LaCharity Chapter 5 Safety and Infection Control

28. The nurse has received a needlestick injury after giving a patient an intramuscular injection but has no information about whether the patient has human immunodeficiency virus (HIV) infection. What is the most appropriate method of obtaining this information about the patient? 1. The nurse should personally ask the patient to authorize HIV testing. 2. The charge nurse should tell the patient about the need for HIV testing. 3. The occupational health nurse should discuss HIV status with the patient. 4. HIV testing should be performed the next time blood is drawn for other tests.

3. The occupational health nurse should discuss HIV status with the patient. Ans: 3 The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about how to obtain a patient's HIV status and order HIV testing is the occupational health nurse. It is unethical for the nurse to personally ask the patient to consent to HIV testing or to perform unauthorized HIV testing. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health).

10. A pregnant patient in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important? 1. Arrange for testing for the Zika virus infection. 2. Discuss need for multiple fetal ultrasounds during pregnancy. 3. Describe potential impact of Zika infection on fetal development. 4. Assess for symptoms such as rash, joint pain, conjunctivitis, and fever

1. Arrange for testing for the Zika virus infection. Ans: 1 Current guidelines recommend that pregnant women who are exposed to Zika virus be tested for infection. Fetal ultrasonography is recommended for any pregnant woman who has had possible Zika virus exposure, but multiple ultrasound studies will not be needed unless test results are positive. Education about the effects of Zika infection on fetal development may be needed, but this is not the highest priority at this time. The nurse will assess for Zika symptoms, but testing for the virus will be done even if the patient is asymptomatic.

14. A patient who has been diagnosed with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take first? 1. Place the patient in an airborne isolation room. 2. Initiate infusion of 500 mL of normal saline bolus. 3. Ask the patient about any recent travel to Asia. 4. Obtain sputum specimen and nasal cultures.

1. Place the patient in an airborne isolation room. Ans: 1 The initial action should be to prevent transmission of avian influenza to other patients, visitors, or health care personnel through the use of airborne, contact, and standard isolation precautions. Initiating IV fluids, determining whether the patient has been exposed to avian influenza through travel, and obtaining cultures are also appropriate, but the highest priority is to prevent spread of infection

3. The nurse is caring for a newly admitted patient with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will the nurse implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/hr. 3. Administer the first dose of oral oseltamivir. 4. Obtain blood and sputum specimens for testing.

1. Start oxygen using a nonrebreather mask. Ans: 1 Because the respiratory manifestations associated with avian influenza are potentially life threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the patient's respiratory problems.

4. A patient has been diagnosed with disseminated herpes zoster. Which personal protective equipment will the nurse need to put on when preparing to assess the patient? Select all that apply. 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

2. N95 respirator 3. Gown 4. Gloves Ans: 2, 3, 4 Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, the nurse should wear an N95 respirator or highefficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and do not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions.

24. While administering vancomycin 500 mg IV to a patient with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the patient's neck and face are becoming flushed. Which action should the nurse take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the patient's temperature.

2. Slow the rate of the vancomycin infusion. Ans: 2 "Red man" syndrome occurs when vancomycin is infused too quickly. Because the patient needs the medication to treat the infection, vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes to avoid vasodilation. Although the patient's temperature will be monitored, a temperature elevation is not the most likely cause of the patient's flushing.

27. The nurse is preparing to insert a peripherally inserted central catheter (PICC) in a patient's left forearm. Which solution will be best for cleaning the skin before the PICC insertion? 1. 70% isopropyl alcohol 2. Povidone-iodine solution 3. 0.5% chlorhexidine in alcohol 4. Betadine followed by 70% isopropyl alcohol

3. 0.5% chlorhexidine in alcohol Ans: 3 Current Institute for Healthcare Improvement guidelines indicate that chlorhexidine is more effective than the other options at reducing the risk for central line-associated bloodstream infections. The other solutions provide some decrease in the number of microorganisms on the skin but are not as effective as chlorhexidine

33. The nurse is checking medication prescriptions that were received by telephone for a patient with hypertensive crisis and tachycardia. Which medication is most important to clarify with the health care provider (HCP)? 1. Carvedilol 12.5 mg PO BID daily 2. Hydrochlorothiazide 25 mg PO daily 3. Labetalol 20 mg IV over a 2-min time period now 4. Hydroxyzine 50 mg PO as needed systolic blood pressure greater than 160 mm Hg

4. Hydroxyzine 50 mg PO as needed systolic blood pressure greater than 160 mm Hg Ans: 4 Hydroxyzine is a first-generation antihistamine that is used to treat patients with anxiety and pruritus. It is likely that the correct medication is hydralazine, a vasodilator that is used to treat hypertension. Hydroxyzine and hydralazine are "look-alike, sound-alike" drugs that have been identified by the Institute for Safe Medication Practices as being at high risk for involvement in medication errors. All treatment prescriptions that are communicated by telephone should be reconfirmed with the HCP; however, the most important order to clarify is the hydroxyzine, which is likely an error.

1. The nurse is caring for a patient with intractable nausea and vomiting. The patient has a temperature of 99°F, a pulse of 100, a respiratory rate of 24, a blood pressure of 90/60, and oxygen saturation of 91%. What is the first action the nurse should take? 1. Start an IV of normal saline. 2. Administer ondansetron 4 mg IV. 3. Apply oxygen at 2 L/min per nasal cannula. 4. Make sure the wall suction is fully functioning.

4. Make sure the wall suction is fully functioning. Ans: 4 Airway patency is the priority for this patient and the first thing the nurse should do is take measures to ensure the airway will be patent by making sure suction is readily available. Intractable nausea and vomiting pose a safety risk for aspiration. The other choices are all acceptable actions, but ensuring there is a patent airway is the first thing the nurse should do.

8. A hospitalized 88-year-old patient who has been receiving antibiotics for 10 days tells the nurse about having frequent watery stools. Which action will the nurse take first? 1. Notify the health care provider about the stools. 2. Obtain stool specimens for culture. 3. Instruct the patient about correct hand washing. 4. Place the patient on contact precautions.

4. Place the patient on contact precautions. Ans: 4 The patient's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium dif icile infection. The initial action should be to place him on contact precautions to prevent the spread of C. dif icile to other patients. The other actions are also needed and should be taken after placing the patient on contact precautions.

31. The nurse is supervising an LPN/LVN who says, "I gave the patient with myasthenia gravis 90 mg of neostigmine instead of the ordered 45 mg!" In which order should the nurse perform the following actions? 1. Assess the patient's heart rate. 2. Complete a medication error report. 3. Ask the LPN/LVN to explain how the error occurred. 4. Notify the health care provider of the incorrect medication dose. _____, _____, _____, _____

1. Assess the patient's heart rate. 4. Notify the health care provider of the incorrect medication dose. 3. Ask the LPN/LVN to explain how the error occurred. 2. Complete a medication error report. Ans: 1, 4, 3, 2 The first action after a medication error should be to assess the patient for adverse outcomes. The nurse should evaluate this patient for symptoms such as bradycardia and excessive salivation, which indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The health care provider should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report.

16. The nurse is preparing to change the linens on the bed of a patient who has a sacral wound infected by methicillin-resistant Staphylococcus aureus. Which personal protective equipment (PPE) items will be used? Select all that apply. 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. Gown 2. Gloves Ans: 1, 2 A gown and gloves should be used when coming in contact with linens that may be contaminated by the patient's wound secretions. The other PPE items are not necessary because transmission by splashes, droplets, or airborne means will not occur when the bed is changed.

30. A patient with atrial fibrillation is ambulating in the hallway on the coronary stepdown unit and suddenly tells the nurse, "I feel really dizzy." Which action should the nurse take first? 1. Help the patient to sit down. 2. Check the patient's apical pulse. 3. Take the patient's blood pressure. 4. Have the patient breathe deeply.

1. Help the patient to sit down. Ans: 1 The first priority for an ambulating patient who is dizzy is to prevent falls, which could lead to serious injury. The other actions are also appropriate but are not as high a priority.

26. The nurse is caring for a patient who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the patient's risk for ventilator-associated pneumonia (VAP)? Select all that apply. 1. Keep the head of the patient's bed elevated to at least 30 degrees. 2. Assess the patient's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the patient's position. 5. Provide oral care with chlorhexidine solution at least daily. 6. Perform inline sterile suctioning via endotracheal tube every 2 hours.

1. Keep the head of the patient's bed elevated to at least 30 degrees. 2. Assess the patient's readiness for extubation at least daily. 5. Provide oral care with chlorhexidine solution at least daily. Ans: 1, 2, 5 The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the patient, but it is not considered essential. Routine suctioning is no longer recommended.

21. Which policy implemented by the infection control nurse will most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? 1. Limit the use of indwelling urinary catheters in all hospitalized patients. 2. Ensure that patients with catheters have at least a 1500-mL fluid intake daily. 3. Use urine dipstick testing to screen catheterized patients for asymptomatic bacteria. 4. Require the use of antimicrobial/antiseptic-impregnated catheters for catheterization.

1. Limit the use of indwelling urinary catheters in all hospitalized patients. Ans: 1 According to the Centers for Disease Control and Prevention (CDC), CAUTIs are the most common health care-acquired infection in the United States. Recommendations include avoiding the use of indwelling catheters and removing catheters as soon as possible. Although a high fluid intake will also help to reduce the risk for CAUTIs, 1500 mL may be excessive for some patients. The CDC recommends against routine screening for asymptomatic bacteriuria. Antimicrobial catheters are a secondary recommendation and may be appropriate if other measures are not effective in reducing the incidence of CAUTIs

35. An 88-year-old patient who has not yet had the influenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough, and runny nose starting about 24 hours previously. Which of these prescribed medications is most important for the nurse to administer at this time? 1. Oseltamivir 75 mg PO 2. Guaifenesin 600 mg PO 3. Acetaminophen 650 mg PO 4. Influenza vaccine 180 mcg IM

1. Oseltamivir 75 mg PO Ans: 1 Because antivirals are most effective when used early in influenza infection, the nurse should administer the oseltamivir as soon as possible to decrease the severity of the infection and risk of transmission to others. Guaifenesin and acetaminophen will help with the symptoms of cough and muscle aching but will not shorten the course of the patient's illness or decrease risk of transmission. The influenza vaccine may still help in preventing future influenza caused by another virus

37. A patient who has had recent exposure to Ebola while traveling in Africa arrives in the emergency department with fever, headache, vomiting, and multiple ecchymoses. Which action should the nurse take first? 1. Place the patient in a private room. 2. Obtain heart rate and blood pressure. 3. Notify the hospital infection control nurse. 4. Start a large bore IV with normal saline.

1. Place the patient in a private room. Ans: 1 The Centers for Disease Control and Prevention guidelines recommend that the initial action be to place the patient in a private room and implement standard, contact, and droplet precautions. Further assessment of the type of possible Ebola exposure, obtaining vital signs, and notification of the infection control nurse will also be needed but should be done after measures to minimize transmission of Ebola are implemented

29. Which medication order for a patient with a pulmonary embolism is most important to clarify with the prescribing health care provider before administration? 1. Warfarin 1.0 mg PO 2. Morphine 2 to 4 mg IV 3. Cephalexin 250 mg PO 4. Heparin infusion at 900 units/hr

1. Warfarin 1.0 mg PO Ans: 1 The Institute for Safe Medication Practices guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose (in this case, 10 mg). The order should be clarified before administration. The other orders are appropriate based on the patient's diagnosis.

12. The nurse notices that the health care provider (HCP) omits hand hygiene after leaving a patient's hospital room. Which action by the nurse is best at this time? 1. Report the HCP to the infection control department. 2. Offer the HCP an alcohol-based hand sanitizing fluid. 3. Provide the HCP with a list of upcoming in-services on hand hygiene. 4. Remind the HCP about the importance of minimizing infection spread.

2. Offer the HCP an alcohol-based hand sanitizing fluid. Ans: 2 Because the most immediate need is to ensure that hand hygiene is accomplished, the nurse should offer an alcohol-based cleanser to the HCP. The other actions may also be needed, especially if there is a pattern of nonadherence to hand hygiene, but further assessment is necessary before these actions are taken.

19. The nurse manager is preparing for another community surge of Covid-19. Personal protective equipment (PPE) is in short supply at the hospital. Which methods are approved by the Center for Disease Control (CDC) for optimizing the supply of PPE during the surge? Select all that apply. 1. Wear a single pair of gloves between patients who have the same illness. 2. Disinfect gloves between patients to prevent cross contamination. 3. Wear the same N95 mask when in close contact with numerous patients. 4. Continuously wear the N95 mask between cohort patient encounters. 5. Use disposable patient isolation gowns for routine covid-19 patient care. 6. Use of cotton masks is acceptable if changed after every patient encounter.

1. Wear a single pair of gloves between patients who have the same illness. 2. Disinfect gloves between patients to prevent cross contamination. 4. Continuously wear the N95 mask between cohort patient encounters. 5. Use disposable patient isolation gowns for routine covid-19 patient care. Ans: 1, 2, 4, 5 The CDC has recommended all the above methods besides wearing an N95 mask between numerous patients and cotton masks. Disposable latex and nitrile gloves can be disinfected up to 6 times using alcohol based hand sanitizer. If N95 masks are unavailable then the recommendation is to utilize goggles, a surgical facemask and a facial shield. N95 masks should not be continuously worn for more than 8 hours and only between a cohort of covid-19 patients. Disposable isolation patient gowns are fluid resistant. Surgical gowns may be used as well but are sterile so they are not as cost efficient.

5. Four patients arrive simultaneously at the emergency department. Which patient requires the most rapid action by the triage nurse to protect other patients from infection? 1. A 3-year-old patient who has paroxysmal coughing and whose sibling has pertussis 2. A 5-year-old patient who has a new pruritic rash and possible measles 3. A 62-year-old patient who has an ongoing methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. A 74-year-old patient who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

2. A 5-year-old patient who has a new pruritic rash and possible measles Ans: 2 Measles is spread by airborne means and could be rapidly transmitted to other patients in the emergency department. The child with the rash should be quickly isolated from the other patients through placement in a negative-pressure room. Droplet or contact precautions (or both) should be instituted for the patients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible measles. The patient who has been exposed to TB does not place other patients at risk for infection because there are no symptoms of active TB.

23. Which information about a patient who has meningococcal meningitis is the best indicator that the nurse can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100°F (37.8°C).

2. Appropriate antibiotics have been given for 24 hours. Ans: 2 Current Centers for Disease Control and Prevention evidence-based guidelines indicate that droplet precautions for patients with meningococcal meningitis can be discontinued when the patient has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the patient's condition is improving but does not indicate that droplet precautions should be discontinued.

18. Which action by the infection control nurse in an acute care hospital will be most effective in reducing the incidence of health care-associated infections? 1. Requiring nursing staff to don gowns to change wound dressings for all patients 2. Ensuring that dispensers for alcohol-based hand rubs are available in all patient care areas 3. Screening all newly admitted patients for colonization or infection with methicillin resistant Staphylococcus aureus (MRSA) 4. Developing policies that automatically start antibiotic therapy for patients colonized by multidrug-resistant organisms

2. Ensuring that dispensers for alcohol-based hand rubs are available in all patient care areas Ans: 2 Because the hands of health care workers are the most common means of transmission of infection from one patient to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use. Wearing a gown to care for patients who are not on contact precautions is not necessary. Although some hospitals have started screening newly admitted patients for MRSA, this is not considered a priority action according to current national guidelines. Because administration of antibiotics to individuals who are colonized by bacteria may promote the development of antibiotic resistance, antibiotic use should be restricted to patients who have clinical manifestations of infection

9. The nurse notes white powder on the arms and chest of a patient who arrives at the emergency department and reports possible anthrax contamination. Which action included in the hospital protocol for a possible anthrax exposure will the nurse take first? 1. Notify hospital security personnel about the patient. 2. Escort the patient to a decontamination room. 3. Give ciprofloxacin 500 mg PO. 4. Assess the patient for signs of infection.

2. Escort the patient to a decontamination room. Ans: 2 To prevent contamination of staff or other patients by anthrax, decontamination of the patient by removal and disposal of clothing and showering are the initial actions in possible anthrax exposure. Assessment of the patient for signs of infection should be performed after decontamination. Notification of security personnel (and local and regional law enforcement agencies) is necessary in the case of possible bioterrorism, but this should occur after decontaminating and caring for the patient. According to the Centers for Disease Control and Prevention guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax.

32. The nurse is caring for a confused and agitated patient who has wrist restraints in place on both arms. Which action included in the patient plan of care can be assigned to an LPN/LVN? 1. Determining whether the patient's mental status justifies the continued use of restraints 2. Undoing and retying the restraints to improve patient comfort 3. Reporting the patient's status and continued need for restraints to the health care provider 4. Explaining the purpose of the restraints to the patient's family members

2. Undoing and retying the restraints to improve patient comfort Ans: 2 Hospital staff who have been trained in the appropriate application of restraints may reposition the restraints. Evaluation of the continued need for restraints, communication with the provider about the patient status, and teaching of the family require RN-level education and scope of practice.

2. The charge nurse is making patient assignments for the day shift. Which patient should be assigned to an RN who is pregnant? 1. A 32-year-old male with coccidiomycosis 2. A 67-year-old female with shingles 3. A 42-year-old female with vancomycin resistant enterococcus (VRE) 4. A 24-year-old male with chicken pox

3. A 42-year-old female with vancomycin resistant enterococcus (VRE) Ans: 3 The National Institute for Occupational Safety and Health lists 17 diseases that pregnant nurses should not be in contact with. These include airborne diseases such as chicken pox, shingles, and coccidiomycosis, as well as other airborne diseases like tuberculosis, measles, and influenza. Vancomycin-resistant Staphylococcus aureus, VRE, and methicillin-resistant S. aureus are spread by direct contact and standard precautions taken by all nurses are sufficient in preventing transmission; thus patients with these diseases are considered safe for a pregnant nurse to take care of.

17. A patient who has frequent watery stools and a possible Clostridium dif icile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN/LVN? 1. Performing ongoing assessments to determine the patient's hydration status 2. Explaining the purpose of ordered stool cultures to the patient and family 3. Administering the prescribed metronidazole 500 mg PO to the patient 4. Reviewing the patient's medical history for any risk factors for diarrhea

3. Administering the prescribed metronidazole 500 mg PO to the patient Ans: 3 LPN/LVN scope of practice and education include the administration of medications. Assessment of hydration status, patient and family education, and assessment of patient risk factors for diarrhea should be done by the RN

20. When the community health nurse is counseling a patient who has an acute Zika virus infection, which information is most important to include? 1. Drink fluids to prevent dehydration. 2. Use acetaminophen to reduce pain and fever. 3. Apply insect repellant frequently to prevent mosquito bites. 4. Symptoms of Zika infection include fever, red eyes, rash, and joint pain.

3. Apply insect repellant frequently to prevent mosquito bites. Ans: 3 Prevention of Zika transmission is the priority because Zika infection usually causes a relatively mild and short-duration illness. Because mosquitos spread Zika infection from infected individuals to others, it is essential that the patient use insect repellant consistently during the active infection. The other information is correct but will not assist in decreasing the risk to the community.

13. A patient with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the assistive personnel who is assisting with the patient's care? 1. Teaching the patient and family members about ways to prevent transmission of VRE 2. Communicating with other departments when the patient is transported for ordered tests 3. Implementing contact precautions when providing care for the patient 4. Monitoring the results of ordered laboratory culture and sensitivity tests

3. Implementing contact precautions when providing care for the patient Ans: 3 All hospital personnel who care for the patient are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, patient teaching, and communication with other departments about essential patient data.

38. A patient who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first? 1. Give acetaminophen 650 mg PO. 2. Administer ondansetron 4 mg IV. 3. Infuse normal saline at 500 mL/hr. 4. Increase oxygen flow rate to 6 L/min.

3. Infuse normal saline at 500 mL/hr. Ans: 3 Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been demonstrated to improve outcomes, the nurse's first action will be to infuse normal saline. Treatment of nausea and headache is appropriate and should be implemented next. There is no indication that this patient is hypoxemic, although patients with Ebola may develop multiorgan failure and require respiratory support.

7. The nurse is caring for a patient who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus. Which nursing action can be assigned to an LPN/LVN? 1. Planning ways to improve the patient's oral protein intake 2. Teaching the patient about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown

3. Obtaining wound cultures during dressing changes Ans: 3 LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN.

11. The nurse at the infectious disease clinic has four patients waiting to be seen. Which patient should the nurse see first? 1. Patient who has a 16-mm induration after a tuberculosis skin test 2. Patient who has human immunodeficiency virus and a low CD4 count 3. Patient who has swine influenza and reports increased dyspnea 4. Patient who has been exposed to Zika virus and has a rash and joint pain

3. Patient who has swine influenza and reports increased dyspnea Ans: 3 The patient with increased dyspnea should be seen first because rapid actions such as oxygen administration and IV fluids may be needed. The other patients will require further assessment, counseling, or treatment, but they do not have potentially life-threatening symptoms or diagnoses

6. The nurse is caring for four patients who are receiving IV infusions of normal saline. Which patient is at highest risk for bloodstream infection? 1. The patient with an implanted port in the right subclavian vein 2. The patient who has a midline IV catheter in the left antecubital fossa 3. The patient who has a nontunneled central line in the left internal jugular vein 4. The patient with a peripherally inserted central catheter (PICC) line in the right upper arm

3. The patient who has a nontunneled central line in the left internal jugular vein Ans: 3 According to the Centers for Disease Control and Prevention guidelines, several factors increase the risk for infection for this patient. Central lines are associated with a higher infection risk, jugular vein lines are more prone to infection, and the line is nontunneled. Peripherally inserted IV lines such as PICC lines and midline catheters are associated with a lower incidence of infection. Implanted ports are placed under the skin and are the least likely central line to be associated with catheter infection

22. The nurse admits four patients with infections to the medical unit, but only one private room is available. Which patient is most appropriate to assign to the private room? 1. The patient with diarrhea caused by Clostridium dif icile 2. The patient with vancomycin-resistant enterococcus (VRE) infection 3. The patient with a cough who may have active tuberculosis (TB) 4. The patient with toxic shock syndrome and fever

3. The patient with a cough who may have active tuberculosis (TB) Ans: 3 Patients with infections that require airborne precautions (e.g., TB) need to be in private rooms. Patients with infections that require contact precautions (e.g., those with C. dif icile or VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other patients with the same diagnosis. Standard precautions are required for the patient with toxic shock syndrome.

36. The nurse is admitting an 80-year-old female patient who has mild dementia and is incontinent. Which is the best way to assess the patient's pressure injury risk? 1. Conduct a full head to toe physical assessment. 2. Rely on empirical knowledge gained by caring for other patients with pressure ulcers. 3. Utilize the Braden Scale. 4. Consult with the wound care nurse specialist.

3. Utilize the Braden Scale. Ans: 3 The Braden Scale for Predicting Pressure Sore Risk is the best way to predict the patient's risk for developing an injury. The scale measures sensory perception, skin moisture, activity, mobility, nutrition, friction, and shear. Conducting a full head to toe assessment would not predict an ulcer. There is no wound, so consulting with the wound care nurse specialist would not be useful. Empirical knowledge is subjective and not evidenced based.

15. Which infection control activity should the charge nurse delegate to an experienced assistive personnel (AP)? 1. Screening patients for upper respiratory tract symptoms 2. Asking patients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the patients' visitors 4. Disinfecting blood pressure cuffs after patients are discharged

4. Disinfecting blood pressure cuffs after patients are discharged Ans: 4 The AP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses

25. A healthy 65-year-old patient who cares for a newborn grandchild has a clinic appointment in May. The patient needs several immunizations but tells the nurse, "I hate shots! I will only take one today." Which immunization is most important to give? 1. Influenza 2. Herpes zoster 3. Pneumococcal 4. Tetanus, diphtheria, pertussis

4. Tetanus, diphtheria, pertussis Ans: 4 Individuals who have contact with infants should be immunized against pertussis to avoid infection and to prevent transmission to the infant. The influenza and pneumococcal vaccines can be administered later in the year, before the influenza season. The herpes zoster vaccine is important to prevent shingles in the patient but does not need to be administered today.

34. A 70-kg patient who has had unprotected sexual intercourse with a partner who has hepatitis B is to receive 0.06 mL/kg of hepatitis B immune globulin. The immune globulin is available in a 5-mL vial. The nurse will plan to administer ____________________ mL.

Ans: 4.2 mL 0.06 mL × 70 kg = 4.2 mL