Safety and Infection Control

The nurse is teaching a group of clients at the community center about burn prevention for children. Which of the following should be included in the teaching?

"The handles of the pots on the stove must be turned inward."

Which finding observed by the nurse would indicate an allergic reaction?

A sign of allergic reaction is swelling of the lips, mouth, and tongue

The nurse has attended a staff education conference about incident reporting. Which of the following statements by the nurse indicates a need for further teaching?

"An incident report should be submitted when a client has an allergic reaction to a newly prescribed antibiotic. It is the correct understanding of incident reporting if the nurse states that a client fall, medication error, and an incorrect prescription that is written for a client require incident reports. These are all considered errors or adverse/preventable events and should be reported to identify strategies to reduce human error and adverse events in the future.

The home health nurse is conducting a safety visit with the family of a toddler who is crawling. Which statement by the parent would require follow-up by the nurse?

"Any furniture with sharp edges we cover with a blanket." Checking the water temperature reduces the risk of burns. Toddlers are unsteady and can fall easily on unsecured rugs. Toddlers put everything in their mouths so small objectives are a choking hazard. Covering the electrical outlets will prevent them from placing items in the outlet.

The nurse is providing staff education on reducing hospital acquired infections by eliminating potential reservoirs of infection. Which of the following statements should be included in the teaching?

"Client bedrails should be disinfected regularly using hospital approved wipes. Research has shown that one of the biggest reservoirs of infection is the client's bedrails. These must be thoroughly sterilized between patients. Gloves are a potential source of infection. If someone is wearing gloves and touches a reservoir then touches the door handle, the door handle becomes a reservoir.

The nurse has taught a client about measures to reduce the risk of repetitive stress injuries. Which of the following statements by the client indicates the need for further teaching?

"Frequent lifting of heavy objects will increase muscle strength and reduce my risk of repetitive stress injuries. Repetitive stress injuries are caused by sports, occupations, and hobbies that cause repetitive motion, causing strain on the joints and tendons. Frequent lifting of heavy objects increases the risk of repetitive stress injuries and requires further teaching

The occupational health nurse is teaching a client about measures to reduce the risk of carpal tunnel syndrome. Which of the following should the nurse include in the teaching?

"Geometrically designed keyboards may assist with reducing strain on your fingers and wrists. A geometrically designed keyboard may reduce strain on fingers and wrists as well as adjustable height desks to allow for alterations in positions throughout the day.

The nurse is teaching a group of parents about measures to reduce the incidence of unintentional poisoning in toddlers. Which of the following statements by a parent indicates a need for further teaching?

"I will keep houseplants on the ground to ensure they do not get knocked over and cause injury." Major causes of unintentional injury in toddlers are accidental poisoning due to ingesting toxic substances, such as plants, chemicals, and medications.

The nurse is teaching a client about fire safety in the home. Which of the following statements by the client indicates the need for further teaching?

"In the event of a fire, I will open all the windows in my house It requires further teaching if the client states that they will open all windows and doors during a fire. The client should be taught to contain the fire, if possible, by closing windows and doors, which deprives the fire of oxygen

A nurse is assisting a healthcare provider with a sterile procedure and prepares to pour a solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution? Place the steps in order, and all steps are to be used.

4. Perform hand hygiene. Remove the bottle cap. 2. Place the bottle cap face-up on a clean surface. 5. Pick up the bottle with the label facing toward the palm. 1. Pour 1 to 2 mL into a receptacle. 3. Pour the solution onto the gauze.

The charge nurse is required to recommend a client that can be discharged in the next hour due to a disaster plan activation. The nurse should recommend which client for discharge?

A client post-laparoscopic cholecystectomy with a prescription for a soft diet A postoperative client who is tolerating oral intake is considered stable for discharge

A community health nurse is educating a group of clients on burn safety. Which client is at a higher risk for burns?

A client with peripheral arterial disease Clients with peripheral arterial disease have decreased blood flow and sensitivity to the lower extremities. Clients with decreased sensation to the feet can suffer burns without realizing the injury.

is the identification of any event or situation that might have resulted in client harm, but the harm did not occur due to timely intervention by healthcare staff.

A near-miss event

he nurse is documenting an occurrence in which the incorrect mole was removed from a client's leg. Which type of practice error should the nurse document as having occurred?

A never-event Never-events are defined by the Joint Commission as surgeries on the wrong body part, foreign objects placed in the client after surgery, and mismatched blood transfusions.

A charge nurse is assigning a room to a client with a history of moderate Alzheimer's. The charge nurse will assign the client to a room in which area of the unit?

Across from the medication room Clients with moderate Alzheimer's may have personality and behavioral changes that lead them to wander and get lost. Medication rooms are frequently used by nurses for patient with Alzheimer

A nurse is providing care to a client experiencing substance withdrawal. Which prescription by the healthcare provider requires clarification?

Ambulate ad lib Clinical manifestations of substance withdrawal include tremors, irritability, and unsteady gait. These manifestations increase the risk for falls

occur when actual harm is inflicted on a client due to healthcare errors.

An adverse event

The nurse is participating in the implementation of a hospital's disaster response plan. Which of the following indicates correct understanding of disaster planning?

Annual drills are required and should include community-wide resources with a simulation of a large influx of clients

The nurse is walking a client to the bathroom who has a history of seizures. The client states "My vision seems to be distorted." What action should the nurse take first?

Return the client to bed The patient is reporting signs and symptoms of an aura, which is a warning sign before a seizure. Returning the client to bed will reduce the likelihood of injury.

The nurse is conducting a compliance survey to identify adherence to infection control practices. While observing handwashing, which of the following findings would require intervention?

Artificial nails are scrubbed using a brush for 30 seconds The CDC and WHO both have recommendations regarding the avoidance of artificial nails in healthcare settings. Handwashing should occur for at least 15 seconds, include the wrists, and rinse water proximal to distal.

Which action by the nurse indicates correct understanding of assignments during a disaster

Assigning a critical care nurse to care for emergent clients in the emergency department Critical care nurses may be reassigned to care for critical patients in the emergency department. Nurses on the medical-surgical floor may be assigned to care for stable clients in the emergency department so that emergency room nurses can perform triage on critical patients.

The charge nurse is observing a newly hired nurse assess the client's ability to ambulate while transferring from a supine position in bed. Which of the following actions by the newly hired nurse requires intervention?

Assisting the client to sit upright with legs dependent on side of bed for 10 seconds

Before administering the medication, which action will the nurse perform first?

Scan the bar code on the client's wristband Client identification should occur before performing interventions

A dayshift nurse administered insulin aspart to a client at 0730. The nightshift nurse calls stating they forgot to document the administration of the same medication to the client at 0630. Which action does the nurse perform next?

Check the client's capillary blood glucose. The nurse's priority action is to assess the client for hypoglycemia due to the administration of a double dose of insulin.

A nurse is preparing to assess a newly admitted client. Which action should the nurse take first?

Checks the client's wristband The nurse should ensure proper identification of the client before providing care. The client's wristband will confirm name, date of birth, and medical record number.

The nurse educator is reviewing the policy about needlestick injuries with a group of staff nurses. Which action should the nurse take first following a needlestick from a contaminated needle?

Clean the site with soap and water The puncture site and skin should be washed thoroughly with soap and water. Then the nurse should follow the next steps in the facility-specific protocol for when a needlestick occurs. Once the nurse has reported the incident to the supervisor, the nurse will be directed to seek immediate treatment.

The home health nurse is assessing a client's home for safety hazards. Which finding observed by the nurse would increase the client's risk for carbon monoxide poisoning?

Client uses a wood-burning stove to heat the home. Carbon monoxide is an odorless, colorless gas that is toxic, and prolonged exposure can lead to brain damage or death. Risk factors for carbon monoxide poisoning include using gasoline-powered vehicles, lawnmowers, barbeques, and wood-burning units or stoves inside the home

A nurse is providing teaching to a client who reports mild hearing impairment associated with aging. what is the best action by the nurse

Clients with a hearing impairment benefit from lip reading and facial cues. plus Sitting at eye-level in front of the client

The nurse is educating a client who has age related macular degeneration on home safety practices. which statement is appropriate

Color-code the controls on your kitchen appliances. Color-coding kitchen appliance controls helps to ensure that the client is able to operate the appliances safely. An example of this is stove burner knobs; turning on the incorrect burner increases the risk of burns and fire. Lights should be bright,

The nurse is planning care for a client with methicillin-resistant staphylococcus aureus pneumonia. Which type of precaution should the nurse implement for this client?

Contact precautions Contact precautions involve the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any of the body fluids is expected.

The nurse is providing an in-service to the nursing staff on needlestick prevention using needle-based safety systems. Which of the following actions should the nurse demonstrate when placing the syringe with a needle in the sharps container?

Immediately engage the safety shield Needle based safety systems have a one-handed safety mechanism built into the device. They should be engaged immediately after use. the safest way to dispose of a used needle is to immediately place it in a sharps disposal container

Which action by the nurse indicate the correct use of fire extinguisher

Correct technique for use of a fire extinguisher includes pulling out the safety pin, aiming the hose at the base of the fire, squeezing the handle to discharge the material, and sweeping the hose from side to side.

Diabetic nephropathy is damage to the kidneys due to elevated blood glucose levels. Diabetic nephropathy does not result in decreased sensory perception.

Diabetic nephropathy is damage to the kidneys due to elevated blood glucose levels. Diabetic nephropathy does not result in decreased sensory perception.

A nurse is providing care to a client with chronic constipation. The client is on neutropenic precautions. Which prescription should the nurse clarify?

Digital disimpaction The nurse should clarify the prescription for digital removal of feces. Digital disimpaction can damage the mucosa along the rectal wall and increase the risk of infection. A client with neutropenia is immunosuppressed

The nurse is performing a dressing change for a client who has an abdominal wound healing by secondary intention. There is a moderate amount of sanguineous drainage on the old dressing. How should the nurse dispose of this dressing?

Discard in a red biohazard waste bin A red bag marked BIOHAZARD is used to dispose of trash that contains liquid or semiliquid blood or other potentially infective material (OPIM), trash contaminated with blood or OPIM that would release these substances if compressed, and trash that is caked with dried blood or OPIM and is capable of releasing these materials during handling.

The nurse is performing client care in response to an external disaster in the community. Which of the following actions should the nurse take first?

Evaluate clients for airway patency and effectiveness of breathing The primary survey during a disaster response is performed to detect life-threatening injuries, which consists of checking for airway-breathing-circulation, disability, exposure, and then facilitation of family

The nurse is providing education on prevention of repetitive stress injuries to an adult client who does virtual learning. Which of the following statements should be included in the teaching

Float the wrists above the keyboard Repetitive strain injury (RSI) is a general term used to describe the pain felt in muscles, nerves, and tendons caused by repetitive movement and overuse. The condition mostly affects the forearms and elbows, wrists and hands, and neck and shoulders. The desktop should be at or below the level of the elbows to reduce shoulder strain. The wrists should be floating above all surfaces. A wrist rest can cause or worsen carpal tunnel syndrome.

The nurse is reviewing the communicable disease policy about what information needs to be provided to the health department. Which statement by the nurse indicates the need for additional education about the policy?

HIPAA prevents the reporting of personal information. HIPPA does not apply to reportable diseases

The nurse is assessing a client for the risk of allergic reactions to products commonly used in the healthcare setting. Which of the following statements by the client requires follow-up?

I avoid eating bananas because they make me itchy. Rationale: Clients should be assessed for risk of allergic reactions to products commonly used in the healthcare setting, such as iodine, adhesive tape, and latex. A sign of allergic reaction includes itching after eating a product. Allergies to foods such as bananas, kiwis and avocados are known to also cause allergic reactions to latex in clients, therefore itching after ingesting bananas may indicate risk of allergic reaction to latex.

The nurse is assessing a client for allergies prior to a scheduled magnetic resonance image (MRI) with contrast. Which of the following statements by the client requires follow-up

I get itchy when I put iodized salt on my food. Clients who are undergoing diagnostic testing with contrast medium should be assessed for allergies to iodine-containing food such as shellfish, cabbage, kale, and iodized salt, which could cause an adverse reaction.

The nurse is interviewing an older adult client in the outpatient clinic about home safety. Which statement by the client indicates the need for intervention?

I like to keep the lighting low because it hurts my eyes Low lighting increases the risk of falling, therefore the nurse should educate the client on the need to increase light brightness or add lighting to the home

The nurse is providing teaching to client on the use of range of motion exercises while on bedrest. Which statement made by a client indicates the need for further teaching?

I will hold my leg when someone rotates the joint." Active range of motion exercises are movements that the client does independently. The client should be instructed to perform the active range of motion exercises. The nurse should instruct the client to perform the movement until resistance is felt. When exercising a joint, the movement should be done at least 3 times. When performing leg exercises, the client should lift the foot about 6 to 12 inches off the bed. Passive range of motion exercises are done with someone performing the exercise.

The nurse is instructing a group of unlicensed assistive personal in the correct use of personal protective equipment. Which statement by the UAP indicates understanding of the correct protocol?

I will wear gloves when performing hygiene care Gloves should be worn for all contact with blood and body fluids, nonintact skin, and mucous membranes for handling soiled items during hygiene care. Masks are worn when exposed to airborne and droplet respiratory disorders, such as tuberculosis or Covid-19, and can be worn any time of year. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. Protective equipment is put on before entering a room

A nurse is providing education to a client with diabetes type 2 on using a blood glucose monitor at home. Which client statement indicates an understanding of the teaching? Question 15 Answer Choices

I will write the date I opened the test strips on the container. Expired test strips can produce inaccurate results. Writing the date on the bottle prevents test strips from being used beyond their expiration date

The nurse is caring for a client with a history of falls. The nurse observes the client attempting to get out of bed unassisted. Which safety device should the nurse implement for this client?

Initiate a pressure bed alarm The nurse should attempt less restrictive safety devices, such as pressure bed alarms. A pressure bed alarm is a safety device that alerts staff if the client attempts to get out of bed.

A nurse is reviewing the medical record for a client with a urethral stricture. Which prescription should the nurse clarify with the healthcare provider?

Insert an indwelling catheter Insertion of an indwelling catheter may cause further trauma to the urethra if the stricture has not been dilated.

The nurse is caring for a client who has an allergy to shellfish. Which of the following products should the nurse avoid when caring for this client?

Iodine and Betadine Clients with shellfish allergies may have a cross-reaction with products that contain iodine, including Betadine

The nurse is planning care for a client who is receiving a hematopoietic stem cell transplant. Which actions should the nurse take?

Keep client care equipment in the room Clients who are receiving stem cell transplants are at high risk for infection. The nurse should plan interventions that prevent infection. The nurse should keep all client care equipment in the room and use dedicated equipment to prevent the spread of infection. The nurse will limit the visitors to the client to prevent exposure. The nurse should provide fresh water, replacing it every hour. The nurse should monitor the client's vital signs every four hours.

A nurse is reviewing new prescriptions for a client with suspected meningitis. The client has a history of atrial fibrillation and is taking warfarin for disease management. Which prescription should the nurse clarify?

Lumbar puncture The nurse should clarify the lumbar puncture order. Clients who are on anticoagulant medications are at risk of bleeding. A lumbar puncture may cause bleeding that can compress the spinal cord.

The emergency department nurse manager is conducting a risk assessment for security planning. Which finding should the nurse manager identify as a potential risk for workplace violence?

Nursing is understaffed on the nightshift Risk factors for workplace violence include, working when understaffed, working at night, high worker turnover, inadequate security personnel, and long waits for clients.

The nurse is reviewing the plan of care with a client who has a prescription to remain supine for 24 hours following a procedure. Which statement should the nurse make to the client regarding positioning?

Place a pillow under your legs The supine position increases pressure on the client's heels and coccyx. To alleviate this pressure, the nurse should instruct the client to keep a pillow under their legs, this will float the heels off the bed and prevent pressure

The nurse has collected a stool specimen from a client with antibiotic associated diarrhea. Clostridium difficile is suspected. What action should the nurse take to transport the specimen to the lab?

Place the specimen in a small biohazard bag Send or transport the specimen to the laboratory in a biohazard bag immediately or within the optimal time from collection as indicated by facility policy and guidelines.

A nurse attended a training session on how to use a powered stand-assist lift to transfer a client to a chair. Which action by the nurse indicates correct use of the device?

Places the sling under the client's arms Placing the sling under the client's arms is a correct method. The sling should be placed around the client's back and under the arms to support the torso during lifting. The feet should be placed on the footrests of the lift to support the weight during transfers. The nurse should instruct the client to place the hands on the lift handles. The powered stand-assist lift is designed to lift the client without assistance from the nurse.

The nurse is adding sterile solution from an open container onto a prepared sterile field. Which action should the nurse take

Pour the sterile solution from a height of five inches When adding sterile solution to prepared sterile field, the nurse should maintain the sterility of the solution and the field by pouring the solution 4 to 6 inches above the sterile container. When using a sterile solution container that has been opened, the nurse should place the cap with edges up and pour out solution lipping the bottle edges before pouring the solution onto the sterile field. The nurse will apply sterile gloves after pouring the sterile solution to prevent contamination.

The nurse is caring for a client who is undergoing internal radiation therapy. Which of the following actions by the nurse is appropriate to ensure safety?

Prohibiting visitation from children For the client undergoing internal radiation therapy, the nurse should prohibit visitation from children or pregnant individuals.

The nurse is caring for a pediatric client who is experiencing a febrile seizure. Which action should the nurse take first?

Protect the child's head from injury Protecting the child from injury would be the highest priority action. Seizure activity may cause the child to have involuntary movements which could result in hitting their head

The nurse is caring for a pediatric client with a new diagnosis of cancer. The parent appears to be quite angry and has made threats toward staff members. Which of the following actions will reduce the risk of workplace violence while maintaining a caring environment?

Remain close to the doorway when talking with the parent. Remaining close to the doorway allows the nurse to leave the room for assistance in case the parent becomes physically violent

A nurse walks into a client's room and hears the unlicensed assistive personnel (UAP) telling the client, "If you continue to use that call bell for no reason, I am going to restrain you." What action does the nurse take?

Report the UAP's statement to the unit manager The statement made by the unlicensed assistive personnel (UAP) is considered assault. Threatening statements to a client should be reported to a supervisor.

The nurse is providing teaching about car seats to a client who is a first-time parent to a premature infant. Which information should the nurse include in the teaching?

Select a car seat with less than 5 ½ inch distance from the crotch strap to the seat back

The charge nurse observes a staff nurse carrying soiled linen in the hallway from a client who is receiving chemotherapy. Which statement by the charge nurse would be most appropriate?

Soiled linens should be held away from the body and placed in a linen cart or bag before leaving the room Linens should be held away from the body to prevent contamination of the nurse's clothing.

A staff nurse is assisting the unit charge nurse with narcotic counts. The staff nurse notices the charge nurse becomes nervous when several discrepancies in the counts are found. Which action should the staff nurse take?

Stop the count and notify the unit manager. It is the nurses' responsibility to report narcotic discrepancies and behaviors indicative of substance abuse. The nurse should stop the count and notify a supervisor.

The nurse is transporting a client in a motorized hospital bed when the cord becomes trapped under the wheel. The cord is visibly damaged. Which of the following actions is appropriate?

Tag the bed for repair and remove it from the patient care area Rationale: The bed should be removed from use and appropriately tagged for repair. Electrical equipment can present a safety hazard to both the patient and health care practitioner when safety measures are ignored. Electrical cords that are bent or twisted may have broken wires inside.

The nurse is caring for a client receiving an intravenous infusion using a smart pump when a system error begins alarming. Which action by the nurse will reduce the risk of injury to the client?

Tag the device for maintenance and remove it from the unit Electrical equipment can present a safety hazard to both the patient and health care practitioner when safety measures are ignored. IV infusion equipment has the potential to experience software and system errors that can result in delayed infusions, over-infusion, under-infusion, or failed infusions. These errors can lead to serious injury and death. When system errors occur, the best action is to remove the device from service until it has been serviced.

The nurse is assessing an older adult client for risk factors associated with falls. Which of the following should the nurse identify as increasing the risk of falls?

Taking an opioid analgesic for pain opioid analgesics and diuretic Factors that increase the risk for falls in older adults include medication use such as opioid analgesics which can cause confusion and drowsiness, as well as diuretic use, which can cause orthostatic hypotension leading to dizziness

The nurse is providing teaching about car seats to the parents of a 30-pound child. Which of the following should be included in the teaching?

The child can be placed in a forward-facing car seat with a harness. A child of 30 pounds can sit in a forward-facing car seat or booster. The buckled clip needs to be at the armpit

The nurse is performing hand hygiene before providing care to a group of clients. The nurse should identify that the use of alcohol-based hand sanitizer would be contraindicated in which of the following clients?

The client receiving treatment for Clostridium difficile the nurse should use soap and water when caring for clients with Clostridium difficile, which is a gram-positive, spore-forming bacteria that is not killed with alcohol.

The nursing supervisor is working in a hospital that is in the path of a hurricane. Which client would be appropriate for immediate discharge?

The client with nondisplaced tibia fracture that has been immobilized Ambulatory clients who need no assistance are the first clients to be safely discharged and relocated. The lowest acuity client here is the tibia fracture as this injury does not require surgical intervention. Clients who are receiving high flow oxygen, IV medication, and experiencing complications should not be discharged.

The nurse is assessing a client's room for safety hazards. Which finding observed by the nurse would increase the client's risk for falls?

The client's side rails are raised on all sides of the bed Raising all side rails on a bed has been shown to increase the risk of client falls because clients may become entrapped and unable to get out of bed

A charge nurse is performing the daily check of the code cart on the unit. Which finding will the nurse report immediately for further inspection?

The defibrillator charging light is off A defibrillator should always be fully charged in case of emergencies.

A nurse is performing an equipment check in a client's room. Which finding requires intervention?

The excess infusion pump electrical cord is tied in a knot Electric cords should not be bent or twisted as this can cause the wires inside the cord to break. The nurse should loosen the cords

Which action by the staff nurse while wearing sterile gloves would require the charge nurse to intervene?

The nurse pulls up the clean sheet over the client's perineum for better draping Touching the clean sheet with sterile gloves will contaminate the gloves. The draping should be completed before the sterile gloves are put on. Touching sterile objects with sterile gloves does not result in contamination.

A nurse is implementing seizure precautions for a client with tonic-clonic seizures. Which action should the nurse take?

The nurse should ensure intravenous access is patent in case pharmacologic treatment is required.

The nurse is completing a home health visit for a client who uses a wheelchair. Which of the following findings indicate the need for home modification?

Uneven flooring in the home For the client who uses a wheelchair, having uneven flooring can be a significant safety issue and modifications are warranted

The nurse is caring for a client with severe osteoarthritis. Which of the following home interventions should the nurse recommend to promote client safety?

Use an assistive device for ambulation. Assistive devices allow a client with severe osteoarthritis to ambulate safely

The nursing supervisor is working in an acute care facility following an earthquake. The building has lost water supply and is on generator power. Which patients should the nursing supervisor evacuate first?

Ventilator dependent adults in the ICU. the most unstable In this case, the loss of power and water makes movement of acutely ill clients the priority. the most unstable based on building integrity, infrastructure, and environmental factors.

The nurse is working in the newborn nursery when an unfamiliar person in scrubs comes to the nursery door and requests to bring a newborn to the parents' room. What action by the nurse is appropriate?

Verify the hospital identification badge Each member of the hospital staff should have an identification badge clearly displayed. The nurse should look at the identification of anyone trying to transport a newborn as this is one way to prevent infant abduction.

The nurse is planning care for a client with a diagnosis of cancer who has received the first dose of intravenous chemotherapy. Which type of precautions should the nurse implement for this client?

Wear a gown and gloves when handling linens and body fluids Chemotherapy drugs are present in the waste and body fluids of clients for 3 to 5 days after administration. Nurses involved in handling chemotherapeutic agents may be exposed to low doses of the agents by direct contact, inhalation, or ingestion. Therefore, PPE should be worn when handling the client's linens

An event that occur when an actual death is inflicted on a client due to healthcare errors.

a sentinel event

The nurse is planning care for a client who is paralyzed on the right side. Where should the nurse place the signaling device?

on the left side of the bed near the client's hand

when wearing personal protective equipment (PPE) before entering the room of a client who is on droplet isolation. In which order should the nurse put on the PPE

the first item to put on is the gown, followed by the mask, face shield, and then gloves. gown mask face shield glove