Module 6: Safety and Infection Control

A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs, the first action is to

Call the poison control center

A nurse is preparing a chemo infusion to be administered to a client with a dx of Hodgkin's disease. Which precaution should the nurse take while working with thi IV infusion

Wear gloves, a mask and eye protection

A nurse educator is providing an inservice program to ED nurses about the signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of inhalation anthrax is

flu-like symptoms

A nurse responds to an external disaster that occured in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first

A victim with a partial amputation of a leg who is bleeding profusely

A teenage client returns to the gynecologist for a followup visit after dx and initial tx of a STI. which statement by the client indicates the need for further teaching

My boyfriend doesn't have to come in for tx

A nurse is reading an article about the role of the American Red Cross in a disaster. Which of the following responsibilities does the article ascribe to the ARC

Providing disaster relief

A nurse, charting the administration of meds to an assigned client at 9pm, notes that atenolol was prescribed to be administered at 9am instead of 9pm. The nurse checks the client's VS, completes an incident report and calls the HCP to report the error. The HCP tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take

Telling the HCP that the error warrants the completion of an incident

A client with a new dx of TB is being admitted to the hospital. During the collection data from the client, which of the following considerations is especially important

The names of close friends and family members

A nurse caring for a 9 month old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request

Remove a restraint from one extremity

A nurse employed in a physician's office hears a client in the waiting room call out, "Help! Fire!". The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately

Removes the clients from the waiting room

A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the IV line. The client's primary HCP does not want to prescribe sedation and the family has requested that the client has not been restrained. Which action by the nurse is best

Staying with the client and counseling with the nurse manager about the situation

A nurse is preparing a continuous IV infusion at the med cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the med cart. Which action should the nurse take to maintain asepsis

Obtain new IV tubing

The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first

Pulling the pin on the fire extinguisher

A HHC nurse is performing an assessment of a client's skin. The nurse, noting multiple treadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client

Putting on a gown and gloves

The unit supervisor of the ED is called at home and toldy by an ED nurse who is on duty that an airplane crash has occurred and numerous casualties will be arriving at the ED. what should the initial response by the unit supervisor be

Has the disaster plan been activated

The nurse administers a dose of ramipril 2.5mg to a client at 0900. While documenting administration of the med, the nurse discovers that 1.25mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client's record

Ramipril 2.5mg was administered at 0900

A nurse receives a phone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client's plan of care

Wearing gloves when emptying the client's bedpan

A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line and central venous line-related sepsis is diagnosed. The nurse interprets this finding as a meaning that this infection is

A healthcare-associated infection

An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted

Close intimate contact

A post office employee with suspected skin anthrax asks the ED nurse whether the infection is curable. What is the appropriate response by the nurse

Abx therapy is usually prescribed and will cure the infection

A hurricane is forecast to make landfall in 48 hours and the staff of the END of an area hospital is advised to prepare for casualties. Which action should the nurse manager who receives the phone call regarding this warning take first

Activating the agency disaster plan

A client with an infection is receiving abx by way of IM injection. The client is also receiving SQ injections of heparin. Which precaution does the nurse understand is most appropriate to help ensure the safety of this client

Applying prolonged pressure to the sites of the IM and SQ sites

A nurse is performing sterile wound irrigation for an assigned client. A nursing assistant enters the client's room and tells the nurse that a physician has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse

Asking the UAP to obtain a telephone number from the physician so that the nurse may return the call after the wound irrigation is complete

A nurse manager tells the nursing staff that the agency's disaster preparedness plan will be distributed to all employees for review. The nurse manager states that the plan is an important component of disaster readiness b/c it primarily

Describes a formal plan of action for the coordination of a response

A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4x4 gauze pads has a small tear. Which action should the nurse take

Discarding the package

A HHC nurse is visiting a client with TB. which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home

Disposing of contaminated tissues in a container with a leak-proof bag

A nurse is attending an inservice program on disaster preparedness. Which of the following events is described as an example of a natural disaster

Drought

A RN is watching as a new LPN suctions a client with a dx of AIDS. which of the following protective devices worn by the LPN would cause the RN to determine that the LPN was performing the procedure safely

Gloves, gown and face shield

A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing lab. Which of the following observations by the instructor indicates a need for further teaching

The nursing student washes her hands before glove removal after emptying a foley bag

A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client's safety

belt

During a lab training session, the nurse is watching as a UAP repositions a client. Which observation tells the nurse that further training is necessary

The UAP keeps his knees straight and his feet close together

A nurse provides instruction to a new UAP regarding the application of a restraint to a client. The nurse watches as the UAP applies the restraint. What observation tells the nurse that the UAP is using correct procedure

The assistant applies the restraint so that the strap doesn't tighten when force is applied against it

A HHC nurse has been called to the home of an older post op CV client's son. The son tells the nurse, "We're using a hospital bed here at home because my mother has fallen out of bed three times." which observation by the nurse reflects an increased risk of this client's falling out of bed

The caregiver leaves both side rails down while the client is in bed

A HHC nurse visits a client who lives in a small apartment to perform an admission assessment. During the home safety assessment, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse

A space heater can be used as long as it's placed at least 3 feet from anything that may ignite

A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls

I took the bathmat out of my tub

An LPN tells the RN that she administered acetaminophen to a client by way of the rectal route rather than the prescribed oral route b/c the client was extremely nauseated. The RN most appropriately

Asks the LPN to complete and file an incident report

A military nurse who is in charge of planning a vaccination clinic to administer the smallpox vaccine to military personnel is preparing a pamphlet that sets forth guidelines for care of the vaccination site. Which guideline should the nurse include in the pamphlet

Avoid sharing towels or other items that have come in contact with the vaccination site

The mother of a 3 year old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately

Call the poison control center

A nurse manager of an ED arrives at work and is told that 4 RNs scheduled to work will not be reporting to work b/c they are ill. Every trauma room is busy and EMS has just called to report that several victims involved in a 10 car wreck on the interstate will be brought to the ED. the nurse manager initially manages this situation by

Calling the nursing supervisor to discuss activation of the disaster plan

A nurse in a long-term care facility recognizes the need to place wrist restraints on a client but the client does not want the restraints applied. The appropriate nursing action would be to

Contact the physician

A nurse is preparing to initiate a continuous tube feeding, using a tube feeding pump. On bringing the pump to the bedside and preparing to plug the pump in, the nurse discovers that there is no available plug in the wall socket. What should the nurse do

Determine the need for appliances now plugged into the needed wall socket

A community health nurse working in a school setting is concerned b/c parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is

Determining the appropriateness of the planned health activity

A nurse has provided instructions to a mother regarding the use of safety seats in car travel for new newborn infants. Which statement by the mother indicates understanding of the instructions

I'll put the baby's carseat in the middle back seat, facing backward and reclined a little

A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate

Placing a surgical mask on the client for transport and for contact with other individuals

A community health nurse is asked to assist in developing a community disaster plan. The nurse determines that this responsibility is a component of which disaster mgmt phase identified by the Federal Emergency Mgmt Agency (FEMA)

Preparedness

A nurse is admitting a postop client from the PACU to the surgical nursing unit. Which of the following measures would the nurse take for the safety of the client

Putting the side rails up after moving the client from the stretcher

Contact precautions are initiated for a client with MRSA infection. The nurse, providing instructions to a UAP about caring for the client, tells the assistant

To wear gloves and a gown when changing the client's bed linen

A nurse employed in a medical care unit is administering meds. She tells a client that she is going to administer his furosemide through his IV. The client tells the nurse that he takes this med orally at home everyday and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action

Varying the physician's rx

A nurse giving a bed bath drops the towel on the floor. The nurse should

Wash her hands and go to the linen room to obtain another towel

Which event would require a nurse to complete and file an incident report

When a visitor suddenly becomes weak and dizzy, the nurse checkers the visitor's BP and takes a visitor to the ED for tx

A nurse performs an evaluation to determine whether a client's home is electrically safe. Which finding indicates the need for further investigation and intervention

Wiring for the TV runs under the carpet

A HHC nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to

Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

A RN is instructing a group of UAPs in the principles of body mechanics. Which of these observations tell the nurse that a student is ugin the principles appropriately SATA a) The UAP keeps the object to be moved as close to his body as possible b) The UAP leans forward when turning a client in bed c) The UAP turns his back to change position while moving a client d) The UAP helps a client requiring total care into a chair without additional assistance e) The UAP positions a box that is to be lifted between his knees

a, e

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant SATA a) Keep all bed linens and dressings in the client's room until the implant is removed b) Wear a lead shield when in the client's room c) Wear a dosimeter film badge when in the client's room d) Limit visits from family to 60min per day e) Allow children to visit the client as long as they are at least 12 years old

a-c

A nurse is reading the H&P exam findings of an older client who had just been admitted to the hospital. Which findings documented in the hx indicate an increased risk for accidents SATA a) Voluntary and autonomic reflexes are slowed b) The client complaints of frequent nocturia c) The client's ROM is limited d) High frequency hearing tones are perceptible e) The client's peripheral vision is decreased f)Transmission of hot impulses is delayed

a-c, e, f

A nurse in PACU receives a client from the OR. for what finding should the PACU nurse assess the client first

airway patency

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive

ambularm

An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin anthrax. For which early sign of skin anthrax does the nurse tell the employees to check their skin

an itchy bump

A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted SATA a) Immune b) GI c) GU d) Lymphatic e) Lungs f) Skin

b, e, f

A triage in an ED is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergency category SATA a) A victim with a forehead laceration that is not bleeding b) A victim with a fractured humerus c) A victim with resp distress d) A victim with multiple non bleeding bruises of the arms and legs e) A victim with partial amputation of the foot

c, e

In which of the following situations would the nurse use the mitten restraints SATA a) To prevent the client from turning side to side b) To prevent the client from getting out of bed c) To prevent the use of the hands while allowing free arm movement d) To secure the shoulders and waist e) To prevent dislodgement of an IV f) To immobilize a client's arm and shoulders

c, e

A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill SATA a) Placing the pieces of broken glass into a plastic bag b) Blotting up the spill with a face cloth or cloth towel c) Disinfecting the area of the blood spill with a dilute bleach solution d) Wearing gloves for the cleanup procedure e) Using tongs to collect any broken glass

c-e

Wrist restraints have been prescribed for a client who is constantly pulling at his G-tube. Which findings does the nurse, developing a care plan, recognize a unexpected outcomes r/t the use of restraints SATA a) The client verbalizes the reason for restraints b) The client is unable to reach the G-tube with his hands c) The client becomes agitated d) The client's left hand is pale and cold e) The skin under the restraint is red f) The client slips his hand from its restraint and pulls at his G-tubea

c-f

A client undergoing chemotherapy is found to have an extremely low WBC and neutropenic precautions, including a lo-wbacterial diet, are immediately instituted. Which of these food items will the client be allowed to consume SATA a) Tossed salad b) Raw celery c) Fresh apple d) Well-cooked cheeseburger e) Italian bread f) Baked chicken

d-f

According to the Federal Emergency Mgmt Agency (FEMA) description of the phases of disaster mgmt, in which phase are the available resources for the care of infants, older clients, the disabled and people with chronic health problems addressed

mitigation

A nurse is providing instructions to a UAP who will be caring for a client in hand restraints. The nurse instructs the UAP to release the restraints to permit muscle exercise

q2h

A nurse is assisting with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions and securing physical care when needed are all examples of which level of prevention

tertiary

A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first

Activating the fire alarm

Which of the following actions are in keeping with the principles of standard precautions SATA a) Wearing a face shield as part of the protective garb during a wound irrigation b) Handwashing before removal of a pair of soiled gloves c) Cleaning of blood spills with soap and warm water d) Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg e) Handwashing between client contacts f) Discarding needles in puncture resistant containers

a, d-f

A nurse leading an educational session about terrorism for members of the community is discussing antrax. Which of the following pieces of information should the nurse provide to the group attending the session SATA a) Anthrax is never fatal b) A blood test is available for the detection of anthrax c) Anthrax can be transmitted from person to person d) No vaccine is available to prevent anthrax e) One way that anthrax can be contracted is through skin

b, e

A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions SATA a) I can use my electric razor while I'm using oxygen b) I have to keep the O2 concentrator out of direct sunlight c) I need to follow the O2 rx exactly d) I have to tell everyone that they can't smoke or have an open flame within 10 feet of the O2 concentrator e) I need to keep the O2 concentrator as close to the wall as possible or put it on the corner

b-d

A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client's safety risk SATA a) Requesting that the client transfer to an assisted living environment for at least 1 month b) Observing the client's gait and posture c) Looking for any hazards in the home environment d) Assessing the client's visual acuity e) Asking a family member to move in with the client until her recovery is complete f) Evaluating the client's muscle strength

b-d, f

A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks SATA a) The use of latex gloves b) The use of shielded needles c) Disposal of needles in special puncture resistant containers d) The use of recessed needles e) The use of needleless devices

b-e

The nursing staff in an ED is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route

inhalation

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list SATA a) Have a first aid kit available b) Plan a meeting place for family members c) Have and adequate supply of rx meds d) Have a firearm or other weapon available e) Have a battery operated radio and a flashlight and batteries available f) Obtain a 1 day supply of water (1 gallon per person)

a, b, c, e

Which of the following statements reflect the principle of sterile technique SATA a) The edge of a sterile field and a border 1 inch inward is unsterile b) Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated c) Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched d) When a sterile field becomes wet, it remains sterile as long as the items on the field are not touch e) Sterile objects that come in contact with unsterile objects are to be considered contaminated f) If a package is not labeled as sterile, it should be considered unsterile

a, b, e, f

A nurse caring for a client with leukemia who is undergoing chemo reviews the latest lab results and notes that the neutrophil count is below 500. Which of the following interventions does the nurse implement on the basis of this finding SATA a) Maintaining sterile occlusion of IV catheters b) Avoiding overinflation of the BP cuff and rotating the cuff among several sites c) Performing meticulous skin decontamination before venipuncture d) Monitoring the client's oral temp e) Providing a soft toothbrush for oral care f) Requiring the client to use an electric shaver rather than a razor

a, c, d

An older client is extremely anxious after admission having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do SATA a) Allow the client to have as many choices regarding his care as possible b) Put the client in a room far from the nurses' station c) Acknowledge the client's feelings d) Keep visitors to a minimum e) Provide info about hospital routines f) Keep the door open and the room lights on at all times

a, c, e

n ED nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation SATA a) A victim with a limb amputation b) A victim who has sustained minor bruising of an arm and the lower legs c) A victim who is alert but complaining of loss of vision d) A victim who is dazed and staggering around the other victims e) A victim who is bleeding profusely from a head laceration

a, c, e

A client with paraplegia has spasticity of the leg muscles. Which interventions should be included in the plan of care for this client SATA a) An as needed rx for muscle relaxant b) The use of restraints to immobilize the limbs c) ROM exercises of the affected limbs d) Removal of potentially harmful objects near the client e) The use of padding against the client's legs when the client is sitting in a wheelchair

a, c-e

Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection SATA a) Emptying urinary drainage systems (foley cath) on each shift unless prescribed otherwise by a physician b) Placing caped needles and syringes in puncture resistant containers c) Changing dressings that become wet or soiled d) Using soap and water to remove drainage, dried secretions or excess perspiration from a client's skin e) Keeping bedside table surfaces clean and dry f) Placing tissues and soiled dressings in paper bags

a, c-e

A HHC nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicates a need for further teaching SATA a) I need to remove my wall to wall carpeting b) I need to use the staircase handrails when I go up the stairs c) I need to use night lights d) I should walk barefoot as much as possible so that I'll know about any wet spots on the floor e) I need to get handrails put up in the bathroom

a, d

A nurse, assessing a client's readiness for d/c, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further SATA a) I don't have any nightlights in the house b) I live in a single-story house c) I keep my personal items within reach when I sit in my easy chair d) I haven't changed the batteries in the smoke detectors in my home for quite a few years now e) I've removed the scatter rugs from the house

a, d

Which of the following actions are means of maintaining medical asepsis to reduce and prevent the spread of microbes SATA a) Practicing hand hygiene b) Sterilizing contaminated items c) Applying a sterile gown and gloves d) Wearing clean gloves to prevent direct contact with blood or body fluids e) Routinely cleaning the hospital environment f) Reapplying a sterile dressing

a, d, e

A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety SATA a) Carpet on stairs secured with tacks b) Small rugs in the living room c) Cereal boxes, canned foods and infrequently used cooking utensils stored on top of the refrigerator d)Clothes hamper at the end of the hallway e) Untacked rugs on the stairs

b, c, & e

A physician writes a rx for the application of a heating pad to a client's back. Which of the following actions should the nurse take when implementing this rx SATA a) Placing a heating pad under the client b) Frequently assessing the client's skin for signs of burns c) Assessing the heating pad periodically for proper electrical function d)Assessing the client's medical hx and risk factors for burns e) Adjusting the heating pad to the high setting

b, c, d

A nurse is assigned to care for a client with an infection c/b MRSA. The client has an abdominal wound that requires irrigation and has a trach attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain SATA a) Shoe protectors b) Face shield c) Gloves d) Mask e) Gown

b, c, e

Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints SATA a) The clients temp b) The date and time of application of the restraint c) The procedure used in applying the restraint d) The client's 24 hour urine output e) Circulatory and neurovascular status of the restrained extremities f) Skin integrity of the restrained body part

b, c, e, f

A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. The client has a tendency to be forgetful. Which items in the home increase the client's risk for injury SATA a) Smoke and carbon monoxide detectors b) Cooking equipment such as a stove c) A water heater thermostat adjusted to a low setting d) Common household objects such as doormats e) A nightlight in the bathroom f) Elevated toilet seat with armrests

b, d

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of symptoms and injury. Which instructions should the nurse provide to the client SATA a) Turn your head slowly when someone speaks to you b) Change positions slowly c) Drive your car only if you're not feeling dizzy d) Remove clutter from your home e) Use public transportation as much as possible

b, d

After discussing the use of restaurants with a client and family, a physician has written a rx for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nurse assistant is using the restraints safely and correctly SATA a) The restraints have been tied to the side rails of the bed b) A safety knot has been used to secure the restraints c) The restraints are applied tightly d) The call light has been placed within reach of the client e) The restraints are being released q2h

b, d, e

Which actions should the nurse take in the event of an accidental poisoning SATA a) Place the client in the supine position b) Determining the type and about of substance ingested c) Inducing vomiting if a household cleaner has been ingested d) Saving vomitus for lab analysis e) Assessing the client's airway patency, breathing and circulation f) Removing any visible materials from the nose and mouth

b-f