MOC/safety and infection

G&D - Burns / Drowning safety

- Begin swimming lessons as soon as possible (4) - Placing fencing around the pool is recommended, however, the child is still at risk for drowning and may not always prevent access

The RN provides care for a pt who experienced a severe eye injury related to an acid splash. The RN administers proparacaine hydrochloride before each examination. What action is most important for the RN to take? - Instruct the pt about the action of the medication - Measure IOP - Instruct the pt not to touch the eye - Informt he pt that the numbing effect will last 15 mins

Instruct the pt not to touch the eye Rubbing or touching the when the eye when anesthetized may cause corneal damage. *IOP measurement is used for glaucoma.

Pt obtains health info from a pt scheduled for a permanent pacemaker insertion. Which info is most important for the RN to convey to the HCP? - Dx with OCD - Using hearing aid in L ear - Works as programmer - Lives in a two story house

Using hearing aid in L ear - The hearing aid may affect the placement of the pacemaker. It should not be placed under the L clavicle in this pt. Wireless hearing aids should not be within 6 inches of the pacemaker.

Preceptor RN supervises new RN w a dressing change of a pt with a newly inserted peritoneal dialysis catheter. After removing the old dressing which new nurse action requires intervention by the RN? - Cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine solution - Applies two sterile 4 x 4 gauze pads to the catheter insertion site - Cleans the insertion site using a circular motion from the outer abdomen toward the insertion site - Tapes the edges of the sterile dressing with paper tape

- Cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine solution - Applies two sterile 4 x 4 gauze pads to the catheter insertion site - Tapes the edges of the sterile dressing with paper tape X - Cleans the insertion site using a circular motion from the outer abdomen toward the insertion site - NO! *We clean the insertion site outward towards the outer abdomen - this requires intervention

What are non-specific manifestations of MI and need immediate attention like 12-lead and CBC?

- Nausea - General Anxiety - Diaphoresis

RN prepares DC teaching for the pt who will perform catheterization at home. Which infection control principle will the RN include in the teaching? SATA - Apply sterile gloves - Boil the catheter after use - Wash hands prior to performing cath - Cleanse the perineal area with soap and water prior to cath - Discard cath after use

- Wash hands prior to performing cath - Cleanse the perineal area with soap and water prior to cath *In the home care setting straight catheters are REUSED once they are CLEANSED with an anti-bacterial liquid soap.

What is Surgical Asepsis? What is an example?

Sterile Technique - focuses on creating and maintaining an area that is free of all organisms. Ex: Operating rooms, FC, sterile dressing changes

When setting up a sterile field, what order does this occur? - Open wrapper for sterile item - Place sterile drape on work surface - Assemble necessary equipment - Dispose of outer wrapper

1 - Assemble necessary equipment 2 - Place sterile drape on work surface 3 - Open wrapper for sterile item 4 - Dispose of outer wrapper

A surgical hand scrub includes the following steps:

1 - Remove bracelets, rings, watches 2 - Turn on water using knee or foot 3 - Clean under nails 4 - Apply antimicrobial scrub agent to hands and forearms with soft sponge for 3-5 mins 5 - Rinse hands and forearms, holding hands higher than elbows (RT CAR)

Pt has a PE and on continuous heparin infusion, what instructions given to the UAP are they able to assist with care? SATA 1 - Use electric razor to shave 2 - Check for red spots in mucosa 3 - Note any bruising 4 - Record rectal temp Q4 5 - Tell the RN is pt reports cold, painful, blue feet 6 - When assisting with repositions use a lift sheet

1 - Use electric razor to shave 5 - Tell the RN is pt reports cold, painful, blue feet - report concerning client reports 6 - When assisting with repositions use a lift sheet *UAP cannot assess and rectal temps should be avoided to prevent risk of bleeding.

RN provides care for an infant w/ Vomiting, Diarrhea, and Respiratory Distress. The infant is being placed on a Cardiac/Apnea monitor. What action does the RN take when connecting the monitor? 1 - Position the green lead on the abd. 2 - Change HR alarm setting to 80-150 3 - Ensure apnea alarm setting is for 10s 4 - Set alarms to silent mode if adult settings cannot be changed 5 - Place tape over small slit in the electrical cord 6 - Set RR alarm setting to 25-55.

1, 2, 6 1: The White Lead is placed over the Right Upper Chest, and the Green Lead is placed on the Abdomen not over a bony area. 2: The normal HR for an infant is 80-150 bpm. 6: The normal RR for an infant is 25-55 per minute. *Apnea is a cessation of breathing for at least 20 seconds, 10 second apnea alarms are too short.

RN on newborn nursery unit develops security measures to prevent infant abductions. Which method is likely to be effective in preventing abductions? 1 - Parents and staff will use a daily password whenever an infant is removed from the room 2 - Staff will be trained to ID a "typical" abductor 3 - Visitors will be limited to immediate family members 4 - Staff will compare ID bands on both infant and parents 5 - Parents will be taught not to use the bathroom when the infant is in the room

1,2,4,5 1: Daily passwords help eliminate fraudulent use of ID badge or unauthorized use of removing the infant. 2: Infant abductions are often taken by females between 12-55. Staff should be alert. 3: PARENTS CAN CHOOSE WHO THEY WANT TO VISIT. 4: Matching ID help prevent abductions. 5: Parents should never leave an infant unattended.

RN visits child with measles, in what order does the RN go into the airborne room? 1 - RN enters room 2 - RN puts on N95 3 - RN steps into anteroom and acknowledges child through window 4 - RN prepares all equipment to take in

4, 3, 2, 1 Anteroom: a smaller room leading into the main one

Who does the RN see first? - A-fib w/ 130 pulse - A-fib w/ 90 pulse - Paroxysmal A-fib w/ palpitations - A-flutter w/ magnesium 2.0

A-fib w/ 130 pulse - Pt with rapid ventricular rate needs to be assessed. Dose for medication may have to be increased, cardiac output can decrease as a result of RVR. *Palpitations with PAF is a common symptom.

When there is a bomb threat do you go up the chain of command or activate the emergency response plan?

Activate the emergency response plan - this provides direction to staff and notifies the appropriately trained individuals.

The RN receives report on a group of pt's. Who does the RN see first? - Drinking contrast for an abdominal CT who reports nausea and abdominal pain - Pt w/ RR of 24 and 93% RA - Pt reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea - Pt whose family member threatened to sue the hospital

All the rest are stable Pt reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea - This may indicate possible bowel obstruction that can be life threatening if the bowel perforates. This can lead to life-threatening complications including peritonitis and hypovolemic shock.

The RN on a rehabilitation unit provides care for a pt with various levels of physical functioning. Prior to establishing a plan of safe use of assistive devices, what action does the RN take first? - Give clear instructions on the use of mobility aids and require teach back - Assess equipment and surrounding area for safety - Assess the pt's capability to balance and transfer - Provide motivational incentives

Assess the pt's capability to balance and transfer - It is important to assess the pt's ability to balance and xfer and use assistive devices prior to making it an activity in the POC. *Safety checks for equipment and surrounding environment is apart of any health care environment - assessment for ability to use equipment is priority.

There is a storm that broke through windows in the hospital. Who should be moved to another unit? - Asthma exacerbation receiving nebulizer treatments - T1D w/ CBG 124 - Post MI and transferred from cardiac care - Peptic ulcer and receiving blood transfusion

Asthma exacerbation receiving nebulizer treatments - Pt is unstable and is experiencing breathing concerns. At risk for ineffective airway clearance due to particles in the room from storm debris.

After caring for a pt, the RN needs to dispose of which item in the biohazard bin? - Linen soiled with urine - Blood-tinged adhesive bandage - Canister of gastric secretions - Empty indwelling catheter

Canister of gastric secretions - A canister of gastric secretions must be placed in a Bio Bag as there is a great risk that secretions can escape and lead to infection. *Blood-tinged bandage "Slightly bloody bandage" can be placed in the trash. Dressings that are soaked with blood are considered Bio wastes.

Who is more at risk for developing Hep. A an needs a vaccine? - Work in hospital - Church is sending me to Africa

Church is sending me to Africa - Traveling to countries with high to medium rates of Hep. A should be vaccinated. - Africa - South America - Asia

What is Medical Asepsis? What is an example?

Clean Technique - focuses on reducing the number of organisms and preventing the transfer from one person to another. Ex: Hand Hygiene, barrier techniques, cleaning the environment.

The school RN assesses school-age pt's who had an asthma attack. Who does the RN see first? - Coughing up copious amounts of sputum - Using abd. muscles to breathe - Client wheezing and no longer heard in one lobe - Prolonged expiration with each breath

Client wheezing and no longer heard in one lobe - Wheezing that has stopped in one or both lobes can be indication of total occlusion of the airway and needs to be assessed ASAP. *It is normal for a pt to use accessory muscles when having an asthma attack

When irrigating the eyes of the pt who was splashed with battery acid the RN gets called to another emergency. What direction does the RN give to the LPN? - Wait here with the pt until I can locate another RN - Cover the eye with a patch and tape a metal eye shield in place - Continue to irrigate the eyes until the pH is within normal limits - Notify the pt's boss that DC will be delayed

Continue to irrigate the eyes until the pH is within normal limits - Eye irrigation is within the LPN's scope of practice. The LPN may measure pH and determine whether it is normal and the pt would be at less risk for harm. *All others result in further acid contact on the eye increasing the risk of harm to the pt

Is dependent and facial edema a priority in a multigravida at 32 weeks gestation experiencing malaise? What is this? What are other S/S? When does this occur?

Dependent and and facial edema in the pregnant pt could indicate pre-eclampsia. The extra fluid is placing additional stress on the CV system (circulation). Other S/S: - Hypertension - Proteinuria BP > 140/90 Happens at 20 weeks gestation

DC planning for a group of pt's. What pt needs a referral for home health care? - Incisional pain 48 hrs after appy - Dx w/ DM and cardiac cath 8hrs earlier - L knee pain 72 hrs following total knee arthroplasty - Dx w/ HF who received a diuretic for the past 3 days.

Dx w/ HF who received a diuretic for the past 3 days. - Pt is at risk for complications related to heart failure and altered fluid balance. Requesting referral for home health is needed to ensure pt safety. Nursing care will include assessment of : - Decreased circulating volume - Tachycardia - Hypotension - Hypokalemia S/S

What is the standard of care that pt's are offered food and hydration and assisted to use the toilet with restraints?

Every 2 hours - ROM - Skin Care/assess - Circulation

Emergency Triage: Who to treat first

First degree burns are considered minor burns - ESI 4 Giving ABX is not appropriate during explosions or burns. They take time to develop and are not immediate risks following an explosion.

The RN reviews the use of Incident Reports with a novice nurse. Which example requires an incident report to be completed? - HCP prescribes ampicillin 900mg, and the pt is administered 1000mg - Vancomycin Hydrochloride is infusing via a peripheral IV line, and the IV site becomes red and swollen - Famotidine is schedule to be admin at 0900, and the pt receives it at 1130 due to pharmacy delay - A L knee arthroscopy is scheduled, but a R knee arthroscopy is performed - A UAP falls due to liquid spilling on the floor

HCP prescribes ampicillin 900mg, and the pt is administered 1000mg - Too much ampicillin was given. Incident report should be done due to Medication Error. Vancomycin Hydrochloride is infusing via a peripheral IV line, and the IV site becomes red and swollen - The site needs to be monitored carefully with Vanco IV because it can lead to Extravasation and Necrosis if infiltration occurs. An incident report should be done due to infiltration. Famotidine is schedule to be admin at 0900, and the pt receives it at 1130 due to pharmacy delay - Med admin was not in a timely manner. A L knee arthroscopy is scheduled, but a R knee arthroscopy is performed - Wrong extremity A UAP falls due to liquid spilling on the floor - Incident reports are required for injury to staff, pt's, and visitors.

Safety for visually impaired - macular degeneration, etc.

Placing belongings in view of the client but indicates respect and promotes control. Ensuring a path from the bed to the bathroom is well lit indicates safety for the pt and is priority.

A pt is changed to 5 units of rapid-acting insulin before meals. The pt's CBG is 250. The RN mistakenly gives the previously prescribed dose of 10 units. Which action does the RN do first? - Report to HCP - Monitor for Hypoglycemia - Offer fruit juice - Admin D50

Report to HCP - Medication errors should be reported to HCP immediately. The RN will monitor for hypoglycemia until the HCP gives further instructions.

The RN prepares to delegate VS measurements to a newly trained UAP. Which statement by the RN is best? - Show me how you were taught to apply a BP cuff - Do you know the normal RR and P for pt's? - Contact me immediately if the VS are abnormal - Are you nervous about measuring VS for the first time?

Show me how you were taught to apply a BP cuff - Assessing the UAP's knowledge, skill, training, and scope of practice before delegating the task is priority. Then, assess UAP's understanding and give a timeline for the task w/ expected outcomes. *The UAP should be given parameters regarding when to contact the RN. "O2 is < 92% and BP < 90 systolic

Who do we assign pt's to float nurses?

Stable pt's with expected outcomes - admitted with PNA and requiring ABX - Admitted with Anemia and requiring a blood transfusion - Stroke 3 days ago and requires enteral feedings *Pt's new diagnosis of HF to be discharged in 24 hrs - pt will need DC teaching - assign to regular floor RN.

The RN cares for a pt that is 400lbs and is bed rest. The RN must assist the pt to move up to the HOB with a draw sheet. What ensures the proper lifting mechanics? - Keeps spine, neck, and back straight and aligned throughout lift. - The RN maintains a narrow stance before pulling upward - The RN remains arm-length distance from the pt while pulling upward - The RN pivots feet in direction of the move prior to moving the pt - The RN placed the bed in Trendelenburg

The RN placed the bed in Trendelenburg The RN pivots feet in direction of the move prior to moving the pt - The placement of the RN's feet also aligns the hips properly and decreases strain on the back, hips, joints. Keeps spine, neck, and back straight and aligned throughout lift. *The RN needs to request 3 more people - not 1! 1 person per 100lbs *The RN should remain as close to the pt as possible when lifting for secure movement.

Proparacaine HCL (Ophthaine)

Topical Anesthetic (anesthetizes the corneal surface). commonly used to facilitate removal of a foreign body (ACID SPLASH) anesthesia lasts 5- 10 minutes. Teach: DO NOT TOUCH THE EYE

There is a fire, what is the order that people should leave?

Who will go first? 1 - Ambulatory pt's who can transport 2 - Pt's in general care units who require some transport assistance 3 - Pt's who require extensive equipment to transfer (Skeletal Traction) 4 - Critically ill pt's who have intensive monitoring (Mechanical Ventilation / Balloon Pumps)

Meningitis symptoms

classic triad of headache, neck stiffness and fever -photophobia (wanting to be in a dark place), vomiting, altered mental status

How is Hepatitis A transmitted?

fecal-oral route; lack of sanitary water supply or the ingestion of foods exposed to infectious waste.