: the inactivated, injectable
vaccine and the live/attenuated, intranasal vaccine (LAIV). Inactivated
influenza vaccine contains noninfectious viral components and cannot cause
influenza. LAIV can cause nasal congestion, sore throat, and headache for a
few days. Some mild symptoms such as nasal congestion, sore throat, and
headache can occur as a result of the immune response to the vaccine but
these are typically minor and short-lived.

Question 14

Dialysis staff are most at risk for exposure to bloodborne
pathogens during:
1) Initiation and termination of dialysis
2) Reprocessing, cleaning, and disinfection procedures
3) Medication administration
4) Vascular access hemorrhage
a. 1, 2
b. 2, 3
c. 2, 4
d. 1, 3

Answer 14

A 1, 2
Rationale: Staff members must follow Standard Precautions when
exposure to blood or other potentially infectious materials is anticipated
or likely. Times during which exposure is most likely to occur include
initiation and termination of dialysis and during reprocessing, cleaning,
or disinfection procedures.

Question 15

According to the Centers for Disease Control and Prevention
(CDC), which type of thermometer should be used in a vaccine
storage unit?
a. Fluid-filled biosafe liquid thermometer
b. Infrared thermometer
c. Chart recorder
d. Probe in a glycol-filled bottle with an external
monitoring device

Answer 15

D Probe in a glycol-filled bottle with an external monitoring device
Rationale: The CDC recommends using a temperature probe in a bottle filled
with a thermal buffer, like glycol, that connects to an external monitoring
device. This allows for temperatures to be monitored without having to
open the unit door. In addition, the CDC recommends the use of digital data
loggers. The CDC does not recommend the use of fluid-filled biosafe liquid
thermometers, infrared thermometers, or chart recorders.

Question 16

A patient in the Emergency Room is diagnosed with bacterial
meningitis due to Neisseria meningitidis. The patient was not
properly isolated, and a number of employees entered her room
without wearing a mask. Which employee should receive PEP?
a. The phlebotomist who drew blood on the patient
b. The respiratory therapist who intubated the patient
c. The radiology technician that performed the chest
radiograph
d. The employee from admissions that registered the patient

Answer 16

B T he respiratory therapist who intubated the patient NOTES
Rationale: PEP is advised for persons who have had intensive, unprotected
contact with infected patients. Unprotected means without wearing a mask,
and intensive contact would be mouth-to-mouth resuscitation, endotracheal
intubation, endotracheal tube management, or close examination of the
oropharynx. Prophylactic therapy should be administered immediately after
the unprotected exposure. Current recommended regimens to eradicate
carriage are rifampin 600 mg orally every 12 hours for 2 days; a single
dose of ciprofloxacin 500 mg orally; or a single dose of ceftriaxone 250
mg intramuscularly. Rifampin and ciprofloxacin are not recommended for
pregnant women.

Question 17

U.S. Occupational Safety & Health Administration (OSHA)
mandates that which of the following vaccines be provided
at no cost to healthcare providers and others at risk for blood
and body fluid exposure?
a. Hepatitis A
b. Hepatitis B
c. BCG
d. Meningococcal

Answer 17

B Hepatitis B
Rationale: Exposure to bloodborne pathogens poses a serious risk to
healthcare personnel. Avoiding occupational blood exposures through
adherence to Standard Precautions and other safe work practices is
essential. The most effective means to prevent transmission of bloodborne
pathogens in healthcare settings include Hepatitis B vaccination, the use of
appropriate barriers to prevent blood and body fluid contact, and preventing
percutaneous injuries by eliminating unnecessary needle use, implementing
devices with safety features, using safe work practices when handling
needles and other sharp devices, and safely disposing of sharps and bloodcontaminated
materials. OSHA’s Bloodborne Pathogen Standard mandates
provision of Hepatitis B vaccine at no cost to all healthcare personnel and
others at occupational risk for blood exposure

Question 18

Which of the following is not proof of measles immunity for NOTES
healthcare personnel?
a. Documentation of vaccination with two doses of live
measles virus-containing vaccine
b. Laboratory evidence of immunity
c. Born after 1957
d. Laboratory confirmation of disease

Answer 18

C Born after 1957
Rationale: According to the ACIP, the following are proof of measles immunity
for healthcare providers: (1) documentation of vaccination with two doses of
live measles virus–containing vaccine, (2) laboratory evidence of immunity,
(3) laboratory confirmation of disease, or (4) born before 1957. The latest
recommendations also state that for unvaccinated personnel who were
born before 1957 and who lack laboratory evidence of measles, rubella, or
mumps immunity or laboratory confirmation of disease, healthcare facilities
should consider vaccinating personnel with two doses of MMR vaccine at the
appropriate interval (for measles and mumps) and one dose of MMR vaccine
(for rubella), respectively.

Question 19

There has been a local bioterrorism event and three healthcare
personnel were exposed to inhalation anthrax. They have been
decontaminated and are taking PEP, and they would like to
return to work. The incubation period of inhalation anthrax is
usually about 7 days but can be as long as 2 months. What
should the IP’s recommendation be regarding work restrictions
for these employees?
a. They will not be allow to return to work for the duration
of the 2-month incubation period
b. They will not be allowed to return to work for the duration
of prophylactic treatment
c. They may return to work but must wear respiratory
protection while in the facility
d. They may return to work with no restrictions

Answer 19

D They may return to work with no restrictions
Rationale: Although work restrictions in such a scenario would likely be
influenced by outside agencies such as the local and state Health Departments
and the CDC, inhalation anthrax is not transmissible among humans so these
exposed healthcare workers pose no risk to patients or other employees.

Question 20

The occupational health nurse has requested the IP’s assistance
in reporting the nursing needlestick rate annually. Which formula
should be used?
a. Total number of needlesticks reported by nursing divided
by the average daily census
b. Total number of needlesticks reported by nursing divided
by the needle devices used by nursing
c. Total number of needlesticks reported by nursing divided
by the number of full-time nurses employed during the year
d. Total number of needlesticks reported by nursing divided
by the number of injections given by nurses

Answer 20

C Total number of needlesticks reported by nursing divided by
the number of full-time nurses employed during the year
Rationale: The rates of needlestick injuries can be identified by occupational
category. For example: total number of needlesticks reported by nursing in 1
year divided by number of full-time equivalent nurses employed in that year
equals the rate of needlesticks per full-time equivalent nurse per year

Question 21

The IP is asked to recommend the length of time a staff member
who has developed influenza should be excluded (furloughed)
from work duties. The staff member was diagnosed with influenza
on March 15. She consults the CDC infection Control Guidance
for the Prevention and Control of Influenza in Acute Care
Facilities and recommends that the employee should:
a. Remain off work until March 20
b. Remain off work for the duration of the illness
c. Remain off work until March 21
d. Remain off work for 5 days (March 20) or until symptoms
have resolved, whichever is longer

Answer 21

D Remain off work for 5 days (March 20) or until symptoms
have resolved, whichever is longer
Rationale: Influenza is primarily spread between individuals via respiratory
secretions (droplet spread). Viral shedding starts 24 to 48 hours after
infection, and typically 24 hours before the onset of symptoms. Shedding
normally persists less than 5 days but can be longer in children and in
immunocompromised persons. Thus, adults are typically infectious from the
day before symptoms begin until approximately 5 days after the onset of
illness. Staff members who develop influenza illness should be furloughed for
5 days after diagnosis or the duration of their illness, whichever is longer.

Question 22

An employee is exposed to a known HIV-positive patient’s blood
via needlestick after giving an intramuscular injection. The patient
has a known high viral load. After the employee has thoroughly
washed the exposed area with soap and water, what is the next
step that should be taken following this exposure?
a. The employee needs to be counseled about using safer sex
practices and to avoid pregnancy, breast-feeding, and blood
and organ donation for 3 months after exposure
b. The employee should be treated as soon as possible with
expanded multidrug PEP
c. The employee should have baseline testing for HIV,
Hepatitis B antigen, and Hepatitis B antibody
d. The employee should be counseled by a clinician
knowledgeable about HIV transmission risks

Answer 22

B The employee should be treated as soon as possible with
expanded multidrug PEP
Rationale: Because the patient is known to have a high HIV viral load, the
exposure should be considered an increased risk for transmission. According
to the CDC, most HIV exposures warrant a two-drug regimen using two
nucleoside reverse transcriptase inhibitors (NRTIs) or one NRTI and one
nucleotide reverse transcriptase inhibitor. The CDC recommends that the
addition of a third (or even fourth) drug should be considered for exposures
that pose an increased risk for transmission or that involve a source in whom
antiretroviral drug resistance is likely.

Question 23

An IP is participating on a multidisciplinary team formed to
decrease sharps injuries in an Ambulatory Surgical Center. Of
the following possible activities, which would be most likely
to assist the team?
a. A quarterly review of sharps injury data stratified
by surgical team
b. An analysis of employee participation in the Hepatitis B
vaccination program
c. Root cause analyses after exposure incidents
d. A review of surgery duration in cases in which sharp
injuries were reported

Answer 23

C R oot cause analyses after exposure incidents NOTES
Rationale: The root cause analysis process takes a retrospective look at
adverse outcomes and determines what happened, why it happened, and
what an organization can do to prevent the situation from recurring. When
conducting a root cause analysis, a multidisciplinary team discovers basic and
contributing causes for what happened. The entire process identifies changes
to a particular process or system that improves safety or reduces process
error. Performing a root cause analysis is the best approach to take
to accomplish the goal of decreasing sharp injuries.

Question 24

A new employee who needs to be tested for TB infection before NOTES
starting work has a history of BCG vaccination. Which method of
TB testing would be the best choice in this situation?
a. The TST would be the best method to use because it is the
most cost-effective testing method
b. A TST would be the best method to use because it
distinguishes latent from active TB infection
c. An interferon-gamma release assay (IGRA) blood test would
be the best method to use because prior BCG immunization
does not cause a false positive with this test
d. An IGRA blood test would be the best method to
use because it is a rapid test and provides results
within 30 minutes

Answer 24

C An interferon-gamma release assay (IGRA) blood test would be
the best method to use because prior BCG immunization does
not cause a false positive with this test
Rationale: An IGRA would be the best choice in this case because it will not
be affected by the employee’s prior BCG vaccination. Other advantages of
IGRAs are that they do not require a follow-up visit to read the test and that
the results are available within 24 hours. However, IGRA testing is generally
more expensive than TST.

Question 25

Which of the following is not evidence of varicella immunity in
healthcare personnel?
a. Evidence of two doses of the varicella vaccine
b. Laboratory evidence of immunity
c. Laboratory confirmation of disease
d. Born before 1980

Answer 25

D Born before 1980
Rationale: According to the ACIP, the following are proof of immunity for
varicella in a healthcare provider: (1) evidence of two doses of the varicella
vaccine, (2) laboratory evidence of immunity to varicella, or (3) laboratory
confirmation of disease. Birth before 1980 should not be considered proof
of immunity for healthcare providers.