Safety and Infection Control

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. What should the nurse do first?

Assess the client's current condition and vital signs. rational: The nurse's first priority is to complete an assessment of the client including assessment of airway, breathing, circulation, and vital signs as well as any change in level of consciousness or obvious injury. The nurse should not move the client or assist the client back to bed until after an assessment has been completed to prevent further injury. Although it may be helpful to know what the client was doing out of bed to assess for potential confusion, the client's immediate safety is the first priority. The nurse would not activate the "Emergency Response" button until an initial assessment was done to determine the need.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g per hour. What is the priority intervention to maintain safety for this client?

Assess reflexes, clonus, visual disturbances, and headache. rational: Central nervous system (CNS) functioning and freedom from injury are priorities in maintaining the well-being of the maternal-fetal unit. If the birth parent has CNS damage related to hypertension or stroke, oxygenation status is compromised, and the well-being of both the client and the infant is at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring liver studies gives an indication of the status of the maternal system, but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first

call the poison control center. rational: Before intervening in any way, the parents should first call the poison control center for specific instructions. Ipecac syrup is no longer recommended for the ingestion of poisons. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.

A client who has been sexually assaulted is admitted to the emergency department (ED). Which is the most important initial statement by the nurse?

"I'll stay with you while you're here." rational: The priority of care for the client is safety. Staying with the client at all times is a priority. The perpetrator most likely threatened the victim that if they informed anyone about the incident, the rapist will severely harm or kill the victim. Staying with the client also supports the development of trust in the nurse by the client. The question regarding the identity of the perpetrator is within the realm of the authorities—not the nurse. Leaving the ED to obtain the rape kit is not the safety priority; this action can be delegated to another individual. Telling an individual to "not worry" is nontherapeutic communication and will not allay the fears of a client who has undergone the trauma of a physical sexual assault.

A nurse is supervising a student during medication administration to a client. Which action by the student would cause the nurse to intervene during the med pass at the bedside?

Check the room number and the client's name on the bed. rational: Checking the client's identification band is the safest way to verify a client's identity because the band is assigned on admission and should not be removed at any time. Asking the client's name would be also be appropriate. Checking the room number isn't appropriate because clients may be transferred from another room and the paperwork may not be correct. Checking the client's name on the bed is not appropriate because names on beds are also not always correct.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next?

Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. rational: The nurse should immediately compare the information on the mother's identification band with that of the neonate's and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.

The nurse is developing a care plan for a client with tuberculosis. Which measures would be implemented for staff prior to entering the room?

Wear a mask at all times when entering the room. rational: A special mask that prevents the passage of airborne droplets is needed to intercept airborne droplet transmission. This choice represents the use of transmission-based precautions specifically to prevent the spread of tuberculosis. Gowns and gloves are not required; visitors are welcomed providing they wear a mask during their visit to protect themselves.

A nurse has just been trained in how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor?

calibrating the machine after installing a new battery rational: To obtain accurate readings, the nurse should calibrate the machine whenever a new battery is installed. To adhere to standard precautions and prevent contact with blood, the nurse's hands should remain gloved throughout blood glucose testing. The nurse should drop the blood — not smear it — onto the reagent pad because smearing can cause an inaccurate reading. To help ensure accurate results, the nurse shouldn't start the timer before the blood sample is collected.

The nurse is teaching the family of a client diagnosed with leukemia about ways to prevent infection. Which instruction has the most impact?

maintaining an intact skin integrity rational: A client with leukemia has a compromised immune system. Maintaining skin integrity is a priority as the skin is a barrier to pathogens. If a pathogen enters the client's system, the client may not be able to fight off the bacteria and it will multiply and spread. Bathing daily can decrease bacteria on the skin but unless there is a break in the skin, the bacteria will remain on the skin. Covering the mouth when coughing protects others but does not have an impact on the client. Ingesting a plant-based diet may be nutritious, which helps the immune system; but, this does not have the most impact.

A neonate receives an intravenous (IV) infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply.

when the infusion is started at the beginning of each shift when the neonate returns from x-ray rational: The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been taken out of the crib, it is not necessary to check alarm settings after the parents visit.