NCLEX: Precautions & Safety Questions

Which statement by a client diagnosed with infectious mononucleosis indicates to the nurse that education has been successful? 1. "I should let my primary healthcare provider know if I start having pain in the side of my stomach" 2. "I can return to my normal activities in 5 days." 3. "I will not let others drink from my glass." 4. "My immediate family needs to get vaccinated against mononucleosis."

3. Correct: Infectious mononucleosis, caused by the Epstein-Barr virus is transmitted by saliva and intimate physical contact like kissing, sharing of utensils, and eating/drinking after others. 1. Incorrect: The client should observe for left upper quadrant abdominal pain radiating to the left scapula as this is an indicator of splenic rupture, a complication of infectious mononucleosis. 2. Incorrect: This is too soon. Most people get better in 2 to 4 weeks; however, some people may feel fatigued for several more weeks. Occasionally, the symptoms of infectious mononucleosis can last for 6 months or longer. 4. Incorrect: There is no vaccine to protect against infectious mononucleosis. The best way of the Epstein-Barr virus is to eliminate contact with oral secretions.

A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate? 1. Assign the client to a private room away from nurses station. 2. Make rounds to assess the client at regular intervals. 3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.

3., 4. & 5. Correct: Remove harmful objects from the client's access, such as sharp objects, straps, belts, ties, glass items, and alcohol. Close supervision is necessary during meals. Increased feelings of self-worth may be experienced when the client feels accepted unconditionally regardless of thoughts or behavior. -Make rounds frequently, at least every 15 minutes. *Do not become predictable with rounds. Predictability allows the client to learn your routine and potentially harm themselves during the time they know you will not be in there. *

AIRBORNE PRECAUTION DZ

MTV'SS M=easles T= uberculosis (TB) V= aricella (chicken pox)/ Herpez Zoster (shingles) S=SARS (Severe Acute Respiratory Syndrome)

DROPLET PRECAUTION DZs

think of SPIDERMAN! ~S - sepsis (Meningococcemia) ~S - scarlet fever ~S - streptococcal pharyngitis ~P - parvovirus B19 ~P - pneumonia ~P - pertussis (whooping cough) ~I - influenza ~D - diptheria (pharyngeal) ~E - epiglottitis ~R - rubella ~M - mumps ~M - meningitis (Haemophilus influenzae or meningococcal) ~M - mycoplasma or meningeal pneumonia ~An - Adenovirus Private Room or cohort Mask Plague Common cold (infants & young children only) Haemophilus influenzae Herpez Simplex *EBOLA*

Varicella (chicken pox)

-Airborne (airborne droplets) and Contact Precautions (skin lesions) -remain in isolation until all lesions are crusted (at least 5 days from onset of lesions) -negative pressure vented room & N95 mask are necessary. The door to the client's room should remain closed. -susceptible persons should not enter the room -ppl who have had varicella before may enter w/o a mask -if immune by vaccination you should wear a mask -Susceptible pts who have been exposed should be placed on Airborne Precautions beginning *10 days* after exposure and continuing through *day 21 after last exposure (up to 28 days if VZIG has been given)*. -considered infectious 2 days before onset of rash and up to 5 days after onset of lesions. -After exposure, use *varicella zoster immune globulin (VSIZ)* as recommended by Infectious Diseases Service.

AIRBORNE PRECAUTION INTERVENTIONS

-Airborne Precautions apply to pts *known or suspected* to be infected with pathogens transmitted by airborne droplet nuclei or evaporated droplets that can remain suspended in the air or can be dispersed within a room or over a long distance PLACEMENT -place pt in a private room that has: 1) monitored negative air pressure in relation to the surrounding areas, 2) 6 to 12 air changes per hour, and 3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital • Keep the room door closed and the client in the room. • Client should have a private room. • When a private room is not available, place the client in a room w/a pt who has active infection w/ the same microorganism *but w/ no other infection.* RESPIRATORY • Wear respiratory protection (N95 respirator) when entering the room of a client with known or suspected infectious pulmonary tuberculosis. • Susceptible pl should not enter the room of clients *known or suspected* to have measles (rubeola) or varicella (chickenpox) if other immune caregivers are available. If they must enter, they should wear a respirator mask. TRANSPORT -Limit the movement and transport of the pt from the room to essential purposes only. • If transport or movement is necessary, place a surgical mask on the client.

Herpes zoster(Shingles) • *Disseminated* (has spread is not localized)

-Airborne and Contact Precautions (lesions & respiratory secretions) -use a monitored room w/ negative pressure & external exhaust -in isolation until all lesions are crusted -Persons immune from prior natural illness *or vaccination may enter without a mask.* -ppl susceptible to varicella should not enter the room -individuals exposed should be managed in consultation with Infection Control. -The door to the pt's room should remain closed and the pt must wear a mask when leaving. -pts are considered *infectious 2 days before* onset of rash and *up to 5 days after onset* of lesions.

SMALLPOX

-Airborne and Contact Precautions *(strict gown/ glove)* -Large and small respiratory droplets, skin lesions, & secretions are infectious -DURATION OF ISOLATION: Onset of rash to separation of scabs (approximately 3 weeks). -*Private rooms preferred* -In event of large outbreak, pts w/ same diagnosis can share respiratory isolation room. -Limit pt transport, if necessary, pt wears mask.

SARS (Severe Acute Respiratory Syndrome)

-Airborne and Contact Precautions w/ goggles over eyes -Respiratory droplets

TUBERCULOSIS

-Pulmonary, confirmed or suspected (sputum smear is AFB positive and/or chest x-ray appearance strongly suggests active TB, i.e., cavitary lesions; or laryngeal. -Airborne Precautions from Airborne droplet nuclei (use a monitored room w/ negative pressure and external exhaust) -specially vented room is necessary -door to the pt's room should remain closed -ppl entering the room should wear specially fitted NIOSH approved respiratory protection. -pt should leave the room only for essential purposes, particularly if the pt has multidrug-resistant TB. -*When leaving the room, the pt should wear a high-filtration surgical mask; for mechanically-supported ventilation, add a bacterial filter to filter the client'' exhaled air.*

MEASLES (Rubeola, Red measles)

-airborne precaution from resp. secretions -use a monitored room with negative pressure and external exhaust) -For 4 days after onset of rash. For immunocompromised pts, maintain precautions for duration of illness -*Promptly notify Infection Control.* -Susceptible persons should stay out of the room. -All other persons should wear a mask upon entry. Pt must wear a mask when leaving the room. -The door to the pt's room should remain closed. -Susceptible pts who have been exposed should be placed on Airborne Precautions beginning *5 days after exposure* and continuing through *day 21 after last exposure* -*pts are considered infectious 4 days before to 4 days after onset of rash.*

The nurse has taught a client who is scheduled for a colonoscopy. Which of the following statements by the client would require follow up? 1. "I will not be able to eat or drink anything for 24 hours before the procedure." 2. "I may experience abdominal cramping after the procedure." 3. "I will be sedated during the procedure." 4. "I will be placed in the knee-chest position for the procedure."

1

The nurse is caring for a client who was brought to the emergency department (ED) by the spouse. Based on the client's injuries, the nurse suspects the client may have been physically abused. Which of the following actions would be most appropriate for the nurse to take? 1. Question the client about the possibility of abuse when the spouse is not in the room. 2. Explain to the client that the client will have to speak with a police officer to rule out the possibility of abuse. 3. Explain to the spouse that the client's injuries appear to be the result of physical abuse. 4. Ask the client and the spouse how long they have been married.

1

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary and lifestyle modifications. Which of the following information should the nurse include in the teaching? Select all that apply. 1. Maintain a high-protein, low-fat diet. 2. Avoid snacks between meals. 3. Sleep with the head of the bed elevated. 4. Stay upright for 2 to 3 hours after eating. 5. Decrease daily intake of sodium.

1,3,4

The nurse is caring for a client who has streptococcal pneumonia. Which of the following infection control precautions should the nurse implement? 1. Request the dietary department provide disposable utensils on the client's meal tray. 2. Wear a surgical mask when obtaining the client's vital signs. 3. Remove fresh flowers from the client's room. 4. Place the client in a private room with monitored negative air pressure

2

What interventions should the nurse plan to implement when admitting a client diagnosed with measles? 1. Admit to a semi-private room with a client diagnosed with tuberculosis (TB). 2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 4. Wear surgical mask when entering the client's room. 5. Assign a nurse who has received the measles vaccine to take care of this client.

2., 3., & 5. Correct: If the client must leave the room, a surgical mask should be worn to prevent transmission to others. Measles can be transmitted via contact, droplet, and airborne methods, so airborne precautions are needed. Healthcare providers who are not immune to measles should not care for a client with measles. 1. Incorrect: The client should be placed in a private room with negative air pressure when airborne precautions are necessary. TB and measles are not like illnesses and should not be placed in the same room. 4. Incorrect: A particulate or N95 respirators should be worn by staff entering the room of a client on airborne precautions. N95 respirators filter particles that you may inhale. A surgical mask prevents the spread of particles during exhalations.

What assessments would be appropriate for the school nurse to perform related to school safety practices and emergency preparedness? 1. Teach about gun control laws. 2. Observe for gaps or changes in levels of sidewalks. 3. Identify which students have special healthcare needs. 4. Locate all entrances and exits to buildings. 5. Identify threats and hazards in the school and surrounding community. 6. Perform a check of all fire extinguishers.

2., 3., 4., 5., & 6. Correct: One of the first things that a school nurse should do is to assess where an accident might happen. Observing for gaps or changes in the level of sidewalks is an example of this assessment. The school nurse should assess for special healthcare needs in the event that the school enters a time of extended lockdown. Some students would require attention during the time of lockdown, such as diabetics who could not wait to receive insulin or have food available. All entrances to the schools must be identified to know where a potential entry for intruder might could occur. Some access points may need to be changed to reduce risk to students. Becoming familiar with all exits is crucial to planning timely and safe evacuation of students if needed. The school nurse can draw upon a wealth of information that exists regarding threats or events that have occurred in the past at the school or in the local community in order to plan for possible future events. Fire extinguishers should be checked on a regular schedule for assessment of access, date of expiration, and functionality. 1. Incorrect: Teaching about laws on gun control is not an assessment, but rather an intervention that can be done. Teaching is not the initial step of the nursing process. Assessment comes first.