Capstone Safety and Infection Control

Select the appropriate personal protective equipment (PPE) that will be applied prior to entering the room of a patient with influenza. A. gloves B. mask C. gown D. goggles E. respirator

A, B, C Influenza is a virus that requires droplet precautions. The PPE used in droplet precautions includes donning gloves, mask, and gown. Respirators are used with airborne precautions such as tuberculosis and varicella. Goggles are used in the event of concern for splashes of bodily fluids or chemicals and not necessary for droplet precautions.

A gunshot wound victim has been brought to your unit. He has chosen to be marked as confidential due to safety concerns. Which of the following interventions should the nurse implement to ensure this client's confidentiality during his hospital admission? Select all that apply. A. Keep the client's name/information out of public areas such as the nurses' station. B. Tell the client's mother he is okay when she calls to ask about him being on the unit. C. Ensure that the client's chart has a facility-assigned security passcode that must be announced by anyone calling for information regarding the patient. D. Remove the patient from confidential status when he asks to be removed. E. Deny that the patient is on the unit when visitors come or call.

A, C, D, E Some clients will need to be placed on a confidential status either by personal request or situational events (e.g., abuse). Nurses must ensure that the client's identity and facility admission remain confidential as long as indicated. Information should never be shared with individuals other than the client unless specifically approved by the client and given the appropriate security passcode.

Which of the following scenarios show(s) appropriate practice of aseptic technique? Select all that apply. A. Do not touch the sterile field unless only touching 1 inch or less of the edges. B. Apply sterile gloves by touching the inside only when applying both gloves. C. If anything on the sterile field is contaminated, dispose of everything and start over. D. Leave the room with the sterile field once organized to ensure sterility. E. Open sterile supplies or instruments away from your body to make sure contamination does not occur.

A, C, E Nurses should not touch the sterile field except the outer 1-inch edges of that field while considered unsterile, should throw away everything on a contaminated sterile field, and open sterile supplies and/or instruments away from their bodies. This ensures that the components of the sterile field remain sterile. Nurses should never leave the sterile field unattended, as this automatically deems the field contaminated. Sterile gloves should be applied by only touching the inside of the first glove to don the glove, followed by using the newly sterile gloved hand to only touch the outside of the second glove to apply.

A nurse is preparing to enter the room of a client needing extensive personal protective equipment (PPE). In which order should the nurse don the following items? Use the letters associated with the answers when ordering your response. A. gown B. goggles C. gloves D. mask

A, D, B, C

A 45-year-old client presents to the ED following a grand mal seizure. In the triage report, the nurse learns that the client has epilepsy causing frequent seizures. Which precautions should the nurse implement? Select all that apply. A. Pad bed side rails. B. Place pillow under all extremities. C. Elevate the bed to the high position. D. Ensure oxygen access. E. Place suction machine in the room. F. Insert bite block in client's mouth.

A, D, E Seizure precautions include padding bed side rails, having access to oxygen and suction, placing a pillow under the head, lowering the bed to the lowest position, and removing objects from the client or bed that may cause injury. Bite blocks should not be placed in the client's mouth.

New parents ask their newborn's neonatal nurse about safety tips for their home with their new baby. Which statement by the nurse is most appropriate? A. "Keep all stuffed animals, pillows, blankets, bumpers, etc. out of the crib." B. "Mattresses should be tight-fitting and crib bars should have at least 3 inches of space between each bar." C. "Have a blanket and a bumper in the crib for warmth and injury prevention." D. "Do not smoke in the baby's room. Other rooms are okay as long as the baby isn't in them."

A. "Keep all stuffed animals, pillows, blankets, bumpers, etc. out of the crib." These items increase the risk of SIDS occurrence due to the potential of suffocation on one of these objects in the crib, especially while the baby is not proficient with moving/rolling. Spacing between crib slats should be minimal—no more than 2 3/8 inches (6 cm). No smoking is safe around babies.

A nurse is discussing medication safety with a toddler client's parent. Which statement made by the parent would be a cause for concern? A. "To get her to take her medicine, we just tell her it's like candy." B. "We store all of our medicine on a really high shelf that even I need a step stool to reach." C. "I always check to make sure the safety cap 'clicks' when I close it." D. "We store our medicines and vitamins together."

A. "To get her to take her medicine, we just tell her it's like candy." Children should never be told that medicine is candy. It is a good practice to make sure safety caps are properly screwed on, although they can sometimes be opened by children. Therefore, medication (including vitamins) should always be stored in an out-of-sight, unreachable area, and preferably in a locked container. There is nothing wrong with storing vitamins and medicines together as long as they are both kept out of reach from children.

A night shift nurse has a client who is confused and withdrawing from alcohol. He is currently in 4 point restraints after attempting to attack one of the nurses. What is the most appropriate action for the nurse to take during his shift? A. Assess the patient's skin integrity around the restraints hourly. B. Ensure the physician has renewed the order for restraints, as this should be done every 12 hours. C. Release the leg restraints to give the client a break and see if combative behavior has gotten better. D. Have the attending physician discontinue the restraints to give the client a chance to behave more appropriately.

A. Assess the patient's skin integrity around the restraints hourly. Combative patients should be assessed hourly, non combative every 2 hours to ensure no skin breakdown around the restraints has occurred. None of the other answer choices are your responsibility.

Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism? A. Bathing together. B. Coughing on each other. C. Sharing pacifiers. D. Eating off the same plate.

A. Bathing together. Direct contact is the mode of transmission for staphylococcus. Staph is not spread by coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not spread through oral secretions.

Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is: A. Correct illumination of the environment. B. amount of regular exercise. C. the resting pulse rate. D. status of salt intake.

A. Correct illumination of the environment. To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate. The amount of regular exercise is not the most important factor to assess. It is only indirectly related. The resting pulse rate is not related to preventing falls. The salt intake is not directly related to preventing falls.

While reviewing orders for a client recovering from a stroke, the nurse notices a new order to ambulate the patient every hour. When the nurse tells the client about this new order, the client states that they feel dizzy and weak. Which of the following actions is most appropriate? A. Discuss the order with the ordering physician. B. Ask the client if they would feel more comfortable if a gait belt was used while ambulating. C. Insist that the client complies with the new order. D. Ensure the client is wearing non-skid footwear.

A. Discuss the order with the ordering physician. For this client, the new order to ambulate hourly does not seem appropriate. The nurse should discuss with the ordering physician as the order may be placed for the wrong client or the client's condition may have changed since the order was written and require follow-up.

The nurse is finishing the admission of a client with a cognitive impairment to the unit. When explaining the call bell to the client, the client does not respond. Which of the following is most appropriate? A. Explain to the client that, in addition to the call bell, they can yell out for help or assistance when needed. B. Turn the lights down to promote rest and relaxation. C. Leave the call bell in the client's hand with the thumb over the button to activate the call bell. D. Ask to move the client to a room at the end of the hallway so that they have an alert roommate that can report any issues with their call bell.

A. Explain to the client that, in addition to the call bell, they can yell out for help or assistance when needed. The client should be provided with a method to alert staff members for help, and if the client is unable to confirm they understand the use of the call bell, the method may need to be modified to include verbally calling out for help.

A nurse is caring for an elderly client and realizes she made an error by administering an antibiotic at the drip rate ordered for normal saline. What is the most appropriate action? A. File an incident report giving objective data about what happened. B. Do nothing. There are no serious risks or side effects to this type of medication error. C. Tell the client that a medication error occurred and about the potential side effects. D. Tell the charge nurse the medication error occurred and that it was due to the previous nurse mislabeling the IV tubing from the antibiotic and normal saline bags.

A. File an incident report giving objective data about what happened. Incident reports are meant to help healthcare team members by identifying all the factors surrounding an error and how to prevent it from occurring again.

The nurse discovers an unconscious 8-year-old in the bathroom. She does a quick assessment and discovers he is not breathing and does not have a pulse. The LPN is alone and does not have quick access to a call button. What should she do first? A. Give 2 minutes of CPR at a compression-ventilation ratio of 15:2. Then, look for help and an AED, and return and resume CPR. B. Look for help and an AED, then give 1 minute of CPR at a compression-ventilation ratio of 15:2. C. Give 2 minutes of CPR at a compression-ventilation ratio of 30:2. Then, look for help and an AED, and return and resume CPR. D. Look for help and an AED, then give 2 minutes of CPR at a compression-ventilation ratio of 30:2.

A. Give 2 minutes of CPR at a compression-ventilation ratio of 15:2. Then, look for help and an AED, and return and resume CPR. Current American Heart Association (AHA) Guidelines recommend that if you find an unconscious infant or child (to puberty) and are alone, you should give 2 minutes of CPR at a compression-ventilation ratio of 30:2, then look for help and AED. A compression-ventilation ratio of 15:2 is used in 2-person CPR.

Which of the following is the FIRST priority in preventing infections when providing care for a client? A. Handwashing B. Wearing gloves C. Using a barrier between client's furniture and nurse's bag D. Wearing gowns and goggles

A. Handwashing Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.

A nurse working an overnight hospital shift is administering medications to her patients. Which of these is the most important thing to do prior to giving medications to her patients? A. Identify the patient by name and date of birth on the patient's wristband and match it to the medication order. B. Identify the patient by name and room number and match the information on the medication order. C. Match the room and bed number to the room and bed number on the medication order. D. Ask the patient his or her name and match it to the one on the medication order.

A. Identify the patient by name and date of birth on the patient's wristband and match it to the medication order. Medication errors are one of the primary areas of medical mistakes. Always identify the patient, preferably using two identifiers, to ensure the right medication is being administered to the right patient. Room and bed numbers are not reliable identifiers and should not be used to identify patients. Always follow the protocols and procedures of your facility for administering medications.

Which of the following statements is incorrect about roles in a fire emergency? A. Media and traffic control should only be handled by the unit's primary physician. B. You may be asked to contribute to the selection of clients to recommend for discharge in order to make beds available to additional clients needing treatment from the fire. C. Your scope of practice may have extended responsibilities depending on your state's policy. D. Specialty physicians can work as generalists in an effort to treat the most clients as quickly as possible.

A. Media and traffic control should only be handled by the unit's primary physician. The media and traffic control should be handled by a designated team member, but it does not necessarily need to be a physician.

The nurse is caring for a client who has had his left arm amputated above the elbow and currently has a limb alert bracelet on the right arm due to phlebitis in the lower arm. Which of the following actions would not require intervention? A. The nurse observes a nursing student use a pulse oximetry probe on the right index finger. B. The nurse observes a phlebotomist preparing to draw blood from the right hand. C. The nurse observes a nursing student place a blood pressure cuff on the right upper arm. D. The nurse observes a phlebotomist preparing to draw blood from the right antecubital fossa.

A. The nurse observes a nursing student use a pulse oximetry probe on the right index finger. The limb alert bracelet means there should be no blood drawn, IV started, or blood pressure cuff used on that arm. It does not prohibit the use of the pulse oximeter probe on the finger.

A patient is scheduled for a cardiac catheterization this afternoon. Which of the following, if noted in the patient's chart by the nurse, is a contraindication to the test? A. The patient is allergic to clams. B. The patient is unable to lie on her right side for more than 15 minutes. C. The patient is allergic to eggs. D. The patient has a history of asthma.

A. The patient is allergic to clams. Cardiac catheterizations require dye, which is made of iodine. Iodine's cross-allergy is shellfish!

When caring for a client with known IV drug use, which statement should the nurse discuss to highlight the risk factors of this behavior? A. The risk of contracting and/or spreading blood borne pathogens such as HIV, which can progress to AIDS, is a huge risk factor with this activity. B. Drug use can lead to unsafe sex practices, increasing the risk of the transmission of sexually transmitted diseases. C. The use of these drugs can increase the risk of contracting diseases due to immunosuppression. D.IV drug use can lead to skin infections at the injection sites and poor health.

A. The risk of contracting and/or spreading blood borne pathogens such as HIV, which can progress to AIDS, is a huge risk factor with this activity. HIV is a blood borne pathogen and sharing needles with IV drug abusers exponentially increases the risk of contracting this disease.

The nurse enters her first client's room to administer morning medications. What is the first thing she should do? A. Verify the client's full name and date of birth. B. See if the client has had breakfast. C. Ask the client to verify his or her medication allergies. D. Review medications and potential side effects.

A. Verify the client's full name and date of birth. Identifying the correct client before action decreases error and is the safest way to administer care.

Which of the following statements is not true about isolation precautions? A. When caring for a client on airborne precautions, goggles or a face shield are required at all times. B. Alcohol-based hand sanitizer should not be used when performing hand hygiene after caring for a patient with C. diff. C. It is okay to leave the door to the patient's room open if they are on droplet precautions. D. Two patients on contact precautions related to the same disease can be placed in the same room.

A. When caring for a client on airborne precautions, goggles or a face shield are required at all times. When caring for a patient on airborne precautions, an N95 mask should be worn at all times; goggles or a face shield should be worn when there is the potential to be exposed to bodily fluids but is not required at all times.

A nurse working in a hospital setting is checking on her patients and notes that one of them has slid down in the bed. The patient states that he is uncomfortable, but that he is unable to reposition himself on his own. The nurse knows that in order to help him and avoid injury to herself, she needs to ____. A. ask the patient to wait a moment while she finds another nurse to assist her in repositioning him B. have him bend his knees and push himself up while she pulls him into the correct position C. stand behind him and lift him primarily using her legs D. bend from her waist and move him up as quickly as possible

A. ask the patient to wait a moment while she finds another nurse to assist her in repositioning him Explanation: The nurse must have assistance from another person in order to correctly reposition the patient and avoid injury to herself. While this takes more time and means the patient will have to wait to be moved, it is the best and safest option for both the nurse and patient.

For which of the following conditions are droplet isolation precautions appropriate? A. parvovirus B. conjunctivitis C. tuberculosis D. rotavirus

A. parvovirus Parvovirus requires droplet precautions; tuberculosis requires airborne precautions; conjunctivitis requires contact precautions; and rotavirus requires contact and enteric precautions.

The nurse is admitting a 70-year-old patient for a procedure. The patient has type I diabetes mellitus with significant peripheral neuropathy, atrial fibrillation controlled with antiarrhythmic medications, and osteoarthritis bilaterally in his knees. He is also on anticoagulants with an INR of 3.0. Given that the nurse knows about the individual risk factors that raise the risk of a fall, accident, or injury while hospitalized, which of the following should be identified as the most significant risk factor for this patient? A. peripheral neuropathy B. atrial fibrillation C. bilateral knee osteoarthritis D. anticoagulant therapy

A. peripheral neuropathy Sensory deficits such as sight, hearing, proprioception, and neuropathy can all raise the risk of a fall, accident, or injury in a hospitalized patient. These factors should be noted at the time of admission and factored into the care plan to protect the patient during his or her time under medical care. Osteoarthritis may limit the patient's mobility. This should be discussed upon admission. Atrial fibrillation that is not controlled can increase the risk of stroke, but this patient is controlled with antiarrhythmic medications. Anticoagulant therapy doesn't raise the risk of a fall, accident, or injury, but it is an important part of the medical history, given that the patient is being admitted for a procedure.

Which of these client room assignments would the nurse question? A. placement of an 89-year-old client with acute delirium at the end of the hallway B. placement of a 34-year-old client with mild head trauma after MVA with a 48-year-old client with arm fracture C. placement of a 75-year-old client with C. difficile with a 23-year-old client with C. difficile D. placement of a 58-year-old client with HIV and bronchitis in a single room

A. placement of an 89-year-old client with acute delirium at the end of the hallway Clients with delirium and at high risk for safety-related events should be roomed near the nurse's station to maintain close monitoring. The assignments of the other clients are appropriate.

Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client: A. verbalizes the role of sexual activity in spread of the disorder. B. states he will make arrangements to drop his college classes. C. acknowledges the need to avoid all contact sports. D. says he will avoid close contact with his three-year-old niece.

A. verbalizes the role of sexual activity in spread of the disorder. The AIDS virus is spread through direct contact with body fluids such as blood and through sexual intercourse. Casual contact with other people does not pose a risk of transmission of AIDS. Unless the client is feeling very ill, there is no need for him to drop his college classes. Contact sports are not contraindicated unless there is a significant chance of bleeding and direct contact with others. Casual contact with other people does not pose a risk of transmission of AIDS. There is no need to limit casual contact with children.

Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure? A. She says to her husband, "Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food." B. "I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital." C. "I understand it will be several weeks before all the radiation leaves my body." D. "I brought several craft projects to do while the radium is inserted."

B. "I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital." The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours after insertion), the client is no longer contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place.

A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement? A. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water." B. "If any healed areas break open I should first cover them with a sterile dressing and then report it." C. "I must wear my Jobst elastic garment all day and can only remove it when I'm going to bed." D. "I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours."

B. "If any healed areas break open I should first cover them with a sterile dressing and then report it." Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage must be reported immediately.

Which of the following statements indicates the client understands proper use of car seat restraints? A. "Now that my daughter is two years old, we need to switch from the reclined car seat to an upright car seat." B. "My three-year-old son still fits comfortably in the rear-facing car seat, so we continue to use it." C. "While using the booster seat, the seatbelt is directly over my daughter's abdomen." D. "When driving by myself, I put the infant car seat in the passenger seat so that I can see my son at all times."

B. "My three-year-old son still fits comfortably in the rear-facing car seat, so we continue to use it." The rear-facing, reclining car seat should continue to be used even after two years of age as long as the child has not outgrown the restraints.

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? A. A diagnosis of AIDS and cytomegalovirus B. A positive PPD with an abnormal chest x-ray C. A tentative diagnosis of viral pneumonia D. Advanced carcinoma of the lung

B. A positive PPD with an abnormal chest x-ray The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.

The LPN is helping a client get out of bed to use the restroom. Which of these actions represents proper ergonomic practice? A. Let the client use your body to pull up in a sitting, then standing, position. B. Aid the client in sitting/standing by lifting with the legs and keeping the back straight. C. Bend over the client to get a good grip when sitting the patient up. D. Lift the client into a standing position by using your leg and back muscles.

B. Aid the client in sitting/standing by lifting with the legs and keeping the back straight. Lifting with the legs prevents back injury.

A nurse is preparing a bag of chemotherapy agent for one of the patients. The nurse accidentally pierces a hole through the bag while attempting to spike it. A moderate amount of chemotherapy spills onto the ground. Which of the following actions should the nurse perform first? A. Continue to prime chemotherapy tubing. B. Cordon off the area and notify housekeeping/facilities of the spill. C. Clean up the spill with wet paper towels. D. Call the pharmacy to have the chemotherapy redosed.

B. Cordon off the area and notify housekeeping/facilities of the spill. Chemotherapy is extremely caustic to any persons and environment it contacts. When chemotherapy spills occur, the nurse must immediately secure the area and notify the facility's designated personnel to have the area appropriately cleaned. The chemotherapy should never be cleaned with inappropriate tools such as paper towels or linens. Since the bag has been compromised, the nurse should no longer prime the tubing or administer the chemotherapy to the patient. The nurse will need to notify the pharmacy to have the chemotherapy redosed, but this is not the priority action.

An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible? A. Hands. B. Droplet nuclei. C. Milk products. D. Eating utensils.

B. Droplet nuclei. Hands are the primary method of transmission of the common cold. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils.

A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? A. Masks should be worn with all client contact. B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. C. Isolation gowns are not needed. D. A private room is always indicated.

B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client's hygiene is poor.

Two days after a coronary artery bypass graft (CABG), a patient is sitting up in a chair by the side of the bed. The nurse walks in and discovers the patient is cold, pale, and responds only to tactile stimulation. Which of the following actions does the nurse take NEXT? A. Take the client's vital signs. B. Help the client back to bed. C. Administer oxygen 2L by nasal cannula. D. Review charts to see if anything like this has ever happened before.

B. Help the client back to bed. Safety first before the patient falls! Then oxygen.

Which statement would be the most accurate in safety education for injury prevention in the home of elderly adults? A. Use the handrail when going up and down the stairs, ensure robes or pants are held up if flowy, and wear comfortable, non-skid footwear. B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable, non-skid footwear. C. Use solid chairs without armrests, remove anything in walkways, and use cordless phones. D. Have raised toilet seats, ensure all throw rugs have gripping material on the floor side, and use grab bars in the shower/bathroom.

B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable, non-skid footwear. Throw rugs, furniture in walkways, and slippery footwear are all fall risks for clients.

The nurse is caring for a client after an ECT treatment. The nurse is MOST concerned if which of the following is observed? A. The client is unable to remember what she ate for breakfast. B. The client complains of backache. C. The client is unable to recall her name. D. The client complains of headache.

B. The client complains of backache.

A nurse inadvertently administers the wrong dose of antibiotic to a patient recovering from surgery. Which of these is the correct course of action for the nurse when documenting this in the patient's medical record? A. The nurse should create an incident report and include a copy of the report in the patient's medical record. B. The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence. C. The nurse should tell the patient of the incident and ask his or her preference on if an incident report should be created and if one is, it should be included in the patient's medical record. D. The nurse should just document the dosage given in the patient's chart. An incident report is not necessary because it was simply the wrong dosage of a drug that was ordered.

B. The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence. A nurse who administers the wrong dosage of an ordered drug must create an incident report. Each employment facility will have specific guidelines to follow in doing so. Generally, the facts of the incident should be recorded in the patient's medical record, but an actual copy of the incident report does not have to go into the record and reference as to its existence does not have to be in the record either.

A nurse is working with a patient who has a contagious condition. In recalling the chain of infection, the nurse knows that an environment favorable for the growth and reproduction of an infectious agent is referred to as ____. A. a vector B. a reservoir C. a susceptible host D. a portal of entry

B. a reservoir The chain of infection has six elements: - a pathogen which is an infectious agent - a reservoir which is any environment that is favorable for the growth and reproduction of an infectious agent - a portal of exit which is a place where an infectious agent gets out of a host - a method of transmission which is the way an infectious organism is transferred from a reservoir to a host - a portal of entry which is the place where an infectious agent enters a host - a susceptible host which is a person who is at risk for infection A vector is an object which can spread an infection via indirect contact. It is one of the three possible methods of transmission.

The most effective way to perform hand hygiene is ____. A. washing hands after gloves are removed post patient care B. either washing your hands for 30 seconds in warm, soapy water or using hand sanitizer if hands are not visibly soiled C. holding hands down after washing to prevent water from rolling down your arm while drying D. using hand sanitizer and rubbing hands together for 30 seconds

B. either washing your hands for 30 seconds in warm, soapy water or using hand sanitizer if hands are not visibly soiled

A patient with a suspected renal tumor is being admitted for an intravenous pyelogram (IVP). The nurse discusses the procedure with the patient in addition to taking a full medical history. Which of these pieces of information reported in the patient's history should the nurse report to the physician performing the IVP? A. penicillin allergy B. iodine allergy C. past history of kidney stones D. past history of appendectomy

B. iodine allergy The nurse is responsible for identifying factors in the patient's medical history that may be contraindicated for the procedure or treatment that is ordered for the patient. Since an IVP involves the use of iodinated contrast dye, the patient's iodine allergy must be reported to the physician to prevent an allergic reaction. The rest of the patient's medical history is acceptable and reveals no contraindications to the procedure.

Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis? A. "If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled." B. "If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline." C. "If I question the sterility of any dressing material, I should not use it." D. "I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s."

C. "If I question the sterility of any dressing material, I should not use it." Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. The 4 X 4s should be soaked prior to donning the sterile gloves. Once the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a need for further instruction.

The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? A. The nurse aide is not wearing gloves when feeding an elderly client. B. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing. C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. D. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.

C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask, gown, and gloves.

The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions? A. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood. B. An aide wears gloves to feed a helpless client. C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. D. A pregnant worker refuses to care for a client known to have AIDS.

C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an instrument such as a hemostat should be used to recap. The hand should never be used. Gloves are not necessary when feeding, since there is no contact with mucus membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin. Masks and protective eye wear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions.

A nurse is preparing to transfer a 32-year-old client with spastic quadriplegia from the client's bed to her wheelchair. Which of the following actions should the nurse take during the transfer? A. Sit the client up and gently twist while lifting the client from the bed to her chair. B. Face the client, plant feet shoulder-width apart, and bend down to lift the client. C. Assist the client from a lying to sitting position, lift the client and pivot to the chair. D. Cradle the client under her legs and arms and lift her into the chair.

C. Assist the client from a lying to sitting position, lift the client and pivot to the chair. Ergonomic principles should be practiced when repositioning and lifting clients. These principles include remaining close to the client, lifting with leg muscles instead of back muscles, pivoting rather than twisting, and maintaining a wide support base.

A physician orders the administration of ibuprofen, but the nurse notices the client is allergic to NSAIDs. What should the nurse do? A. Ask the client if he or she feels comfortable taking the medication. B. Contact the healthcare provider to verify the order and discuss concerns. C. Administer the medication per the healthcare provider's order. D. Find out how serious the client's reaction is to NSAID exposure.

C. Contact the healthcare provider to verify the order and discuss concerns. Verifying orders that do not seem appropriate for your client is a safety procedure and a form of advocating for your client's safe healthcare.

A nurse is caring for a patient receiving intravenous drug therapy via an infusion pump. The pump continues to sound an alarm and the nurse is unsure if it is administering the drug correctly. Which of these is the correct course of action for the nurse to follow? A. Silence the alarm, continue the infusion, and watch the patient for signs of further problems. B. Continue to try to get the pump to work as to keep on schedule with the patient's drug therapy. C. Discontinue the infusion, replace the pump with a functioning one and restart the infusion, and then label the broken pump and place it in a designated area for broken equipment. D. Discontinue the infusion, replace the pump with a functioning one, and leave the malfunctioning pump outside of the patient's room for someone else to try.

C. Discontinue the infusion, replace the pump with a functioning one and restart the infusion, and then label the broken pump and place it in a designated area for broken equipment. The nurse is responsible for the safe use of all equipment involved in patient care. In this instance, if the nurse is unsure if the pump is malfunctioning, then it should be replaced, labeled as broken, and removed from the work area to prevent another infusion area with a different patient. Never assume an alarm is in error and do not try to fix malfunctioning equipment if properly functioning ones are available for use. The facility may have specific requirements as to who is to be notified of broken equipment and these should be followed.

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST? A. Institute seizure precautions B. Assess neurologic status C. Place in respiratory isolation D. Assess vital signs

C. Place in respiratory isolation The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.

A patient being treated for uterine cancer has just had an internal radiation implant placed. The fire alarm sounds and, without thinking, the patient stands up. The radiation implant falls out and onto the floor. What is the NEXT action the nurse should take? A. Call the physician. B. Call the radiation specialist. C. Retrieve tongs, place the dislodged implant in a lead-lined container, and call the radiation specialist. D. Use a fork to push the implant into a specimen jar and close it.

C. Retrieve tongs, place the dislodged implant in a lead-lined container, and call the radiation specialist. It is the nurse's responsibility to contain the radioactive implant before calling the radiation specialist.

Which of the following is an incorrect step in the acronym for use of a fire extinguisher? A. Pull the pin on the fire extinguisher. B. Aim at the base of the fire. C. Spray in the middle of the fire until extinguished. D. Squeeze the trigger on the fire extinguisher to release the spray.

C. Spray in the middle of the fire until extinguished. **P**—Pull the pin on the fire extinguisher. **A**—Aim at the base of the fire. **S**—Squeeze the trigger on the first extinguisher to release the spray. **S**—Sweep the spray from side to side until the fire is extinguished.

Which of the following statements about sterile gloves is true? A. Hand hygiene is only required after removing sterile gloves. B. You should use the wrist of the dominant hand to adjust your mask or eye shield after donning sterile gloves. C. You should glove your dominant hand and then glove your non-dominant hand. D. After donning the gloves, you should discard the glove packaging by picking up the outer corner and placing it in the trash.

C. You should glove your dominant hand and then glove your non-dominant hand. Hand hygiene should be performed before donning sterile gloves. The nurse should avoid touching the outer corner of the glove packaging as it is not considered sterile, and similarly, the nurse should avoid touching their mask or eye shield while wearing sterile gloves.

A nurse in the emergency room is taking care of a 4-year-old patient who has a suspected case of impetigo. The nurse knows that which of the following precautions is most important to prevent the spread of this infection? A. airborne precautions B. standard precautions C. contact precautions D. droplet precautions

C. contact precautions Impetigo is an infectious skin condition that is spread via skin to hand contact or indirect contact of the skin and other surfaces. Contact precautions are, therefore, necessary to limit the spread of this skin infection.

A nurse on the medical/surgical floor is caring for an elderly, postoperative patient with dementia who is in restraints because she refuses to stay in bed or keep her IVs in. The nurse knows that she will have to provide range of motion exercises and ask if the patient needs to use the restroom how often? A. every 8 hours B. every 6 hours C. every 2 hours D. every 4 hours

C. every 2 hours For this patient, the use of restraints is necessary to prevent injury during a fall and to help the patient recuperate from surgery. In addition to frequent monitoring to ensure correct placement of the restraints and the need for continued use, the nurse needs to provide bathroom opportunities and range of motion exercises every 2 hours.

The nurse is caring for a client who is restrained with wrist restraints due to violent behavior. How often should the nurse assess the client's skin? A. every 15 minutes B. every 30 minutes C. every hour D. every two hours

C. every hour For clients restrained because of non-violent behavior, the skin should be assessed every two hours. When the client is restrained due to violent behavior, the skin should be assessed every hour.

The nurse at a family practice is responsible for reviewing home safety issues with all patients. She knows that there is an increased risk of falls in which of these two groups of patients? A. toddlers and the elderly B. infants and toddlers C. infants and the elderly D. the elderly and school-age children

C. infants and the elderly Infants and the elderly both have increased risk of falls. Nurses should educate the parents and/or caregivers of infants about safe places for sleep and play to prevent a fall. In the elderly, nurses must consider age-related factors, both physical and cognitive that can increase the risk of falling. Note: Even though toddlers (ages 1-4) are more mobile than infants (ages 0-1), statistics show that infants are more susceptible to falling. This may be due to being left in unsafe places (on changing tables, beds, grocery carts, etc.) and the lack of knowledge of and experience with space and their bodies.

Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse's preoperative goals for Mrs. M. would include: A. independently ambulating around the unit. B. reading the routine preoperative education materials. C. maneuvering safely after orientation to the room. D. using a bedpan for elimination needs.

C. maneuvering safely after orientation to the room. Independently ambulating around the unit is not appropriate because the unit environment can change and injury could result. Assistance is necessary because of the client's visual deficit. It is unlikely the client can see well enough to read the materials. Maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely. Using the bedpan is an unnecessary restriction on the client as she can be oriented to the bathroom or to call for assistance.

A nurse who works in an outpatient surgical center develops a new respiratory illness. She has atypical symptoms and is not responding to conventional therapies. Her work history includes spending considerable amounts of time in her facility's central supply and equipment sterilization areas. Her treating physician suspects her illness is linked to a workplace exposure. Where is the best place for the nurse to obtain information regarding her potential workplace exposures? A. the Occupational Safety and Health Administration (OSHA) website B. the Centers for Disease Control and Prevention's (CDC) reportable illness hotline C. the Safety Data Sheets/SDS (formerly referred to as Material Safety Data Sheets/MSDS) at her facility D. the equipment manufacturer's service center and help desk

C. the Safety Data Sheets/SDS (formerly referred to as Material Safety Data Sheets/MSDS) at her facility Nurses may be exposed to various potentially hazardous materials and chemicals in the workplace. A list of all of the chemical agents found in a particular employment setting can be obtained via a nurse's Safety Data Sheets/SDS (formerly referred to as Material Safety Data Sheets/MSDS) which, by law, must be kept at the facility. The governing body that mandates the use of SDS is the Occupational Safety and Health Administration (OSHA). OSHA also has guidelines on the safe handling of potentially biohazardous materials that include recommendations from the Centers for Disease Control and Prevention (CDC). Workplace-related illness is not reportable to the CDC. While information about occupational exposures may be derived from an equipment manufacturer, this information should be readily available to an employee via the SDS.

The nurse is caring for a pediatric client recently diagnosed with Type I diabetes. Which of the following statements indicates a need for further instruction? A. "Even though these needles are very small, they still need to be disposed of in a sharps container." B. "The sharps container at home should be replaced before it is completely full." C. "It is not okay to reuse the insulin needle even if it's the same type of insulin." D. "I can use an empty water bottle to dispose of my used insulin needles when I'm at school."

D. "I can use an empty water bottle to dispose of my used insulin needles when I'm at school." The client should always use a sharps container to dispose of the insulin needles.

The family member of a client confronts the nurse because they are upset that a belt restraint is being used to prevent the client from getting out of bed. Which of the following statements is the least appropriate response? A. "The documentation for regular assessments ensures the care team regularly reviews the use of the restraint and the client's response." B. "The care team regularly checks that the belt restraint is positioned for proper functioning." C. "The client is regularly assessed to ensure the least restrictive restraint is being used." D. "The restraint order is renewed every day by the physician, so you will need to discuss your concerns with that provider tomorrow."

D. "The restraint order is renewed every day by the physician, so you will need to discuss your concerns with that provider tomorrow." In order to ensure the least restrictive restraint is used, the client is regularly assessed, the restraint use and client response is documented, and the restraints are checked for proper functioning. While a physician order is required and renewed every 24 hours, the use is being constantly assessed.

When working after the occurrence of a natural disaster, the LPN uses a color coding system for triaging clients. Which of these would be an accurate example of this? A. Yellow is placed on a client who is stable and can wait the longest to be treated. B. Green is placed on a client with an occluded airway and difficulty breathing. C. Red is placed on a client who is losing a lot of blood due to massive trauma. D. A black sticker is placed on a client whose injuries prove to be fatal.

D. A black sticker is placed on a client whose injuries prove to be fatal. Black indicates dead on arrival or for whom nothing can be done toward survival.

Which of the following would be considered an internal disaster? A. A fire starts in the hospital parking lot. B. An earthquake occurs. C. A hurricane is approaching. D. An unknown caller says there is a bomb in the hospital lobby.

D. An unknown caller says there is a bomb in the hospital lobby. An internal disaster occurs within the walls of the hospital while an external disaster occurs outside of the hospital. In this situation, a bomb threat called in is an internal disaster as the location is the lobby of the hospital.

When assessing a client that has an order for bilateral wrist restraints, which of the following questions is least relevant? A. Has the client's mental status changed? B. Are the client's vital signs within their normal range? C. Are bilateral wrist restraints the least restrictive option for the client's situation? D. Are there enough staff members to allow enough time to monitor the client during a trial release of the restraints?

D. Are there enough staff members to allow enough time to monitor the client during a trial release of the restraints? Trial releases of the restraints should be performed to assess the client's response, but the staff ratio or convenience should not be a factor in performing this assessment.

The nurse is caring for a patient with Meniere's disease. The nurse knows that the most important consideration in regard for patient safety is to: A. Offer the patient alternative meal choices from the cafeteria. B. Remind the patient to wash her hands frequently, especially after voiding or before meal times. C. Raise the side rails on the patient's bed. D. Ask the nursing assistant to walk with the patient when she needs to use the bathroom.

D. Ask the nursing assistant to walk with the patient when she needs to use the bathroom. Patients with Meniere's disease can get attacks of vertigo very suddenly, so a nursing assistant can provide stability. Raising the side rails counts as a restraint.

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client? A. Reverse isolation B. Respiratory isolation C. Standard precautions D. Contact isolation

D. Contact isolation Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient"s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia.

The nurse hears a commotion in a room that is occupied by another nurse's client. When entering the room, the nurse finds the client has fallen while walking back from the bathroom. Which of the following actions is least appropriate? A. Write an incident report. B. Find another staff member to assist in moving the client, if needed. C. Assess the client prior to attempting to move the client. D. Find the client's regular nurse.

D. Find the client's regular nurse. After a fall, the first priority is to assess the client. If the client is not injured, the nurse should not attempt to move the client by themselves. An incident report should be written. It is not a priority to find the client's regular nurse.

A nurse is in the operating room where x-rays are being taken during the procedure. What is the best way to use this equipment safely? A. Ensure the time out has been done prior to any x-ray imaging being taken. B. Make sure the client does not have any metal in their body which could cause the machine to malfunction. C. Ensure the equipment being used to take x-rays has sterile drapes and covers on it to prevent contamination of the sterile field. D. Have a lead apron and thyroid shield on when being exposed to active radiation, such as x-rays.

D. Have a lead apron and thyroid shield on when being exposed to active radiation, such as x-rays. Lead aprons are a safety equipment required for healthcare members to use to protect themselves during radiation exposure.

Which question is least useful in the assessment of a client with AIDS? A. Are you a drug user? B. Do you have many sex partners? C. What is your method of birth control? D. How old were you when you became sexually active?

D. How old were you when you became sexually active? Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for AIDS. Birth control methods are important to prevent a baby from being born with the AIDS virus. The age at which sexual activity began it not relevant as it does not usually provide information that identifies the presence of risk factors for AIDS.

A client comes into the Emergency Department with symptoms of chest tightness, difficulty breathing, blood tinged purulent sputum, and night sweats. What is the best action for the nurse to take? A. Get the client in a negative air pressure room and alert the attending of active tuberculosis B. Review admission criteria, cohort client with a patient positive for the flu, and draw blood for full work up blood panel. C. Arrange for a chest x-ray and private room, then wait for results. D. Implement airborne precautions, arrange for a chest x-ray of the client, and get the client to negative air pressure, private room.

D. Implement airborne precautions, arrange for a chest x-ray of the client, and get the client to negative air pressure, private room. These are all symptoms of tuberculosis and need to be treated as such until confirmed or disproven by tests. These actions help to prevent the spread of this airborne disease.

https:/A client placed under neutropenic precautions asks you how she can prevent infection. Which advice would be most appropriate? A. Wash hands when finished cleaning up after pets. B. Only brush teeth once a day or every other day. C. Do not let visitors within 10 feet. D. Only use pads for menstrual periods.

D. Only use pads for menstrual periods. Tampons may cause tears in the vagina that could lead to infection, so patients with neutropenic precautions should avoid using them. People with low WBCs should avoid cleaning up after pets and have someone else take on the task, instead. Teeth should be brushed with a soft toothbrush twice daily to help prevent infection. Healthy visitors are typically okay, though in some circumstances, it may be best for them to wear a mask, gown, or gloves when in close contact.

A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? A. Order a stat admission CBC. B. Place a urine collection bag and specimen cup at the bedside. C. Place a cooling mattress on his bed. D. Pad the side rails of his bed.

D. Pad the side rails of his bed. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.

An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is A. Limit visits by staff. B. Encourage family phone calls. C. Position in a bright, busy area. D. Speak soothingly and provide quiet music.

D. Speak soothingly and provide quiet music. The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Putting the client in a bright, busy area would probably add to his confusion. The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.

A nurse is working in a client's room who is positive for C. Diff (clostridium difficile). What is the best action for the nurse to take? A. Wear gloves and gown during client care. B. Wear gloves when having any physical contact with the client. C. Don a mask, gown, and gloves when working with this client. D. Wear gloves and a mask when cleaning the client.

D. Wear gloves and gown during client care. C. Diff. is a bacteria with which contact precautions are used and gloves and gown are the proper PPE for this precaution. C. Diff is listed only for contact precautions, not droplet. You do not inhale the droplets of the bacteria and then get the infection like you would influenza or another respiratory virus. You have to come in contact with it through skin/clothing so gown and gloves are the only requirement. Some people may prefer to wear masks, but it is not mandatory and is not a standard/recommended practice. NCLEX tests do not allow for personal experience, just the textbook standard.

A nurse is counseling an 87-year-old female patient and her daughter. The patient is obese, has multiple medical problems, including dementia, and takes numerous medications. The patient is preparing to move in with her daughter for full-time care. Which of the following is least important for the nurse to discuss with the patient and her daughter. A. proper ergonomics for lifting/assisting the patient in her activities of daily living B. side effects of her medications C. fall prevention and safety D. fire safety and prevention

D. fire safety and prevention While fire safety and prevention is certainly a worthwhile topic to discuss, given this patient's particular set of problems of obesity, polypharmacy, dementia, and advanced age, the other choices should take priority during the review of safety and accident prevention.

The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to: A. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing. B. congratulate the nurse on the use of good technique. C. discuss dressing change technique with the nurse at a later date. D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.

D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing and before donning the sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. However, the nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.

There has been a mass casualty shooting at a nearby school. A nurse is working in the emergency department and is asked to triage clients as they arrive at the hospital. One of the clients arriving at the emergency department is in a wheelchair speaking to a nurse frantically while clutching his leg around a bloodied bandage and his foot is oddly angled. Based on this information, which of the following tag colors would the triage nurse assign this client? A. red B. black C. green D. yellow

D. yellow The client in the question has an injury that would need to be addressed but does not appear to be life-threatening based on the information provided. Clients with life-threatening injuries would be assigned a red tag. Those that are ambulatory with minor injuries would be assigned a green tag. Black tags are reserved for those who are deceased or with injuries that are not compatible with survival.