Passpoint: Safety and Infection Control

A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which of the following actions by the nurse is the best solution?

Hold the medication until speaking with the NP. "The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication."

A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of the car and beginning to approach the client's building, a group of people begin following and jeering at the nurse. Which is the nurse's best response to this situation?

Leave the area in the car, provided the nurse can get to it safely. "The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove themself from the situation, provided this can be achieved without incurring further risk."

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?

talking with the nurse "Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse."

A charge nurse is completing client assignments for the nursing staff on the pediatric unit. Which client would the nurse refrain from assigning to a pregnant staff member?

an 8-year-old with Rubella "Rubella (German measles) has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women. Ringworm is caused by a fungal infection on the skin. Standard hand hygiene is necessary. Kawasaki's disease is an autoimmune disease in which blood vessels become inflamed. Roseola is a virus transferred by oral secretions."

A school-age child is admitted to the hospital with acute rheumatic fever with chorea-like movements. Which eating utensil should the nurse remove from the meal tray?

fork "For a child with chorea-like movements, safety is of prime importance. Feeding the child may be difficult. Forks should be avoided because of the danger of injury to the mouth and face with the tines."

A child with a body surface area (BSA) of 0.82 m2 has been prescribed actinomycin 2.5 mg/m2 intravenously. What is the correct amount to be given? Record your answer using two decimal places.

2.05 "0.82 m2 × 2.5 mg/m2 = 2.05 mg"

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?

Inform the anesthesiologist. "The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The preanesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure."

A client experiencing neutropenia is in reverse isolation. When the client asks why the family has to wear a mask, which explanation is best?

It is to protect you from outside infections introduced by others. "Neutropenia is an abnormally low level of neutrophils making the client susceptible to infections. Care needs to be provided to limit exposure to infections by both healthcare workers and family who are visiting. While it is true that reverse precautions are a standard of care prescribed by health care providers, this does not fully answer the client's question. Stating the goal of protecting the client from outside infections from all who encounter the client is the best explanation."

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do?

Remove all metal objects on the day of the scan. "Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis."

Which instruction should a nurse include in an injury-prevention plan for a pregnant client?

Take rest periods during the day. "The client should be instructed to avoid becoming fatigued and to take rest periods during the day. Fatigue can lead to injuries. The nurse should instruct the client to wear a seat belt below the tummy, not across it, and to position the steering wheel toward her chest, not her abdomen, to prevent injury to the fetus. Learning a new activity or sport while pregnant can lead to injury."

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device. "Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use."

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

an isolation room three doors from the nurses' station "A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease. "

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client

onto the bedpan. "A client who's dizzy and anemic is at risk for injury because of their weakened state. Assisting the client with the bedpan would best meet their needs at this time without risking the client's safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up."

A nurse is performing a sterile dressing change. Which action contaminates the sterile field?

pouring solution onto a sterile field cloth "Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field."

When the client is involuntarily committed to a hospital because the client is assessed as being dangerous to himself or others, which client rights are lost?

the right to leave the hospital against medical advice "When a client is committed involuntarily, the right to leave against medical advice is forfeited. All the other rights are preserved unless there is further court action or a case of imminent danger to self or others (hitting staff, cutting self)."

When changing a sterile surgical dressing, a nurse first must

wash her hands. "To prevent the spread of microorganisms, the nurse should always wash her hands before providing client care. When changing a sterile surgical dressing, the nurse also must put on sterile gloves, remove the old dressing while wearing clean gloves, open sterile packages, and moisten the dressings with sterile saline. However, these actions follow hand washing."

A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?

Apply cool water to the burned area. "To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately."

The nurse is caring for an elderly patient who needs help with ADLs. Which of the following is most important for the nurse to understand to avoid injury when implementing care?

Bending and twisting while providing care may cause injury. "Bending and twisting during routine care, such as bathing, should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as possible during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back."

The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action?

Offer to show family members how to perform hand hygiene using soap and water or alcohol rub. "The nurse should address the family member's oversight and promote infection control, but in a way that is nonconfrontational. Offering to show the family members how to perform hand hygiene achieves these goals. Moving signage may not result in a behavior change. Speaking about hospital-acquired infections may not result in improved hand hygiene."

A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which infection control practice does the nurse consider most important for this client?

adhering diligently to aseptic technique "The client in this scenario is neutropenic, which places the client at risk for contracting an infection. All measures of aseptic technique must be used to protect the client. The other options do not provide complete protection for the client."

Which nursing intervention is most important in preventing septic shock?

maintaining asepsis of indwelling urinary catheters "Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention."

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

manual resuscitation bag "The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag."

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

measles "Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation."

Which action by the nursing assistant would require immediate intervention by the nurse?

restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room "The nurse supervising a nursing assistant will need to intervene when a nursing assistant restrains a client requiring one-on-one observation to leave the room. It should be reinforced with the nursing assistant to call for a replacement for the time needed to leave the client. Assisting a preschooler in a bathroom is appropriate for that age group. Transporting an infant in a bassinet is appropriate and within the scope of the nursing assistant's job. Removing the toddler from the mother's bed to the crib is appropriate. Cosleeping is dangerous for the child, and the mother should be educated on the risks."

A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

If I notice tingling in my lips or mouth, gargling may help the symptoms. "The client requires further teaching if they state they will gargle to help alleviate tingling in the lips or mouth. Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The physician may order an epinephrine pen for the client to self-administer epinephrine if they experience an allergic reaction away from the office setting."

The nurse meets with a client in the outpatient clinic who is suicidal and refuses participate in creating a suicide safety plan. What should the nurse do next?

Arrange for immediate hospitalization on a locked unit. "A suicide safety plan is a written set of instructions to follow if a client begins to have self-harm thoughts. Plans are written by the client and care team when the risk for suicide is not considered high enough to warrant hospitalization. The nurse should arrange for immediate hospitalization on a psychiatric intensive care unit when the suicidal client refuses to help develop a safety plan. A psychiatric intensive care unit or locked unit is the appropriate setting and least restrictive environment to provide safety for a high-risk client. When clients are treated in an outpatient area, procedures must be in place for swift admission to an inpatient area that has a locked unit. The group home, a partial program, or a subacute unit would not provide the maximum safety that the client needs."

A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?

washing the hands and wearing latex gloves "During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand washing alone would neither provide adequate protection nor comply with standard or routine precautions. The nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur during a postpartum assessment."

The nurse removed the client's name band because the client's arm was edematous. The client has an intravenous infusion in the other arm. What are the nurse's options for replacing the client's name band? Select all that apply.

- Apply the name band on the client's leg. - Apply the name band loosely on the client's arm with the intravenous infusion. "The nurse may apply the name band on the client's leg and apply the name band loosely to the arm with the intravenous infusion. The nurse should refrain from taping the name band on the client's bed so that the client is wearing the name band. The nurse does not want to occlude circulation by placing a larger name band on the edematous arm. The client needs to have a name band, and the nurse should not rely on the client to identify their name and date of birth without a name band."

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit. "The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary."

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask?

Are you going to hurt yourself? "The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to cope with the voices and to assess the client's impulse control. The nurse's assessment will then determine the course of action to take regarding the client's safety. Asking when the client hears the voices and how long the client has heard them is important but not as important as determining whether the client will act on what the voices are saying. Asking, "Why are the voices starting again?" would be inappropriate because the client may not know why and may not be able to answer the nurse."

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priory intervention?

Ask for additional information from the client. "The client experienced an event that needs follow up. The nurse should ask for additional information and from there determine what further action is needed. The nursing supervisor should be contacted after additional information is received. The hospital administrator does not need to be contacted."

The nurse is planning care for a client with severe postoperative pain. There is a prescription for morphine written as "10 mg MSO4" on the medical record. What should the nurse do first?

Contact the health care provider (HCP) who prescribed the medication. "The nurse should first contact the HCP because the prescription for the morphine is not complete. The Joint Commission of the United States and the Institute for Safe Medication Practices Canada recommend not to use MSO4 because it can apply to morphine as well as to magnesium sulfate. There is no mention of an IV system being needed. The morphine should not be in the medication cabinet because the prescription is not complete. Although pharmacy may offer a suggestion as to what the medication prescribed is, the best means to confirm the intent of the prescription is to contact the HCP who wrote the prescription."

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take?

Contact the previous nurse requesting that the nurse correct the error. "The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records."

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Increase the frequency of client observation. "The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem."

A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse in the operating room do?

Initiate a time-out. "The Universal Protocol is used to prevent wrong site, wrong procedure, and wrong person surgery. Actions included in the protocol are as follows: conduct a preprocedure verification process, mark the procedure site, and perform a time out. Exceptions to the Universal Protocol are routine or "minor" procedures, such as venipuncture, peripheral IV line placement, insertion of oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the surgeon or circulating nurse will initiate a time out to verbally confirm a review of informed consent and procedures completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies have been removed. The Chief of Surgery and Medical Director are the ones who will verify the surgeons' levels of expertise."

A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority?

Instruct the client to remain in bed. "The priority intervention is to have the client remain in bed to prevent falls. The other options are correct; however, client safety is the priority."

A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

Offer a face mask to the person with the cold and use this as an opportunity for further teaching. "Offering a face mask is the best approach; it protects the child while supporting the family and using the situation as an opportunity for learning. Instructing family members that it isn't healthful to share food and to avoid the child if they're sick are technically correct, but these responses don't include a rationale that enables the family to understand why these actions are important. The nurse should have posted an isolation sign on the child's door long before the time of the child's discharge."

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond?

Please press the call button. I'll disconnect you from the monitor so you can get out of bed. "The nurse should instruct the client to use the call button when she needs to use the bathroom. The nurse will need to disconnect the fetal monitor and mark the strip to indicate the activity. If the client's partner disconnects and reconnects the monitor, the nurse can't determine if the readings are accurate. Inserting a catheter without a physician's order or not allowing the client to get out of bed isn't acceptable nursing practice."

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first?

Remove the client from the room. "The acronym RACE promotes the safest sequence of response to fire. The letters stand for Remove the client from the scene, Activate the alarm, Contain the fire, and Extinguish the blaze."

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action?

Report the error, complete the proper paperwork, and meet with the unit manager. "Making an error can be very stressful and a nurse may feel great pressure to hide the mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, the nurse must still report the error and complete the proper paperwork. The nurse should contact the physician and follow their instructions, but shouldn't bypass proper protocol."

A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception?

Tattoos are easily removed with laser surgery. "A common misconception regarding tattoos is that tattoos can be removed. Removing a tattoo is not an easy process, and most people are left with a significant scar. Also, the procedure is expensive and not covered by insurance. Because of the moderate amount of bleeding with a tattoo, both hepatitis B and HIV are potential risks if proper techniques are not followed. Allergic reactions are possible when establishments do not use Food and Drug Administration-approved pigments for tattoo coloring. Reactions can also occur in clients who are hypersensitive to the pigments or tools used."

A 10-month-old infant is admitted with a harsh, barking cough and respiratory stridor. What are the most appropriate precautions for the nurse to follow when caring for the child?

Use an isolation gown and gloves in the room. "According to the Centers for Disease Control and Prevention and the Public Health Agency of Canada, croup in infants requires contact isolation."

A client with severe shortness of breath comes to the emergency department. The client tells the emergency department staff that they recently traveled to China for business. Based on the client's travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

airborne and contact precautions "SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles."

A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute?

airborne precautions "Transmission of SARS can be contained by airborne precautions that include an insolation room with negative pressure, use of N-95 respirator, and use of personal protective equipment. The disease is spread by the respiratory, not enteric, route. Hand washing alone is not sufficient to prevent transmission. Reverse isolation (protection of the client) is not sufficient to prevent transmission."

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact "A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces"

Which nursing intervention is appropriate for a client with an arm restraint?

monitoring circulatory status every 2 hours "A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint."

The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique?

nasogastric (NG) tube placement "The GI system isn't a sterile system; therefore, NG tube placement doesn't require sterile technique. I.V. insertion requires sterile technique because intentional penetration of the skin occurs. The urinary system is sterile, so the nurse must maintain sterility during catheter placement. Burns have a high risk for infection; the nurse must maintain sterile technique to decrease this risk."

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:

review the unit's procedure manual. "A nurse should always refer to a policy and procedure manual for instructions on correctly performing a procedure. Asking another new nurse for assistance or attempting to perform an unfamiliar procedure without the necessary information makes the new nurse liable for errors that occur. A nurse who tells a client that she isn't experienced decreases that client's confidence in the nurse's credibility."

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

- Ease the client to the floor. - Maintain a patent airway. - Obtain vital signs. - Record the seizure activity observed. "To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded."

A nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What should the nurse do next?

Assess the client and notify the client's physician. "This is a medication error. The priority is to assess the client and then call the physician to advise them of the error and seek further direction. The other options do not describe the steps the nurse should take to ensure client safety following a medication error. They also include decisions and judgments outside the nurse's scope of practice."

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

Assume a reclining or flat position. "The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall."

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment?

Known allergies "Since cardiac catheterization involves the injection of a radiopaque dye. It is most important for the nurse to determine if this client has allergies to iodine or shellfish. The other three parameters are also part of the assessment, but are not the priority."

A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection?

practicing thorough hand washing "Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room."

A client is scheduled for a renal arteriogram. No allergies are recorded in the client's medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used?

pruritus "The nurse should be alert for pruritus, which may indicate a mild anaphylactic reaction to the arteriogram dye. The client would have an increased respiratory rate. Nausea would be more likely with a food allergy or intolerance and would not be associated with a reaction to the dye. Psoriasis is a chronic condition triggered by a hyperimmune response."

A wife brings her husband to the emergency department with a bleeding gunshot wound to the leg. The wife tells the nurse that her husband was trying to commit suicide. In what order should the nurse perform the actions from first to last? All options must be used.

- Assess the gunshot wound. - Remove potentially harmful objects from the area. - Ensure constant observation. - Assess current suicide risk. "The nurse first assesses and treats the bleeding gunshot wound. Next, the nurse removes any objects the client could use to harm himself, and ensures that the client will have constant observation. The nurse then assesses the client's immediate risk for suicide, and bases subsequent decisions on the level of risk. Once the client is safe and the wound is treated, the nurse contacts the crisis intervention team."

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities. "The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities."

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next?

Notify the physician and security immediately. "The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security because they're specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen, and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana."

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism?

Wear a face mask when in close contact with the client. "RSV infection necessitates droplet precautions, including the use of a facemask. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection."

A client who has recently had a fractured hip repaired must be transferred from the bed to a wheelchair. Which of the following should the nurse consider while assisting the client?

The appropriate proximity and visual relationship of the wheelchair to the bed must be maintained. "The wheelchair should be angled close to the bed so the client can pivot on the stronger leg. When the wheelchair is within the client's visual field, the client will be aware of the distance and direction the body must navigate to transfer safely and avoid falling. During a transfer, the knees need to be extended to support the weight, the bed needs to be in low position, and pivoting needs to be accomplished on the unaffected leg."

A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority?

Use an organized, efficient team approach to apply and secure the restraints. "Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots."

The nurse notices that a nurse colleague is wearing a lower lip ring. The nurse should:

request that the nurse remove the ring. "Professionalism in nursing is demonstrated by a nurse's appearance and ownership of actions; appearance is one means of contributing to a positive experience in a health care setting. The nurse should discuss the situation with the colleague first. To go to the manager's office or to direct the colleague to go to the Office of Infection Control will not promptly correct the professional dress code violation. Paging the nursing supervisor does not follow the line of command for reporting problems. Nurses must support professionalism; dress is an aspect of professionalism."

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is best associated with restraint use in the client who requires BiPAP?

The client will maintain adequate oxygenation. "BiPAP is a type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric pressure. This type of ventilatory support assists clients with COPD who retain PaCO2. Restraints are necessary in this client to maintain BiPAP therapy if the client attempts to dislodge the mask despite instruction not to do so. Maintaining oxygenation is the expected outcome in this client. Remaining safe, understanding the rationale for restraints, and collaborating with the health care team to begin discharge planning are important, but not the best outcome with relation to BiPAP."

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). What should the nurse do first?

Verify the prescription to use the restraint. "Before using any restraints, the nurse must verify that a health care provider (HCP) has written a prescription for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmar surface of the hand."

The nurse is caring for a neonate diagnosed with early onset sepsis and is being treated with intravenous antibiotics. Which instructions will the nurse include in the parents' teaching plan?

Wash hands thoroughly before touching the neonate. "The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. It is not necessary for parents to wear protective gear near the isolation incubator. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate's psychological development. Normally, the neonate does not need to be isolated. The baby will not spread sepsis via respiratory droplets to parents, so it is not necessary for the parents to wear a mask."

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.

-Assess the client's current condition and vital signs. -If no acute injury, get help, and carefully assist the client back to bed. -Notify the client's health care provider (HCP) and family. -Document as required by the facility. "The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the client who fell and, finally, document the event on the client's health record."

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist restraints. In carrying out this order, which nursing actions would be appropriate? Select all that apply.

-Perform a face-to-face behavior evaluation every hour. -Tie the restraints in quick-release knots. -Document the client's condition. -Document alternative methods used before the restraints were applied. -Document the client's response to the intervention. "Preventing a client from a fall or harm is of utmost importance. Applying restraints is a last resort when all other alternative interventions have been attempted. A face-to-face evaluation must be performed every hour. Restraints are tied in knots that can be released quickly and easily. The nurse would document the client's condition, any alternative methods used before the restraints were applied, and the client's response to the interventions. Restraints would never be secured to side rails because doing so can cause injury if the side rail is lowered without untying the restraint."

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate?

A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. "A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. Hormonal contraceptives, implants, and injections offer no protection against HIV transmission. Safe sex practices include hugging, petting, mutual masturbation, and protected sexual intercourse. Abstinence is the most effective way to prevent transmission."

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order. "After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence."

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?

whether the client needs to navigate stairs routinely at home "Knowing whether the client must routinely navigate steps at home is most important. If the client must navigate steps, special crutch-walking techniques must be taught to safely navigate the stairs. Although pets, parking on the street, and driving a car with a stick shift can pose problems for the client, these factors aren't important to know before discharging the client with crutches."

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply.

- The spouse places soiled dressing supplies in the kitchen garbage can. - Sheets with wound drainage are washed in lukewarm water. "Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing dressing care."

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?

Perform thorough hand washing before and after touching any child in the day care center. "Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection."

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L (2.5 mmol/L), serum sodium level 140 mEq/L 140 mmol/L), and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, the client's total urine output has been 50 ml. Which physician order should the nurse question?

Change the second I.V. solution to dextrose 5% in water. "The nurse should question the physician's order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. site until the client's blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and their specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias."

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment. "It is helpful for the nurse to review the documented drug allergy listing and to use this as a basis for an assessment and discussion with the client. Drugs identified as contributing to an allergic reaction must be recognized and avoided as a serious risk to the client. It is poor practice not to pursue an allergy assessment simply because a client initially reports not being sure exactly what allergies are present; the client may respond well to prompting and an engaged interview. The goal of the nurse is to reach the most complete history and assessment possible with the client. Allergies can occur at any point in treatment, so the most recent allergies do not hold increased importance."

The nurse may apply the name band on the client's leg and apply the name band loosely to the arm with the intravenous infusion. The nurse should refrain from taping the name band on the client's bed so that the client is wearing the name band. The nurse does not want to occlude circulation by placing a larger name band on the edematous arm. The client needs to have a name band, and the nurse should not rely on the client to identify their name and date of birth without a name band.

- Confirm identification with the client using two identifiers. - Obtain a new identification name band. - Ask the previous nurse to verify client identification. "The nurse will need to confirm identification with the client using two identifiers, obtain a new identification name band, and ask the previous nurse to verify client identification. Investigating why the client's name band is missing and using the medical record is not sufficient for client identification and does not fix the issue of the missing name band."

A nurse who is 6 months pregnant is assigned to a client with a diagnosis of HIV. The nurse tells the manager that she is unable to care for the client because it would be a risk to her baby. Which of the following is the most appropriate statement by the manager?

You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care. "By following standard precautions and using personal protective equipment when exposed to or handling blood or body fluids there should be no risk of exposure. The other options are either ineffective or not necessary when caring for a client who is HIV positive."

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

droplet precautions "Meningococcal infections are spread through close mucous membrane or respiratory contact with large respiratory droplets. Meningococcal infections are not spread by small airborne organisms or contact with a person's skin or contaminated items. Standard precautions, used when touching body fluids, are not sufficient to prevent the spread of meningitis."

A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error. "Although no harm came to the child, this scenario is an example of a medication error. The nurse should follow the facility's procedure for reporting the error because it allows the facility to adequately assess the causes of medication errors, and isn't meant to place blame on any one person. The nurse in this instance doesn't need to notify the physician because there was no harm to the child. Also, the nurse shouldn't document that an error took place in the child's chart; doing so may place her at risk in the event of a lawsuit."