EAQ: Safety and Infection control

Which intervention promotes safe movement of objects to protect the back?

Use handles or grips on the object

Which risk factors are associated with adolescent suicide?

Victim of family violence Dependence on alcohol, drugs, or both Uncertainty related to sexual orientation Repeated demonstration of poor impulse control

The nurse is teaching a group of college-age women the characteristics of a potential male batterer. Which signs would the nurse include?

Male batterers are often unable to empathize with others and perceive themselves as "special" and deserving of special attention for being the provider or protector in relationships. Batterers usually have low self-esteem and deficits in assertiveness, as well as inadequate communication skills and a rigid view of gender stereotypes.

Which situations come under the second level of Maslow's hierarchy of needs?

Rationale According to Maslow's hierarchy of needs, the second level of needs involves safety and security needs. This includes both physical and psychological security and safety of the person. Clients who are taunted by their boss every day, have spouses that are part of a criminal gang, or live next to a factory that manufactures harmful chemicals are display second level needs. A client who laments about not having friends or does not like interacting with people is displaying a third level of needs (love and belonging needs).

Which would the nurse teach a client with newly diagnosed pancytopenia caused by chemotherapy? Begin a program of vigorous mouth care. Avoid traumatic injury and exposure to infection. Increase oral fluid intake to at least 3 L/day. Report unusual tingling sensations in the extremities.

Avoid traumatic injury and exposure to infection. Rationale Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase the susceptibility to infection.

Which finding would the nurse be most concerned about when reviewing the chart of a client scheduled for an amniocentesis?

Rationale Because of the possibility of fetomaternal hemorrhage, administering Rho D immune globulin to the woman who is Rh negative is standard practice after an amniocentesis. Hepatitis B, prior uterine surgery, or active genital herpes do not increase the risk for maternal or neonatal complications of amniocentesis.

When preparing to safely administer medications to newborns, it is important for the nurse to recognize which factors as contributors to reduced renal medication excretion?

Rationale In newborns, renal blood flow, glomerular filtration, and active tubular excretion contribute to reduction of renal medication excretion.

Which gastrointestinal factor affects medication absorption and places infants at risk?

Gastric acidity Emptying time Rationale Rationale Gastric acidity and emptying time are gastrointestinal factors that affect medication absorption in the infant.

A primary health care provider prescribes carboprost to be administered to a postpartum client with intractable vaginal bleeding. Which prior condition noted in the client's history would alert the nurse to question this prescription?

History of asthma Rationale Carboprost is contraindicated in clients with asthma because of its respiratory side effects of coughing and dyspnea.

A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. Which action would the nurse's plan of care include?

Withholding oral fluid intake Rationale Withholding oral intake of fluids is part of the preparation for a cesarean birth. This client has active herpes, which can be transmitted to the infant during a vaginal birth.

When caring for a sedated client who is being mechanically ventilated, which action will the nurse take first when the low flow alarm is persistently sounding? Adjust the alarm settings. Notify the respiratory therapist. Ventilate manually and call for assistance. Check all connections and ventilator tubing

Ventilate manually and call for assistance. Rationale If an alarm is persistently sounding, the nurse would mechanically ventilate the client and ask another member of the health care team to take actions such as notifying the respiratory therapist, checking ventilator connections, or assessing the endotracheal tube cuff pressure.

Which agents of bioterrorism can be treated effectively with antibiotics? Plague Anthrax Botulism Tularemia Hemorrhagic fever

Plague Anthrax Tularemia Rationale Bioterrorism agents such as plague, anthrax, and tularemia are caused by bacterial species and are treated effectively by antibiotics. Botulism is treated with antitoxin though several vaccines are being studied. There are no established antiviral medications for most viruses causing hemorrhagic fever.

Which feeling would the nurse be trying to prevent in other clients when the nurse sets limits on a client with bipolar disorder, manic episode, who has a superior, authoritative, and condescending manner?

Anger Rationale The nurse is trying to prevent anger in other clients. A person with a condescending, superior attitude typically evokes feelings of anger in others and will increase their anxiety.

Which leukocyte is responsible for the allergic response?

Rationale Basophils stimulate the inflammation of allergy and hypersensitivity reactions. Monocytes are responsible for the destruction of bacteria and cellular debris before maturing into macrophages. Eosinophils act against parasitic infestations and limit inflammatory reactions. The main function of the macrophages is phagocytosis.

Which clinical finding during labor induction requires the nurse to discontinue the oxytocin infusion?

Several late fetal heart rate decelerations return to baseline after the contraction is over Think Veal Chop and (L) late decelerations equal (P) placental insufficiency.

When interviewing and assessing a 17-year-old client, which findings alert the nurse to explore substance abuse with the adolescent?

Failing grades Blood spots on clothing Absenteeism from school Long-sleeved shirts in warm weather

The nurse recognizes that premature infants are at risk for increased sensitivity to medications due to which factors? Body size Blood-brain barrier Renal drug excretion Hepatic drug metabolism Protein binding of the drugs

Blood-brain barrier Renal drug excretion Hepatic drug metabolism Protein binding of the drugs Rationale In infants, immaturity of the pharmacokinetic processes, including the blood-brain barrier, renal drug excretion, hepatic drug metabolism, and protein binding of the drugs, as well as drug absorption, all contribute to increased sensitivity to drugs.

The nurse is teaching a client with chlamydia about medication compliance and preventing recurrence. Which statement by the client indicates the need for further instruction?

Rationale Clients should refrain from sexual intercourse for 7 days after treatment

Which statement regarding the role of the community emergency response teams (CERTs) would the nurse include in a presentation to the community regarding the need for volunteers? "You will learn triage skills during the training process." "You will need to report to your nearest hospital in the event of a natural disaster." "You will learn decision-making and rescuer safety skills during the training process." "You will be required to submit your name as a first responder in the event of a natural disaster.

"You will learn decision-making and rescuer safety skills during the training process." Rationale CERTs are recognized by the Federal Emergency Management Agency (FEMA) as important partners in emergency preparedness. As part of the CERT team, members learn decision-making and rescuer safety skills. CERTs are an extension of the first responder services. They can offer immediate help to victims and organize untrained volunteers to assist until professional services arrive. CERT team members are not taught triage skills; they are not required to report to the nearest hospital in the event of a natural disaster; they are not required to submit their names as first responders.

To ensure antibody-mediated immunity, which actions would the nurse instruct an older client to implement? Obtain a shingles vaccination. Receive a tetanus booster injection. Obtain the pneumococcal vaccination. Receive annual testing for tuberculosis. Receive an annual influenza vaccination. Avoid obtaining the pertussis vaccination.

Obtain a shingles vaccination. Receive a tetanus booster injection. Obtain the pneumococcal vaccination. Receive an annual influenza vaccination. Rationale Because older adults are less able to make new antibodies in response to the presence of new antigens, they should receive the shingles vaccination. Because older adults may not have sufficient antibodies present to provide protection when they are reexposed to microorganisms they have already generated antibodies against, booster shots are encouraged. The pneumococcal and influenza vaccinations help create antibodies in response to new antigens. Testing for tuberculosis addresses cellmediated immunity for the older client.

Which parent education would the nurse provide about the preferred carrying position for an infant with cerebral palsy prone to scissoring of the legs? Strapped in an infant seat Wrapped tightly in a blanket Under the arm in a football hold Strapped in an infant seat Wrapped tightly in a blanket Under the arm in a football hold

Strapped in an infant seat Wrapped tightly in a blanket Under the arm in a football hold. Rationale Muscular hypertonicity often causes scissoring of the legs in infants with cerebral palsy, and prolonged periods in such positions may worsen the infant's musculoskeletal health. Carrying the infant astride the parent's hip prevents scissoring by keeping the infant's legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant's legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.

To safely administer medications intravenously in infants, the nurse would be cognizant of which intravenous (IV) medication effect?

Prolonged Rationale When a prescription is administered intravenously, the levels decline more slowly in an infant than in an adult.

After the nurse educator finishes teaching a group of new staff nurses about postoperative care of the vascular bypass client, which statement by the new nurse indicates that more education is needed?

A client report of throbbing pain typically indicates vascular reocclusion." Rationale Throbbing pain occurs with the pulsations of arterial blood flow and is common after arterial bypass as blood flow is restored to the extremity.

Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the healthcare provider? Apical heart rate 55 beats per minute Premature ventricular contractions

Premature ventricular contractions Rationale Digoxin toxicity can manifest with premature ventricular contractions (PVCs) or other ventricular dysrhythmias such as ventricular tachycardia or fibrillation. The nurse would communicate the presence of PVCs to the provider and anticipate collaborative actions such as checking digoxin level and potassium level.

During the activation of an emergency preparedness plan, which individual would communicate with the media?

Director of human resources

Which instruction(s) would the nurse provide for a cervical spine injury client with a halo in place?

"Attach the vest wrench to the jacket for emergency access." "Observe the pin sites and report purulent drainage to your doctor." "Check to make sure one finger fits between the device and your skin."

Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant? Use enemas to prevent straining during bowel movements. Avoid eating hot food or liquid that can burn the mouth. Use an electric shaver instead of a straight-bladed razor. Apply ice to any areas of trauma like bumps and scrapes.

Avoid eating hot food or liquid that can burn the mouth. Use an electric shaver instead of a straight-bladed razor. Apply ice to any areas of trauma like bumps and scrapes. Rationale Stool softeners, rather than enemas, should be used to prevent straining because enemas can cause rectal bleeding.

Which action would the administrator of a community hospital take during a mass casualty event?

Contact the county health department for assistance.

Which information would the nurse document in the medical record regarding a client's reported allergies?

Medication names Type of allergic reaction Epinephrine (EpiPen) use for allergic reaction

Which aspect of safe medication administration in the pediatric population does the nurse need to consider? Medications can cause unanticipated side effects. Dosing ranges are an important component in the process. Many medications have not been tested on children. Some of the medications may be ineffective in children. Medication sensitivity in infants is the same as in adults

Medications can cause unanticipated side effects. Dosing ranges are an important component in the process. Many medications have not been tested on children. Some of the medications may be ineffective in children. Rationale Medication sensitivity in infants depends on many factors specific to their developmental phase and is not like medication sensitivity in adults

Which techniques would the nurse suggest to parents of a toddler to promote medication adherence? Praise the child for taking the medication. Mix the prescription with a small amount of juice. Allow the child to suck on a frozen treat before giving the prescription. Offer a treat "to get the taste out" right after administration of the medication. Refrigerate the prescription even if the medication does not require refrigeration.

Praise the child for taking the medication. Allow the child to suck on a frozen treat before giving the prescription. Offer a treat "to get the taste out" right after administration of the medication. Refrigerate the prescription even if the medication does not require refrigeration. Rationale Prescriptions should not be mixed in juice; however, the medication may be able to be given with food or milk.

Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system?

Rationale Care of clients with chest tubes includes ensuring the chest tube dressing is tight and intact to prevent tube dislodgement and air leak. The nurse will palpate the skin to detect subcutaneous emphysema. The chest tube drainage system is placed below the chest. If a chest tube falls out, the nurse will cover the site with sterile gauze and immediately notify the health care provider

Which client would benefit most from the administration of prophylactic antibiotics?

Rationale Prophylactic antibiotics are indicated in the preoperative hip replacement client because this decreases the occurrence of infection postoperatively. Prophylactic antibiotics are indicated for the client with congenital bicuspid aortic valve disease because this decreases the risk of endocarditis with an invasive procedure. Prophylactic antibiotics are indicated for the current chemotherapy treatment client because this decreases the risk of infection due to neutropenia. A client with the chickenpox infection has a viral infection for which antibiotics are ineffective. A fever of unknown origin should not be treated with antibiotics because that may eliminate the ability to discover the causative organism, and a virus could be the cause of the fever.

Which parental statements indicate a correct understanding of sunburn prevention in a toddler? "I will keep my child indoors between 10:00 AM and 2:00 PM." "I will make sure my child wears a baseball cap while outside." "I will be sure to reapply sunscreen if my child sweats more than usual." "I will make sure my child wears cotton clothing with a tight weave while outside. "I will use sunscreen with an SPF of 15 or higher for my child."

Rationale To protect the toddler from sunburn, it is important to keep him or her out of the sun between 10:00 AM and 2:00 PM, ensure the child wears a baseball cap while outside, reapply sunscreen after profuse sweating, and make sure the child is dressed in cotton clothing with a tight weave. These statements all indicate correct understanding of the information presented by the nurse.