CHAPTER 13 Provision of a Safe Environment

Disposal of infectious wastes

1. Handle all infectious materials as a hazard. 2. Dispose of waste in designated areas only, using proper containers for disposal. 3. Ensure that infectious material is labeled properly. 4. Dispose of all sharps immediately after use in closed, puncture-resistant disposal containers that are leak-proof and labeled or color-coded. Needles (sharps) should not be recapped, bent, or broken because of the risk of accidental injury ( needle stick).

Removal of PPE (4) Mask or Respirator

Grasp bottom ties then top ties to remove.

Physical restraints

Physical restraints restrict client movement through the application of a device.

Removal of PPE (2) Goggles/Face Shield

Remove by touching clean band or inner part.

Common drug-resistant infection

Vancomycin-resistant enterococci (VRE) Methicillin-resistant Staphylococcus aureus (MRSA), Multidrug-resistant tuberculosis, Carbapenem-resistant Enterobacteriaceae (CRE)

Biological Warfare Agents Plague

1. Plague is caused by Yersinia pestis, a bacteria found in rodents and fleas. 2. Plague is contracted by being bitten by a rodent or flea that is carrying the plague bacterium, by the ingestion of contaminated meat, or by handling an animal infected with the bacteria. 3. Transmission is by direct person-to-person spread. 4. Forms include bubonic (most common), pneumonic, and septicemic (most deadly). 5. Symptoms usually begin within 1 to 3 days and include fever, chest pain, lymph node swelling, and a productive cough (hemoptysis). 6. The disease rapidly progresses to dyspnea, stridor, and cyanosis; death occurs from respiratory failure, shock, and bleeding. 7. Antibiotics are effective only if administered immediately; the usual medications of choice include streptomycin or gentamicin. 8. A vaccine is available.

Biological Warfare Agents Ebola Virus Disease (EVD)

1. Previously known as Ebola hemorrhagic fever 2. Caused by infection with a virus of the family Filoviridae, genus Ebolavirus 3. First discovered in 1976 in the Democratic Republic of the Congo. Outbreaks have appeared in Africa and in several other countries in the world. 4. The natural reservoir host of Ebolavirus remains unknown. It is believed that the virus is animal-borne and that bats are the most likely reservoir. 5. Spread of the virus is through contact with objects (such as clothes, bedding, needles, syringes/sharps, or medical equipment) that have been contaminated with the virus. 6. Symptoms similar to hemorrhagic fever may appear from 2 to 21 days after exposure.

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room

1. Private room or cohort client Rationale: Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3. Activate the fire alarm. Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

Biological Warfare Agents

A. A warfare agent is a biological or chemical substance that can cause mass destruction or fatality.

Nurse's Role in Exposure to Warfare Agents

A. Be aware that, initially, a bioterrorism attack may resemble a naturally occurring outbreak of an infectious disease. B. Nurses and other health care workers must be prepared to assess and determine what type of event occurred, the number of clients who may be affected, and how and when clients will be expected to arrive at the health care agency. C. It is essential to be aware that changes in the microorganism can occur that may increase its virulence or make it resistant to conventional antibiotics or vaccines.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? Keeps the area free of microorganisms Confines microorganisms to the surgical site Protects self from microorganisms in the wound Reduces the risk for growing opportunistic microorganisms

Keeps the area free of microorganisms Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound apply to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

Priority Nursing Actions Event of a Fire

Race 1. Rescue clients who are in immediate danger. 2. Activate the fire alarm. 3. Confine the fire. 4. Extinguish the fire. PASS 1. Obtain the fire extinguisher. 2. Pull the pin on the fire extinguisher. 3. Aim at the base of the fire. 4. Squeeze the extinguisher handle. 5. Sweep the extinguisher from side to side to coat the area of the fire evenly.

Biological Warfare Agents Ebola Virus Disease (EVD) Interventions

a. If the assessment indicates possible infection with EVD, the client needs to be isolated in a private room with a private bathroom or a covered bedside commode with the door closed. b. Health care workers need to wear the proper personal protective equipment (PPE) and follow updated procedures designated by the Centers for Disease Control and Prevention for donning (putting on) and removing PPE. c. The number of health care workers entering the room should be limited, and a log of everyone who enters and leaves the room should be kept. d. Only necessary tests and procedures should be performed, and aerosol-generating procedures should be avoided. e. Refer to the CDC guidelines for cleaning, disinfecting, and managing waste. f. The agency's infection control program should be notified, as well as state and local public health authorities.

Steps to Prevent Injury to the Health Care Worker When Moving a Client

▪ Use available safety equipment. ▪ Keep the weight to be lifted as close to the body as possible. ▪ Bend at the knees. ▪ Tighten abdominal muscles and tuck the pelvis. ▪ Maintain the trunk erect and knees bent so that multiple muscle groups work together in a coordinated manner.

Downing PPE (3) Goggles/Face Shield

Adjust to fit according to agency policy.

Biological Warfare Agents Ebola Virus Disease (EVD) Assessment

Ask the client if he or she traveled to an area with EVD such as Guinea, Nigeria, or Sierra Leone within the last 21 days or if he or she has had contact with someone with EVD and had any of the following symptoms: a. Fever at home or a current temperature of 38° C (100.4° F) or greater b. Severe headache c. Muscle pain d. Weakness e. Fatigue f. Diarrhea g. Vomiting h. Abdominal pain i. Unexplained bleeding or bruising

When a client is expressing severe anxiety by sobbing in the fetal position on the bed, what is the nurse's priority? Ensuring a safe therapeutic milieu Monitoring and documenting vital signs Eliminating the cause of the client's anxiety Ensuring that the client's physical needs are met

Ensuring a safe therapeutic milieu Client safety is the nurse's first priority, and because the client has not experienced any physical injuries and is not at risk, attention should be directed toward psychiatric risk, in this case crisis control. The severely stressed individual is likely to experience increased vital signs and will continue to have physiologic needs such as food and water; however, these issues do not take priority over a psychiatric crisis. The client will not be able to concentrate on therapy related to identifying the source of the anxiety until the crisis has been managed.

Donning PPE (1) Gown (gown, gloves, mask) prior to patient's arrival)

Fully cover front of body from neck to knees and upper arms to end of wrist. Fasten in the back at neck and waist, wrap around the back.

The administrator of a skilled nursing facility is reviewing the organization's internal emergency management plan. Which statement best describes the goal of this plan? Identify staff to work overtime Maintain client, staff, and visitor safety Minimize the loss of material resources Select clients to transfer to another facility

Maintain client, staff, and visitor safety The most important outcome for any internal disaster is to maintain client, staff, and visitor safety. Identifying staff to work overtime, minimizing the loss of material resources, and selecting clients to transfer to another facility might be parts of the internal emergency management plan; however, these are not the goals of the plan.

Chemical Warfare Agents Phosgene

Phosgene is a colorless gas normally used in chemical manufacturing that if inhaled at high concentrations for a long enough period will lead to severe respiratory distress, pulmonary edema, and death.

A client begins fighting and biting other clients. The primary healthcare provider prescribes a stat injection of haloperidol. How will the nurse implement this prescription? Quickly, with an attitude of concern Before the client realizes what is happening After the client agrees to receive the injection Quietly, without any explanation of the reason for it

Quickly, with an attitude of concern Quickness is used for safety; an attitude of concern may help reduce the client's anxiety. The client must be told why sedation is being used; to do so surreptitiously will reduce the client's trust. A client who is this upset will not agree to a sedative; the client may harm self or others and must be sedated.

Downing PPE (2) Mask or Respirator (gown, gloves, mask) prior to patient's arrival)

Secure ties or elastic band at neck and middle of head. Fit snug to face and below chin. Fit to nose bridge. Respirator fit should be checked per agency policy.

Clostridium difficile

Spread mainly by hand-to-hand contact is a health care setting. Clients taking multiple antibiotics for a prolonged period are most at risk.

ESI-1 Five-Level Emergency Severity Index

Stability of Vital Function (ABC): Unstable Life Threat or Organ Threat: Obvious How soon patient should be seen by physician: Immediately Expected resource intensity: High resource intensity. Staff at bedside continuously. Often mobilization of team response. Examples: Cardiac arrest, intubated trauma patient, overdose with bradypnea, severe respiratory distress.

Types of Fire Extinguishers

Type A Wood, cloth, upholstery, paper, rubbish, plastic Type B Flammable liquids or gases, grease, tar, oil-based paint Type C Electrical equipment

Contact precautions Diseases

a. Colonization or infection with a multidrug-resistant organism b. Enteric infections, such as Clostridium difficile c. Respiratory infections, such as respiratory syncytial virus (RSV) d. Influenza: Infection can occur by touching something with flu viruses on it and then touching the mouth or nose. e. Wound infections f. Skin infections, such as cutaneous diphtheria, herpes simplex, impetigo, pediculosis, scabies, staphylococci, and varicella zoster g. Eye infections, such as conjunctivitis h. Indirect contact transmission may occur when contaminated object or instrument, or hands, are encountered.

Contact precautions Barrier protection

a. Private room or cohort client b. Use gloves and a gown whenever entering the client's room.

Measures to Prevent Falls

▪ Assess the client's risk for falling; use agency fall risk assessment scale. ▪ Assign the client at risk for falling to a room near the nurses' station. ▪ Alert all personnel to the client's risk for falling; use agency fall risk alert procedures and methods as necessary. ▪ Assess the client frequently. ▪ Orient the client to physical surroundings. ▪ Instruct the client to seek assistance when getting up. ▪ Explain the use of the nurse call system. ▪ Use safety devices such as floor pads, and bed or chair alarms that alert health care personnel of the person getting out of bed or a chair. ▪ Keep the bed in the low position with side rails adjusted to a safe position (follow agency policy). ▪ Lock all beds, wheelchairs, and stretchers. ▪ Keep clients' personal items within their reach. ▪ Eliminate clutter and obstacles in the client's room. ▪ Provide adequate lighting. ▪ Reduce bathroom hazards. ▪ Maintain the client's toileting schedule throughout the day.

The Joint Commission: 2018 National Patient Safety Goals

▪ Improve the accuracy of client identification. ▪ Improve the effectiveness of communication among caregivers ▪ Improve the safety of using medications ▪ Focus on the risk points related to medication reconciliation ▪ Reduce the harm associated with clinical alarm systems ▪ Reduce the risk of health care-associated infections ▪ Identify client safety risks ▪ Prevent mistakes in surgery

Chemical Warfare Agents Mustard gas

Mustard gas is yellow to brown and has a garlic-like odor that irritates the eyes and causes skin burns and blisters.

Nuclear Warfare

1. Acute radiation exposure develops after a substantial exposure to radiation and is referred to as nuclear warfare. 2. Exposure can occur from external radiation or internal absorption. 3. Symptoms depend on the amount of exposure to the radiation and range from nausea and vomiting, diarrhea, fever, electrolyte imbalances, and neurological and cardiovascular impairment to leukopenia, purpura, hemorrhage, and death.

Biological Warfare Agents Tularemia (rabbit fever)

1. Tularemia (also called deer fly fever or rabbit fever) is an infectious disease of animals caused by the bacillus Francisella tularensis. 2. The disease is transmitted by ticks, deer flies, or contact with an infected animal. 3. Symptoms include fever, headache, and an ulcerated skin lesion with localized lymph node enlargement, eye infections, gastrointestinal ulcerations, or pneumonia. 4. Treatment is with antibiotics such as streptomycin, gentamicin, doxycycline, and ciprofloxacin. 5. Recovery produces lifelong immunity (a vaccine is available).

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield

4. Gloves, gown, goggles, and a mask or face shield Rationale: Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway

4. Placing the client in a semiprivate room at the end of the hallway Rationale: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.

Poison iterventions

8. Interventions a. Remove any obvious materials from the mouth, eyes, or body area immediately. b. Identify the type and amount of substance ingested. c. Call the Poison Control Center before attempting an intervention. d. If the victim vomits or vomiting is induced, save the vomitus if requested to do so, and deliver it to the Poison Control Center. e. If instructed by the Poison Control Center to take the person to the emergency department, call an ambulance. f. Never induce vomiting following ingestion of lye, household cleaners, grease. or petroleum products. g. Never induce vomiting in an unconscious victim.

What does the nurse identify as an early sign of chronic lead poisoning (plumbism) in school-aged children? Anemia Seizures Cognitive impairment (CI) Renal calcium dysfunction The bone marrow is most susceptible to lead toxicity. Interference with hemoglobin biosynthesis leads to early signs and symptoms of anemia. Seizure activity and CI are late responses indicating central nervous system involvement. Renal calcium dysfunction is a late response indicating kidney damage; loss of protein and other substances occurs first.

Anemia The bone marrow is most susceptible to lead toxicity. Interference with hemoglobin biosynthesis leads to early signs and symptoms of anemia. Seizure activity and CI are late responses indicating central nervous system involvement. Renal calcium dysfunction is a late response indicating kidney damage; loss of protein and other substances occurs first.

According to the American Academy of Pediatrics, what precautionary measures should a nurse instruct parents to follow to prevent a child from being accidentally poisoned? Select all that apply. Refer to medicine as candy. Dispose of unused and unneeded medication safely. Keep potential poisons away from the sight and reach of children. Transfer dangerous substances from an original container to an alternate container. Make sure all containers and cabinets are securely closed after use

Dispose of unused and unneeded medication safely. Keep potential poisons away from the sight and reach of children. Make sure all containers and cabinets are securely closed after use

Removal of PPE (3) Gown

Gown Unfasten at neck, then at waist. Remove using a peeling motion, pulling gown from each shoulder toward the hands. Allow gown to fall forward, and roll into a bundle to discard.

Removal of PPE (1) Gloves

Grasp outside of glove with opposite hand with glove still on and peel off. Hold on to removed glove in gloved hand. Slide fingers of ungloved hand under clean side of remaining glove at wrist and peel off.

After a mass causality scene, the nurse finds that a group of victims with minor injuries arrived to a hospital in a private vehicle. Which disaster triage tag does the nurse finds on victims? Red Black Green Yellow

Green The green-tagged victims have minor injuries, can move themselves to hospital from a mass causality scene in a private vehicle, and are also called "walking wounded" victims. Red- tagged victims can't ambulate themselves as they are severely injured. The black-tagged victims are dead or expected to die and require ambulances to transfer them. The yellow-tagged victims can have large wounds that require assistance to ambulate.

Chemical restraints

Medications given to inhibit a specific behavior or movement.

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicate that the client is hearing voices. When a nurse begins to walk toward the client, the client pulls out a large knife. What is the best approach by the nurse? Firm Passive Empathetic Confrontational

Firm A firm approach prevents anxiety transference and provides structure and control for a client who is out of control. A passive approach for a client who may be out of control does not provide structure, which may increase the client's anxiety. Although the nurse should always base a therapeutic response on empathy, an obviously empathetic response may indicate to the client that the behavior is acceptable. A confrontational approach in this situation may escalate the client's agitation and precipitate further acting out.

Which client injury would receive a black tag by the triage nurse during a mass casualty incident? Concussion Ankle sprain Open femur fracture Full-thickness body burns 80% total body surface area (TBSA)

Full-thickness body burns 80% total body surface area (TBSA) A black tag indicates the client has suffered an extensive injury and is expected, or allowed, to die. Typical examples of black-tagged clients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation. Full-thickness body burns 80% TBSA would qualify as an extensive full-thickness body burn. Clients with a concussion, ankle sprain, and open femur fracture would receive yellow and green tags.

Measures to promote safety in ambulation for the client

Gait belt may be used to keep the center of gravity midline. a. Place the belt on the client prior to ambulation. b. Encircle the client's waist with the belt. c. Hold on to the side or back of the belt so that the client does not lean to one side. d. Return the client to bed or a nearby chair if the client develops dizziness or becomes unsteady. e. When finished safely ambulating the client, remove belt and replace it in its appropriate storage area.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? The dosage is kept at a minimum. Only a small part of the body is irradiated. The client's physical condition is not a risk factor. Nutritional environment of the affected cells is a risk factor. Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the healthcare provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.

Only a small part of the body is irradiated. Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the healthcare provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.

Downing PPE (4) Gloves

Select appropriate size and extend to cover wrists of gown.

ESI-5 Five-Level Emergency Severity Index

Stability of vital function (ABC): Stable Life threat or organ threat: No How soon patient should be seen by physician: Could be delayed Expected resource intensity: Low resource intensity. Examination only Examples: Cold symptoms. minor burn, recheck (e.g., wound), prescription refill.

Biological Warfare Agents Smallpox

The overall deadliest known disease in the history of the world. In the 20th century alone there were approximately 500,000,000 people who died of this disease. 1. Smallpox is transmitted in air droplets and by handling contaminated materials and is highly contagious. 2. Symptoms begin 7 to 17 days after exposure and include fever, back pain, vomiting, malaise, and headache. 3. Papules develop 2 days after symptoms develop and progress to pustular vesicles that are abundant on the face and extremities initially. 4. A vaccine is available to those at risk for exposure to smallpox.

Alternatives to safety devices for a client with confusion

a. Orient the client and family to the surroundings with every interaction and identify the client by their name. b. Explain all procedures and treatments to the client and family. c. Encourage family and friends to stay with the client, and use sitters for clients who need supervision. d. Assign confused and disoriented clients to rooms near the nurses' station. e. Provide appropriate visual and auditory stimuli, such as a night light, clocks, calendars, television, and a radio, to the client; leave the client's room door open. f. Place familiar items, such as family pictures, near the client's bedside. g. Maintain toileting routines. h. Eliminate bothersome treatments, such as nasogastric tube feedings, as soon as possible. i. Evaluate all medications that the client is receiving. j. Use relaxation techniques with the client. k. Institute exercise and ambulation schedules as the client's condition allows. l. Collaborate with the PHCP to evaluate oxygenation status, vital signs, electrolyte/laboratory values, and other pertinent assessment findings that may provide information about the cause of the client's confusion.

Restraints (safety devices) are protective devices used to limit the physical activity of a client or to immobilize a client or an extremity.

a. The agency policy should be checked and followed when using side rails. b. The use of side rails is not considered a restraint when they are used to prevent a sedated client from falling out of bed. c. The client must be able to exit the bed easily in case of an emergency when using side rails. Only the top two side rails should be used. d. The bed must be kept in the lowest position.

Airborne precautions Barrier Protection

a. Used for clients known or suspected to be infected with pathogens transmitted by the airborne route. b. Single room is maintained under negative pressure; door remains closed except upon entering and exiting. c. Negative airflow pressure is used in the room, with a minimum of 6 to 12 air exchanges per hour via high-efficiency particulate air (HEPA) filtration mask or according to agency protocol. d. Ultraviolet germicide irradiation or HEPA filter is used in the room. e. Health care workers wear a respiratory mask (N95 or higher level). A surgical mask is placed on the client when the client needs to leave the room; the client leaves the room only if necessary.

Biological Warfare Agents Botulism

1. Botulism is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium botulinum (death can occur within 24 hours). 2. Its spores are found in the soil and can spread through the air or food (improperly canned food) or via a contaminated wound. 3. Botulism cannot be spread from person to person. 4. Symptoms include abdominal cramps, diarrhea, nausea and vomiting, double vision, blurred vision, drooping eyelids, difficulty swallowing or speaking, dry mouth, and muscle weakness. 5. Neurological symptoms begin 12 to 36 hours after ingestion of food-borne botulism and 24 to 72 hours after inhalation and can progress to paralysis of the arms, legs, trunk, or respiratory muscles (mechanical ventilation is necessary). 6. If diagnosed early, food-borne and wound botulism can be treated with an antitoxin that blocks the action of toxin circulating in the blood. 7. For wound botulism, surgical removal of the source of the toxin-producing bacteria may be done; antibiotics may be prescribed. 8. No vaccine is available.

Biological Warfare Agents Hemorrhagic fever

1. Hemorrhagic fever is caused by several viruses, including Marburg, Lassa, Junin, and Ebola. 2. The virus is carried by rodents and mosquitoes. 3. The disease can be transmitted directly by person-to-person spread via body fluids. 4. Manifestations include fever, headache, malaise, conjunctivitis, nausea, vomiting, hypotension, hemorrhage of tissues and organs, and organ failure. 5. No known specific treatment is available; treatment is symptomatic.

Environmental Safety Fire safety

1. Keep open spaces free of clutter. 2. Clearly mark fire exits. 3. Know the locations of all fire alarms, exits, and extinguishers 4. Know the telephone number for reporting fires. 5. Know the fire drill and evacuation plan of the agency. 6. Never use the elevator in the event of a fire. 7. Turn off oxygen and appliances in the vicinity of the fire. 8. In the event of a fire, if a client is on life support, maintain respiratory status manually with an Ambu bag (resuscitation bag) until the client is moved away from the threat of the fire and can be placed back on life support. 9. In the event of a fire, ambulatory clients can be directed to walk by themselves to a safe area and, in some cases, may be able to assist in moving clients in wheelchairs. 10. Bedridden clients generally are moved from the scene of a fire by stretcher, their bed, or wheelchair. 11. If a client must be carried from the area of a fire, appropriate transfer techniques need to be used. 12. If fire department personnel are at the scene of the fire, they will help evacuate clients.

Radiation safety

1. Know the protocols and guidelines of the health care agency. 2. Label potentially radioactive material. 3. To reduce exposure to radiation, do the following. a. Limit the time spent near the source. b. Make the distance from the source as great as possible. c. Use a shielding device such as a lead apron. 4. Monitor radiation exposure with a film (dosimeter) badge. 5. Place the client who has a radiation implant in a private room. 6. Never touch dislodged radiation implants. 7. Keep all linens in the client's room until the implant is removed.

Standard Precautions Description

1. Nurses must practice standard precautions with all clients in any setting, regardless of the diagnosis or presumed infectiveness. 2. Standard precautions include hand washing and the use of gloves, as well as washing hands after gloves are removed. Additionally, standard precautions include the use of masks, eye protection, and gowns, when appropriate, for client contact. 3. These precautions apply to blood, all body fluids (whether or not they contain blood), secretions and excretions, nonintact skin, and mucous membranes.

Chemical Warfare Agents Sarin

1. Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. 2. It enters the body through the eyes and skin and acts by paralyzing the respiratory muscles.

Biological Warfare Agents Anthrax

1. The disease is caused by Bacillus anthracis and can be contracted through the digestive system, abrasions in the skin, or inhalation through the lungs. 2. Anthrax is transmitted by direct contact with bacteria and spores; spores are dormant encapsulated bacteria that become active when they enter a living host (no person-to-person spread) (Box 13-6). 3. The infection is carried to the lymph nodes and then spreads to the rest of the body by way of the blood and lymph systems; high levels of toxins lead to shock and death. 4. In the lungs, anthrax can cause buildup of fluid, tissue decay, and death (fatal if untreated). 5. A blood test is available to detect anthrax (detects and amplifies Bacillus anthracis DNA if present in the blood sample). 6. Anthrax is usually treated with antibiotics such as ciprofloxacin, doxycycline, or penicillin. 7. The vaccine for anthrax has limited availability. Skin Spores enter the skin through cuts and abrasions and are contracted by handling contaminated animal skin products. Infection starts with an itchy bump like a mosquito bite that progresses to a small liquid-filled sac. The sac becomes a painless ulcer with an area of black, dead tissue in the middle. Toxins destroy surrounding tissue. Gastrointestinal Infection occurs following the ingestion of contaminated undercooked meat. Symptoms begin with nausea, loss of appetite, and vomiting. The disease progresses to severe abdominal pain, vomiting of blood, and severe diarrhea. Inhalation Infection is caused by the inhalation of bacterial spores, which multiply in the alveoli.

Standard Precautions Interventions

1. Wash hands between client contacts; after contact with blood, body fluids, secretions or excretions, nonintact skin, or mucous membranes; after contact with equipment or contaminated articles; and immediately after removing gloves. 2. Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items; remove gloves and wash hands between client care contacts. 3. For routine decontamination of hands, use alcohol- based hand rubs when hands are not visibly soiled. For more information on hand hygiene from the Centers for Disease Control and Prevention (CDC), see www.cdc.gov/handhygiene/ 4. Wear masks and eye protection, or face shields, if client care activities may generate splashes or sprays of blood or body fluid. 5. Wear gowns if soiling of clothing is likely from blood or body fluid; wash hands after removing a gown. 6. Steps for donning and removing personal protective equipment (PPE) (Table 13-2) 7. Clean and reprocess client care equipment properly and discard single-use items. 8. Place contaminated linens in leak-proof bags and limit handling to prevent skin and mucous membrane exposure. Dispose according to agency policy. 9. Use needleless devices or special needle safety devices whenever possible to reduce the risk of needle sticks and sharps injuries to health care workers. 10. Discard all sharp instruments and needles in a puncture-resistant container; dispose of needles uncapped or engage the safety mechanism on the needle if available. 11. Clean spills of blood or body fluids with a solution of bleach and water (diluted 1:10) or agency-approved disinfectant.

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan specific to the facility. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties.

2. Activate the emergency response plan specific to the facility. Rationale: In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan specific to the facility. Once the emergency response plan is activated, the actions in the other options will occur.

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug.

2. Contact the electrical maintenance department for assistance. Rationale: Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. The use of electrical appliances near a sink also presents a hazard.

Droplet precautions Diseases

a. Adenovirus b. Diphtheria (pharyngeal) c. Epiglottitis d. Influenza (flu) e. Meningitis f. Mumps g. Mycoplasmal pneumonia or meningococcal pneumonia h. Parvovirus B19 i. Pertussis j. Pneumonia k. Rubella l. Scarlet fever m. Sepsis n. Streptococcal pharyngitis

Airborne precautions Diseases

a. Measles b. Chickenpox (varicella) c. Disseminated varicella zoster d. Pulmonary or laryngeal tuberculosis

102. The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat

2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 6. Ingestion of contaminated undercooked meat . Answer: 2, 3, 6 Rationale: Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deer flies.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1. Check the client's temperature. 2. Isolate the client in a private room. 3. Check a complete set of vital signs. 4. Contact the primary health care provider.

2. Isolate the client in a private room. Rationale: The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Nigeria. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0° C (100.4° F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the primary health care provider and other state and local authorities of the client's signs and symptoms.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client's skin

2. Safely securing the safety device straps to the side rails Rationale: The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year- old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department.

3. Call the Poison Control Center. Rationale: If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes

4. Every 30 minutes Rationale: The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

Which assessment data would cause the nurse to question the administration of activated charcoal for a toddler-age client who presented in the emergency department after an accidental overdose of aspirin (ASA)? Bloody stool Nausea and vomiting Altered mental status Eczema type rash on the skin

Altered mental status A toddler-age child who presents to the ED after an accidental poisoning with an altered mental status would cause the nurse to question the order for activated charcoal. Bloody stool, nausea and vomiting, and an eczema type rash on the skin would not contraindicate this medical prescription for the treatment of an ASA overdose.

Electrical safety

Any electrical equipment that the client brings into the health care facility must be inspected for safety before before use. 1. Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard; remove equipment that is not in proper working order and notify appropriate staff. 2. Use a 3-pronged electrical cord. 3. In a 3-pronged electrical cord, the third, longer prong is the ground; the other 2 prongs carry the power to the piece of electrical equipment. 4. Check electrical cords and outlets for exposed, frayed, or damaged wires. 5. Avoid overloading any circuit. 6. Read warning labels on all equipment; never operate unfamiliar equipment. 7. Use safety extension cords only when absolutely necessary, and tape them to the floor with electrical tape. 8. Never run electrical wiring under carpets. 9. Never pull a plug by using the cord; always grasp the plug itself. 10. Never use electrical appliances near sinks, bathtubs, or other water sources. 11. Always disconnect a plug from the outlet before cleaning equipment or appliances. 12. If a client receives an electrical shock, turn off the electricity before touching the client.

According to the disaster triage tag system, which color tag would the nurse feel is most suitable for a client who died in an earthquake? Red Black Green Yellow Clients who are dead or are expected to die are issued a black tag according to the disaster triage tag system. A red tag is issued to the clients who have an immediate threat to life. A green tag is issued to the nonurgent or "walking wounded" clients. A yellow tag is issued to clients who can wait a short time to receive care.

Black Clients who are dead or are expected to die are issued a black tag according to the disaster triage tag system. A red tag is issued to the clients who have an immediate threat to life. A green tag is issued to the nonurgent or "walking wounded" clients. A yellow tag is issued to clients who can wait a short time to receive care.

Droplet precautions Barrier protection

a. Used for clients with known or suspected infection with pathogens transmitted by respiratory droplets, generated when coughing, sneezing, or talking. b. Private room or cohort client (a client whose body cultures contain the same organism) c. Wear a surgical mask when within 3 feet of a client; place a mask on the client when the client needs to leave the room.

Documentation Points With Use of a Safety Device (Restraint)

▪ Reason for safety device ▪ Method of use for safety device ▪ Date and time of application of safety device ▪ Duration of use of safety device and client's response ▪ Release from safety device with periodic exercise and circulatory, neurovascular, and skin assessment ▪ Assessment of continued need for safety device ▪ Evaluation of client's response

A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child? Keeping the child from inflicting any self-injury Helping the child improve communication skills Helping the child formulate realistic ego boundaries Providing the child with opportunities to discharge energy

Keeping the child from inflicting any self-injury All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury? Performing a jaw thrust maneuver Preparing for a needle thoracostomy Initiating cardiopulmonary resuscitation Providing oxygen via a nonrebreather mask

Performing a jaw thrust maneuver The jaw thrust maneuver is the recommended procedure for opening the airway of an unconscious client with a possible spinal or neck injury. Needle thoracostomy should be performed in a client with absent breath sounds. Cardiopulmonary resuscitation should be initiated in a client when there is no pulse. Providing oxygen via a nonrebreather mask is mainly performed when the client is conscious.

Restraints (safety devices)

a. Use alternative devices, such as pressure-sensitive beds or chair pads with alarms or other types of bed or chair alarms, whenever possible. b. If restraints are necessary, the primary health care provider's (PHCP's) prescriptions should state the type of restraint, identify specific client behaviors for which restraints are to be used, and identify a limited time frame for use. c. The PHCP's prescriptions for restraints should be renewed within a specific time frame according to agency policy. d. Restraints are not to be prescribed PRN (as needed). e. The reason for the safety device should be given to the client and the family, and their permission should be sought and documented. f. Restraints should not interfere with any treatments or affect the client's health problem. g. Use a half-bow, a safety knot (quick release tie), or a restraint with a quick release buckle to secure the device to the bed frame or chair, not to a movable part of bed (including the side rails). h. Ensure that there is enough slack on the straps to allow some movement of the body part. i. Assess skin integrity and neurovascular and circulatory status every 30 minutes and remove the safety device at least every 2 hours to permit muscle exercise and to promote circulation (follow agency policies). j. Continually assess and document the need for safety devices. k. Offer fluids if clinically indicated at least every 2 hours. l. Offer bedpan or toileting every 2 hours.

A nurse is providing discharge medication teaching to a client who will be taking furosemide and digoxin after discharge from the hospital. What information is most important for the nurse to include in the teaching plan? Maintenance of a low-potassium diet Avoidance of foods high in cholesterol Signs and symptoms of digoxin toxicity Importance of an adequate intake and output The risk of digoxin toxicity increases when the client is receiving digoxin and furosemide, a loop diuretic; loop diuretics can cause hypokalemia, which potentiates the effects of digoxin, leading to toxicity. Digoxin toxicity can result in dysrhythmias and death. When a client is receiving a loop diuretic, the diet should be high in potassium. Although teaching the need to avoid foods high in cholesterol may be included in the teaching plan, it is not the priority. Although it is important to maintain adequate intake and output because potassium chloride should not be taken when there is a decreased urinary output, the priority is monitoring for signs of digoxin toxicity.

Signs and symptoms of digoxin toxicity The risk of digoxin toxicity increases when the client is receiving digoxin and furosemide, a loop diuretic; loop diuretics can cause hypokalemia, which potentiates the effects of digoxin, leading to toxicity. Digoxin toxicity can result in dysrhythmias and death. When a client is receiving a loop diuretic, the diet should be high in potassium. Although teaching the need to avoid foods high in cholesterol may be included in the teaching plan, it is not the priority. Although it is important to maintain adequate intake and output because potassium chloride should not be taken when there is a decreased urinary output, the priority is monitoring for signs of digoxin toxicity.

ESI-4 Five-Level Emergency Severity Index

Stability of vital function (ABC): Stable Life threat or organ threat: No How soon patient should be seen by physician: Could be delayed Expected resource intensity: Low resource intensity. One simple diagnostic study (e.g., x-ray) or simple procedure (e.g., sutures) Examples: Close extremity trauma, simple laceration, cystitis.

ESI-3 Five-Level Emergency Severity Index

Stability of vital function (ABC): Stable Life threat or organ threat: Unlikely but possible How soon patient should be seen by physician: Up to 1 hour Expected resource intensity: Medium to high resource intensity. Multiple diagnostic studies (e.g., multiple laboratory studies, x-ray) or brief observation. Complex procedure (e.g., IV fluids, medications) Examples: Abdominal pain or gynecologic disorders unless in severe distress, hip fracture in older patient.

ESI-2 Five-Level Emergency Severity Index

Stability of vital function (ABC): Threatened Life threat or organ threat: Likely but not always obvious How soon patient should be seen by a physician: Within 10 minutes Expected resource intensity: High resource intensity. Multiple, often complex diagnostic studies. Frequent consultation Continuous monitoring Examples: Chest pain probably resulting from ischemia, multiple trauma unless responsive

What should the nurse teach the parents of an infant about the use of car seats? The infant should ride in a front-facing car safety seat. The infant should ride in a car safety seat until one year of age. The infant should be restrained properly in a federally approved car The infant should always ride in a car seat restrained to the front seat of the car. The nurse should teach the parents to use a federally approved car safety seat to transport the infant. The infant should be properly restrained to the properly installed safety seat. The American Academy of Pediatrics (AAP) requires the infant to ride in a rear-facing car safety seat. The infant should ride in a car safety seat until two years of age. The infant should ride in a rear-facing restraint in the front seat of the car only if it does not have a passenger-side air bag.

The infant should be restrained properly in a federally approved car The nurse should teach the parents to use a federally approved car safety seat to transport the infant. The infant should be properly restrained to the properly installed safety seat. The American Academy of Pediatrics (AAP) requires the infant to ride in a rear-facing car safety seat. The infant should ride in a car safety seat until two years of age. The infant should ride in a rear-facing restraint in the front seat of the car only if it does not have a passenger-side air bag.

What are the primary nursing interventions to check the circulation in a client? Select all that apply. 1 The nurse should prepare for chest decompression. Incorrect2 The nurse should evaluate the level of consciousness. 3 The nurse should prepare for endotracheal intubation. Correct4 The nurse should monitor the vital signs, especially the pulse. Correct5 The nurse should maintain vascular access with a large-bore catheter.

The nurse should monitor the vital signs, especially the pulse. The nurse should maintain vascular access with a large-bore catheter. As a primary nursing intervention for circulation, the nurse should check the vital signs of the client, especially the pulse and blood pressure of the client. The nurse should maintain vascular access with a large bore catheter during an intervention involving the circulation. The nurse should prepare for chest decompression if required with a tension pneumothorax, because this could lead to cardiovascular collapse. Evaluation for level of consciousness is a nursing intervention to assess disability. The nurse should prepare for endotracheal intubation as a nursing intervention for cervical spine and airway