ch 24 and 27

After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? select all that apply.

-used fingerstick lancet -used syringe with attached needle (p. 615)

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?

Before entering the clients room. (p. 612)

Which priority action should be implemented by the charge nurse when observing a new graduate nurse gathering a stool specimen?

Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids (pg. 614)

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?

Open a new sterile dressing kit (p. 6285)

A nurse is inserting a client's urinary catheter and notices a hold in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field?

Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves. (p. 633)

A nurse prefers to use an alcohol-based hand rub when providing care for clients. In which case is this practice contraindicated?

The nurse is caring for a client with a c. difficile infection (p607)

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. (p. 786-789)

Which action should the nurse perform first after an exposure to a client's body fluids?

Wash the exposed area with soap and water(p. 604)

Which nurse would be at the highest risk of causing a hazardous situation?

a nurse who has worked 32 hours of overtime this week. (p. 754)

After a client falls out of bed, the nurse completes:

a safety event report (incident report) (p. 778)

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The A in this acronym stands for which of the following?

activate the fire alarm and notify the appropriate person (p. 776)

What client would require a negative flow room?

an 81 year old man with active tuberculosis and a productive cough (p. 615)

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

ask to examine the client alone in order to speak to her privately. (p. 755)

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

assess the need for assistance with ambulation (p. 778)

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

clear clutter in the walkways of the new home (p. 760)

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse.

discard the supplies and field and prepare a new sterile field. (p.633)

The nurse is providing education to a group of healthy adults. Which nursing recommendation best promotes client safety in an independent living environment?

encourage exercise that improves balance and muscle strength (p. 772)

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

ensure that two fingers can be inserted between the restrain and the clients extremity (p. 789-789)

What is the leading cause of injury-related deaths in adults 65 and older?

falls (p.754)

Which personal protective equipment (ppe) should the nurse don to enter the room of a client who is diagnosed with clostridium difficile?

gown and gloves (p. 610)

Which nursing action is a component of medical asepsis?

handwashing and removing gloves (p. 603)

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

have a meeting place outside the home in case of fire. (p 760)

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?

health care associated infection (HAI) (p. 608)

The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?

identifies clients full name and date of birth (p770)

To eliminate needlesticks as potential hazards to nurses, the nurse should:

immediately deposit uncapped needles into a puncture proof plastic container (p. 605)

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing.

in bag marked "biohazards" (p. 614)

Health care workers may be exposed to a common occupational injury such as:

inadvertent needlestick (p. 754)

A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. Which would be most appropriate to include?

install handrails in stairways and bathrooms. (p. 772)

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls.

involve family members in the clients care (p. 757)

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medication in clearly labeled containers (p. 777)

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practicioner (p. 776)

What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital?

orienting client to the surroundings decreased the potential for injury (p. 762-763)

Any microorganism capable of disrupting physiologic body processes is a:

pathogen (p.595)

The nurse has completed a client's personal care and is now removing personal protective equipment. What is the nurse's best action when removing gloves?

pinch in middle of palm

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

placing the client in a bed with a bed alarm (p.. 775)

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

polypharmacy and use of multiple extension cords (p. 773-798)

Personal Protective equipment (ppe) is used in health care facilities from primarily which reason?

ppe protects clients from infections that may be carried bythe care team and also protects the care team from infections carried by clients. (p624-627)

Which interventions will be most effective in preventing the spread of infection in the health care setting.

proper handwashing (p. 603)

An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching?

put a small nightlight in the hall and stairway (p. 766)

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:

recapping a needle (p.616)

The nurse on a medical-surgical unit notices smokes from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

remove the client from the room. (p. 765)

What generalization can be made about safety in client care?

safety is a paramount concern underlying all nursing care (p. 752)

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?

staff education on utilizing hand hygiene. (p. 599)

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart?

stethoscope that remains in the clients rooms (p. 610)

A nurse was injured when a client with Alzheimer's disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

the report provides a detailed and objective account of the circumstances before, during, and after the event. (p. 778)

The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home?

use nightlights in bedrooms and bathrooms. (p. 755)

What nursing action demonstrates safe injection practice?

use sterile single use disposable syringes for each injection (p 615)

A nurse has sustain a puncture would on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?

wash the area with soap and water (p. 616)