NCLEX Safety and Infection Control

Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? Select all that apply. 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.

1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. (1., & 2. Correct: Cleaning from front to back will decrease the risk of infection by reducing the number of microorganisms at the urethral meatus. Keeping the umbilical cord clean and dry will decrease the risk of infection and will allow it to fall off. 3. Incorrect: The top of the diaper should be placed just below the umbilicus to prevent exposure to body waste and moisture. Placing the diaper above the umbilical cord will cause the diaper to rub the umbilicus, which will increase the risk of infection. 4. Incorrect: This would keep the umbilical cord moist and could lead to infection. Also a sterile dressing is not warranted. The umbilical cord needs to be kept dry so it will fall off. 5. Incorrect: The newborn should not be placed in water until after the umbilical cord falls off. Water submersion keeps the cord moist and at risk for infection. The umbilical cord should be kept dry so that it will fall off.)

The nurse is planning to teach a group of assisted living residents about tuberculosis (TB) infection. What should the nurse include? Select all that apply. 1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 4. Obtain a yearly chest x-ray. 5. Proper disposal of tissues.

1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 5. Proper disposal of tissues. (1., 2., 3. & 5. Correct: In an effort to prevent transmission of TB to others, the nurse should carefully instruct about the importance of hygiene measures, including mouth care, covering the mouth when coughing and sneezing, proper disposal of tissues, and hand hygiene. A TB skin test is especially important when living in tight quarters such as an assisted living center. 4. Incorrect: Chest x-rays are not needed yearly, especially without signs and symptoms of TB.)

The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? Select all that apply. 1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves

1. Face shield 3. Gown 4. Mask 5. Regular exam gloves (1., 3., 4. & 5. Correct: The nurse should implement transmission based contact precautions. During drainage of an abscess, the nurse may come into direct and indirect contact of the contaminated body fluids. The nurse needs the protection of a gown, mask, face shield, and regular exam gloves. Since the nurse is not directly assisting with the wound care, regular exam gloves are appropriate. 2. Incorrect: Sterile gloves are not necessary since the nurse is holding the client and not directly assisting with the wound care procedure.)

A home health nurse inspects the home of a client scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness. What safety interventions should the nurse recommend based on findings within the home? Two story, four bedroom home located in quiet neighborhood. Yard uncluttered. Five steps leading to front door. Sturdy railings on both sides of steps. Interior home clean and well organized. No clutter noted on floors. Multiple throw rugs throughout the downstairs living area. Three bedrooms and two bathrooms located upstairs. One bedroom and one bathroom located downstairs. Client's bedroom is upstairs. Shower stall in downstairs bathroom. Select all that apply. 1. Place ramp over the front steps. 2. Move client's bedroom downstairs. 3. Remove throw rugs. 4. Secure furniture so client can use for support. 5. Apply nonskid strips to shower stall.

1. Place ramp over the front steps. 2. Move client's bedroom downstairs. 3. Remove throw rugs. 5. Apply nonskid strips to shower stall. (1., 2., 3., & 5. Correct: The client will have difficulty navigating the steps, both outside and inside the home. The client may trip on throw rugs, and shower stalls are slippery when wet. These things, along with the generalized weakness, makes the client more prone to falls. These interventions will promote safety for the client and decrease the risk of falling. 4. Incorrect: Do not have client rely on furniture for support while walking as they may not provide the consistent support needed to prevent falls. The client should use prescribed assistive devices, which are designed to help prevent falls when used properly.)

In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? Select all that apply. 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 6. Obtain assistance from other nurses or nurse assistants as needed.

1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 6. Obtain assistance from other nurses or nurse assistants as needed. (1., 2., 3., & 6. Correct: When in a standing position, the center of gravity is at the center of the pelvis. The wider the base of support and the lower the center of gravity the nurse maintains, the greater the stability for the movement. Using both the arms and the legs provides a sense of balance for the activity. It is always smart to seek more assistance when needed to avoid injury to self. 4. Incorrect: Rolling, turning, and pivoting are less likely to cause injury than attempting to lift. Lifting puts more strain on the back than these other methods. 5. Incorrect: The larger muscles of the thighs, buttocks, and shoulders should be utilized for activity because the smaller muscles such as those in the back and arms are more susceptible to injury.)

A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? 1. Send the client to the waiting room. 2. Place the client in a negative pressure room. 3. Put a surgical mask on the client. 4. Initiate contact precautions.

2. Place the client in a negative pressure room. (2. Correct: The client may have smallpox, which is very contagious. Smallpox can also be used as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure. 1. Incorrect: Sending this client to the waiting room will expose others to smallpox. Even if you don't recognize these specific disease symptoms, fever and rash should cue you to thinking of this as a potential infectious disease. 3. Incorrect: Having the client wear a surgical mask is not sufficient in this case. All healthcare providers should wear a N95 respirator when in contact with the client. After the client is sequestered, the nurse should notify the ED primary healthcare provider for further treatment instructions. 4. Incorrect: Airborne precautions are necessary because that is the primary transmission mode for smallpox.)

The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? Select all that apply. 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.

2. Removing the hair with clippers. 4. Using a depilatory cream. (2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery.)

The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? 1. Apply gauze padding beneath the tubing. 2. Use petroleum jelly on the nares and cheeks. 3. Provide mouth and nose care every 4 hours as needed. 4. Place the oxygen tubing above the ears.

2. Use petroleum jelly on the nares and cheeks. (2. Correct: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy. 1. Incorrect: The charge nurse would not need to intervene if the new nurse applied gauze padding beneath the tubing to protect the client's skin. This is acceptable. 3. Incorrect: The charge nurse would not need to intervene if the new nurse provided mouth and nose care every four hours as needed to protect the client's skin and mucous membranes. This is acceptable. 4. Incorrect: The charge nurse would not need to intervene if the new nurse placed the oxygen mask straps well above the client's ears to protect the client's skin. This is acceptable.)

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care? 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days.

3. A two year old with excessive drooling and a weak cough. (3. Correct: The two year old is exhibiting signs of respiratory difficulty with excessive drooling and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in which rapid progression to severe respiratory distress can occur . Airway takes priority over the other clients. 1. Incorrect: The partial amputation would have associated bleeding could be seen next, but airway takes priority. 2. Incorrect: Most fevers in children do not last for long periods and do not have much consequence. Elevated temperature would not take priority over airway. Antipyretics can be given in triage. 4. Incorrect: The migraine is not emergent. Take care of life-threatening illnesses/injuries first. Remember, pain never killed anyone.)

A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority? 1. Place client with a roommate who is able to notify staff when client wanders. 2. Discuss safety goals with family, encouraging them to spend time with client. 3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night. 4. Reorient the client every shift regarding floor policies and safety procedures.

3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night. (3. Correct: The family specifically informed the nurse that the client wanders at night. When preparing care plan safety goals, the nurse understands the priority is to ensure client safety and have staff personnel to stay with the client during those hours of wandering. This action does not require a licensed nurse; therefore, a unlicensed assistive personnel UAP is the most appropriate staff to sit with the client. 1. Incorrect: It is neither ethical nor legal to expect another client to be accountable for a roommate's behavior or whereabouts. 2. Incorrect: The nurse would indeed discuss plans for client safety with the family and encouraging the family to spend time with the client can be helpful. However, this does not release the staff from the responsibility for the client's safety. 4. Incorrect: This client is known to have dementia and re-explaining policies and safety procedures every shift would not ensure this client's compliance, understanding or safety.)

The charge nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 3. Going between client rooms wearing the same pair of gloves to collect I&O reports. 4. Cleaning a blood pressure cuff with a disinfectant.

3. Going between client rooms wearing the same pair of gloves to collect I&O reports. (3. Correct: Gloves should be removed and hands washed before leaving each client's room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients. 1. Incorrect: No intervention is needed because this is an appropriate action. Do not carry soiled linen down the hall to place in a receptacle. 2. Incorrect: No intervention is required because this is an appropriate action. Clients with tuberculosis (TB) need to be on airborne precautions in a negative pressure room with the door closed. 4. Incorrect: Equipment used against intact skin should be thoroughly cleaned with low level disinfectant between uses to reduce the load of microorganisms to a level that is not threatening to the next client. Therefore, no intervention is needed since the action is appropriate.)

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen? 1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Place the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed.

3. Place the linen into a leak proof container sitting outside the room. (3. Correct: Soiled linen should be placed in a leak proof container for transport off the unit to the laundry. Make sure the linen bags are not overfilled which would prevent complete closure. 1. Incorrect: Linen should be held away from the body to prevent contamination of the nurse's clothes. The linens should be handled as little as possible to avoid possible contamination of air, surfaces and persons. 2. Incorrect: Gloves should always be worn when handling soiled linen. A gown is not necessary. Soiled linen should be carried away from the body with minimal handling to prevent contamination. 4. Incorrect: Soiled linen should not be placed on the floor. All linens should be handled and transported in a way that will minimize contamination and maintain a clean environment for the client, healthcare workers and visitors.)

A client is hospitalized for recurrent angina with hypertension and has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? Prescriptions: Spironolactone 50 mg. P.O. once daily. Metoprolol 25 mg. P.O. once daily. Diltiazem 120 mg. P.O. once daily. Potassium 10 meq. P.O. once daily. 2 GM. sodium diet. 1. 2 gram sodium diet. 2. Metoprolol 25 mg. P.O. once daily. 3. Potassium 10 mEq. P.O. once daily. 4. Diltiazem 120 mg. P.O. once daily.

3. Potassium 10 mEq. P.O. once daily. (3. Correct. This client is being treated for recurrent angina with hypertension. The admission prescriptions include spironolactone daily, which is a potassium-sparing diuretic. Therefore, the client should not be taking a daily dose of potassium. Prior to discharge, this client will also need instructions on avoiding additional potassium in the diet such as salt substitutes. 1. Incorrect. A "2-gram sodium diet" would be appropriate for a client with hypertension. 2. Incorrect. Metoprolol is a beta-blocker used to decrease preload, which will also decrease pulse and blood pressure. The dose is appropriate for this client and does not need to be questioned. 4. Incorrect. Diltiazem is a calcium channel blocker which vasodilates the arterial system and reduces recurrent angina by decreasing afterload. Additionally, calcium channel blockers help to decrease blood pressure. This medication and dose are appropriate for this client and would not need to be questioned.)

The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.

3. Read about formalin on the Material Safety Data Sheet (MSDS). (3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of information. Calling another department does not ensure that the nurse will get as comprehensive information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of hazardous material. 4. Incorrect: The nurse can place the biopsy into a container with formalin and is within the scope of practice for the nurse.)

The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider? Select all that apply. 1. Document the prescription prior to the end of the shift. 2. Explain to the pimary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.

3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. (3. & 4. Correct: Whenever a verbal or telephone prescription is given, the nurse is to transcribe the prescription, and then read it back to the prescribing primary healthcare provider at the time the prescription is given for validation of accuracy of the prescription received. Otherwise an error may occur. 1. Incorrect: Errors are more likely to be made if documentation is not made at the time the prescription is received. 2. Incorrect: Nurses can take telephone prescriptions; however, safety measures include writing down the prescriptions immediately and repeating the prescriptions to the primary healthcare provider. 5. Incorrect: Asking the primary healthcare provider to wait until rounds is not appropriate, as nurses can take telephone prescriptions with appropriate safety measures to ensure accuracy.)

During shift change the night charge nurse reports to the day charge nurse that a client, admitted with an ingestion of unknown drugs, received a prescription for physical restraint at 3:00 am because the client was incoherent, combative, and attempting to leave the facility. On last assessment at 7:00 am, the client was still combative. What is the best action by the day shift charge nurse? 1. Since the client is still combative, continue the restraints. 2. Remove restraints until the primary healthcare provider writes the prescription. 3. Assign an unlicensed assistive personnel (UAP) to check on the client periodically. 4. Obtain a prescription from the primary healthcare provider.

4. Obtain a prescription from the primary healthcare provider. (4. Correct: A prescription for physical restraints must be renewed every 4 hours if restraints are still needed. Generally, restraints are not used past a 24 hour period. The prescription for the restraint should include why the client requires physical restraints and a time period for using them and no more than 24 hours. 1. Incorrect: Do not assume. The oncoming nurse needs to assess the client in order to determine if restraints are still needed for the safety of this client. 2. Incorrect: If the client is indeed still incoherent and combative, restraints are still warranted to prevent the client from harming self or others. 3. Incorrect: Periodical checks will not keep the client from harming self or others and "periodically" is not an acceptable time frame for this action.)

Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? Select all that apply. 1. Recap the needle after use to prevent injury. 2. Reinsert the sylet if it becomes loose in the vascular assess device. 3. After drawing up saline to flush an intravenous (IV) line, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible. (4. & 5. Correct: Puncture resistant biohazard containers should be replaced when three-quarters full to prevent hand injury when disposing of sharps. Use of "needleless" devices reduces the risk of needle stick injuries. 1. Incorrect: For safety precautions and transmissions of infection, needles should never be recapped due to the possibility of injury while recapping. 2. Incorrect: Reinserting the stylet may cause injury to the nurse and client. 3. Incorrect: For safety precautions of the nurse or another person, a needle should never be placed in a pocket. The cap could come off and stick someone.)

What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage? 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment

4. Suction equipment (4. Correct: Insertion of a large orogastric tube designed for rapid lavage often causes gagging and vomiting, so suction equipment should be readily available to reduce the risk of aspiration. Maintaining the client's airway is the priority. 1. Incorrect: You would need an emesis basin because of the chance of vomiting, but suction equipment is the priority due to aspiration. 2. Incorrect: An x-ray is the preferred method to check initial placement, once the tubing is inserted. Suction equipment is the priority when inserting the tube due to risk of aspiration. 3. Incorrect: There are no key words in the question to suggest the client needs oxygen at this time.)

These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first? 1. The client whose blood pressure is 40 palpable, heart rate 30, and respirations 6. 2. The comatose client with fixed and dilated pupils. 3. The unresponsive client with an open head fracture and visible white matter. 4. The client with a sucking chest wound and tension pneumothorax.

4. The client with a sucking chest wound and tension pneumothorax. (4. Correct: This client would be tagged red and would be immediate. This is a life threatening injury that can be helped, if done so quickly. 1., 2., & 3. Incorrect: In a disaster this client would be tagged black- expectant: injuries that are extensive and chances of survival are unlikely even with definitive care.)

Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough

4. Whooping cough (4. Correct: Droplet isolation precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should wear a surgical mask while in the room. Mask must be discarded in trash after leaving the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. 1. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room {examples: MRSA, VRE, diarrheal illnesses, open wounds, Respiratory syncytial virus (RSV)}. Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. 2. Incorrect: Airborne isolation precautions are used for diseases or very small germs that are spread through the air from one person to another (examples: Tuberculosis (TB), measles, varicella). Healthcare workers should ensure client is placed in an appropriate negative air pressure room (a room where the air is gently sucked outside the building) with the door shut. Wear a fit-tested NIOSH-approved N-95 or higher level respirator while in the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. Ensure the client wears a surgical mask when leaving the room. Instruct visitors to wear a mask while in the room. 3. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room.

A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask? Select all that apply. 1. "Are you hearing voices today?" 2. "What are the voices saying?" 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 5. "Are the voices telling you to harm yourself or anyone else?"

1. "Are you hearing voices today?" 2. "What are the voices saying?" 5. "Are the voices telling you to harm yourself or anyone else?" (1., 2. & 5. Correct: The nurse must assess for hallucinations. The nurse needs to know what the voices are saying to determine the level of threat. The nurse needs to know if the command hallucination exists and whether it involves harming self or others which must be reported. These answers are important to know, as the client has a history of command hallucinations. 3. Incorrect: The priority is safety of the client and others on the unit. This question does not get the most essential information related to command hallucinations that may cause the client to engage in behavior that is harmful to self or others. 4. Incorrect: This question does not focus on the problem: command hallucinations. If you assume the worse, you want to know if the voices from the command hallucinations are telling the client to harm self or others.)

The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. 2. A client admitted with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound. 3. A client with ulcerative colitis exhibiting diarrhea. 4. A client with a fever of 99.1ºF (37.2°C) two days post gastrectomy.

1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. (1. Correct: Clostridium Difficile is a spore forming bacterium that has significant healthcare associated infections (HAI) potential. Clients with intravenous catheters are at a higher risk for HAI. 2. Incorrect: This client was admitted with MRSA already present which indicates that this is a community acquired infection. The client did not acquire a healthcare associated infection. 3. Incorrect: Clients with ulcerative colitis have diarrhea. Diarrhea in this instance does not indicate a possible healthcare associated infection. 4. Incorrect: Low grade fever may occur after surgery. The temperature of 99.1°​ F (37.2° C) does not indicate a HAI at this time.)

Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time? 1. Call the primary healthcare provider. 2. Reposition the client. 3. Increase the suction level. 4. Irrigate the tube.

1. Call the primary healthcare provider. (1. Correct: Do not tamper with fresh surgery tubes. Call the primary healthcare provider for blood draining from the NG tube after gastrectomy. 2. Incorrect: This delays care and does not resolve an occluded NG tube. 3. Incorrect: Increasing the suction level is very dangerous for the client. This could cause hemorrhage in this client. 4. Incorrect: Although the healthcare provider may prescribe for the tube to be irrigated later, the healthcare provider should be notified of the presence of blood initially. Irrigating the fresh NG tube in this situation could lead to increased bleeding.)

The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? Select all that apply. 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain

1. Color Changes 2. Drainage 3. Odor 4. Fever 6. Increased Pain (1., 2., 3., 4. & 6. Correct: Infections may cause color changes, drainage, odor, fever, & increased pain. Bleeding is a sign of hemorrhage, trauma, anemia or other blood disorders but not infection. 5. Incorrect: Bleeding is not a sign of infection. It may occur along with an infection but will not be caused by it.)

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations? Select all that apply. 1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Meningococcal 5. Haemophilus influenza type B (Hib).

1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 5. Haemophilus influenza type B (Hib). (1., 2., & 5. Correct: By the age of two, the DTaP, IPV, MMR, Hib, varicella, pneumococcal, and rotovirus vaccines should have been received. The nurse should clarify this with the parent. 3. Incorrect: This vaccine is recommended for people 60 years or older whether or not the person has ever had chicken pox and is at risk for developing shingles. Although the vaccine can be given to adults between the ages of 50-59, routine administration is not recommended. 4. Incorrect: The minimum age for administering the meningococcal vaccine is two years of age. The recommended age for administering the meningococcal vaccine is at 11 or 12 years of age, or 13 through 18 years of age if they did not previously receive this vaccine. It is especially important for teens going to college and who are likely to stay in close quarters such as a dorm.)

Which prescriptions would the nurse recognize as being appropriate for the client with shingles? Select all that apply. 1. Private room 2. Negative pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room

1. Private room 2. Negative pressure airflow 3. Respirator mask (1., 2. & 3. Correct: According to the current standards of Standard Precautions per the CDC, the client with shingles should be placed on airborne precautions which require the use of a private room with negative pressure airflow and a N-95 respirator mask. 4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood or body fluids. This is not required for airborne precautions. 5. Incorrect: Negative pressure is required in order to prevent the airborne infection from spreading outside of the room. Positive pressure is used only in protective environments such as when immunocompromised clients require protection from potential infectious agents outside of the room.)

A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag? 1. Traumatic amputation to the left lower leg. 2. 2nd and 3rd degree burns over 75 % of the body. 3. Fracture of the humerus. 4. Blood pressure of 90/40 and lethargic.

2. 2nd and 3rd degree burns over 75 % of the body. (2. Correct: 2nd and 3rd degree burns over 60% of the body put the client in the triage category of black- expectant: injuries are extensive and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties but not abandoned. Comfort measures should be provided when possible. 1. Incorrect: This client is tagged red and needs immediate care. Injuries are life-threatening but survivable with minimal intervention. Individuals can move quickly to black-expectant if treatment is delayed. 3. Incorrect: This client is tagged green and placed in the minimal category. Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. 4. Incorrect: This client is tagged red and is immediate with signs of shock.)

During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit.

2. Call for another urinary catheter and a pair of sterile gloves. (2. Correct: Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety. 1. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. The client would be at high risk of developing a urinary tract infection. The catheter cannot be made sterile by the use of alcohol. 3. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. Inserting the now non-sterile catheter puts the client at risk for infection. There is no reason at this time to start antibiotics. 4. Incorrect: The catheter is contaminated, but the sterile field is still okay. It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit.)

The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container

2. In a chemotherapy sharps container (2. Correct: Empty vials and sharps such as needles and syringes used in delivering chemotherapy agents should be disposed of in a chemotherapy sharps container. These waste containers are designed to protect workers from injuries and are disposed of by incineration at regulated medical waste facilities. 1. Incorrect: Hazardous, drug-contaminated sharps should not be placed in red biohazard containers that are used for infectious wastes, since these are often autoclaved or microwaved. 3. Incorrect: Biohazard waste containers are not designed for sharps and can cause injuries. 4. Incorrect: Chemical containers are not designed for sharps and can cause injuries.)

A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually? Select all that apply. 1. Chest xray 2. Mammography 3. Influenza vaccine 4. Tuberculous (TB) skin test 5. Colonoscopy

2. Mammography 3. Influenza vaccine (2. & 3. Correct: It is recommended that women age 45-54 should have a mammogram annually. Women 55 or older should have a mammogram every 2 years. The influenza vaccination is recommended annually for persons 6 months and older. 1. Incorrect: Chest x-ray is not done routinely since that exposes the client to low doses of radiation. A chest x ray would be ordered as a diagnostic radiographic examination. 4. Incorrect: Tuberculosis (TB) skin test yearly is required for high risk individuals, such as those working in the healthcare field or in nursing homes or other close-contact areas. This test is not recommended annually at a specific age for low risk individuals. 5. Incorrect: Colonoscopy is recommended for clients beginning at age 50, but not annually (every 10 years with no problems) until the age of 75. A colonoscopy should be performed more frequently if there is a change in bowel habits, obvious or occult blood in the stool or abdominal pain.)

A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? 1. Surgical scrub 2. Time-out 3. Sponge and instrument count 4. Inspection of the surgical site

2. Time-out (2. Correct: Time-out, done immediately before the procedure, is a final verbal verification of the correct client, procedure, site, and implant. Time-out is active communication among all members of the surgical/procedural team, initiated by a member of the team before surgery. 1. Incorrect: Surgical scrub should be done before entering the surgical suite. 3. Incorrect: The scrub nurse does instrument and sponge counts numerous times before, during, and after the procedure. 4. Incorrect: Simple inspection of the surgical site is not enough. The team must verbally communicate what is to be done, on what limb. Additionally, the limb should be marked as "This knee" or "yes".)

A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?"

3. "Come to the clinic now so that we can help you." (3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby.)

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should take my needles to the nearest hospital for disposal. "

3. "I may use any hard plastic container with a screw-on cap." (3. Correct: At home, an FDA approved sharps container is not needed, however, needles, syringes, and sharps may be disposed of in a hard plastic container. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from injury by the sharps. 1. Incorrect: Syringes must be placed in a safe container in order to protect others from becoming injured by sharps. Wrapping the needle in a paper towel and placing in the trash increases the possibility of injury to someone. 2. Incorrect: The hospital is not involved in sharps disposal in the home. A hard plastic container with a screw on cap is an acceptable container to dispose of needles. 4. Incorrect: The hospital is not involved in sharps disposal in the home. The client can dispose of needles safely at home in a hard plastic container with a screw on cap. The needle should not be brought to the hospital for disposal.)

A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.

3. Consult with the pharmacy for a different medication concentration. (3. Correct: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the drug is prescribed IM, the route should not be changed to IV administration because this violates the prescription as written. 2. Incorrect: The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. You want to avoid having to give three injections. 4. Incorrect: The concern is not drug information or administration; it is the concentration, which can only be provided by the pharmacy.)

A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse

3. Lead poisoning (3. Correct: Lead may be found in the soil around rusted cars and can cause lead exposure. Old paint contains lead. Chips of paint may be consumed by young teething children. Old, run-down apartments may also have pipes which contain lead. Exposure to and consuming even small amounts of lead can be harmful. No safe lead level in children has been identified, and lead can affect nearly every system in the body. Mental and physical development can be negatively impacted by lead in the body. 1. Incorrect: Although the nurse does need to check immunizations, the hints in the stem indicate several problems that should direct the focus to lead poisoning, which is the priority. Immunization should be administered if the child is not on schedule, but consequences of lead poisoning is much more serious. 2. Incorrect: There was nothing in the stem indicating school problems. This would not take priority over lead exposure assessment. 4. Incorrect: Although poverty and poor housing conditions have been identified as environmental factors for potential abuse, the stem of this question does not provide additional cues that would indicate abuse. Assessment for lead poisoning would be the priority in this situation based on the environmental issues identified.)

The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? Select all that apply. 1. Don sterile gloves. 2. Place the client on reverse isolation. 3. Wear a particulate respirator 4. Obtain a consent form. 5. Initiate airborne precautions.

3. Wear a particulate respirator 5. Initiate airborne precautions. (3. & 5. Correct: A disposable particulate respirator that fits snugly around the face is needed. The client needs to be on acid-fast bacilli (AFB) isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 1. Incorrect: Sterile gloves are not needed. Standard precautions indicate clean gloves. 2. Incorrect: The client needs to be on airborne isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 4. Incorrect: A consent is not necessary.)

An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? 1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn."

4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn." (4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client secretions or excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask. This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB). 1. Incorrect: This is a correct statement regarding the prevention of infection. Hand washing with soap and water is part of standard precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part of the first line of defense against the spread of infection.)

A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.

4. A clean needle sticks the nurse through blood-soiled gloves. (4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick. 1. Incorrect: This is considered a clean stick. The needle is sterile initially and has not been contaminated prior to removal of the needle from the syringe. 2. Incorrect: This is considered a clean stick since the suture needle has not been inserted into the client prior to the needle stick. 3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and has not been contaminated since it was not inserted into the client.)

A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse's initial action? 1. Tell the client to stay calm, and that treatment will be provided soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Find a safe place away from the client and then notify security.

4. Find a safe place away from the client and then notify security. (4. Correct: Self-protection is a priority. There is no advantage to protecting others if medical caregivers are injured. Security officers and police must gain control of the situation first, and then care is provided. 1. Incorrect: This does not provide safety for the nurse and might increase the client's anger. 2. Incorrect: This is not a true statement and does not provide immediate safety for the nurse. Clients seeking treatment are not refused care in the ED. 3. Incorrect: This is not the initial action. Finding a safe place is the first action for the nurse's safety. Also, the angry client does not need to be sent to the waiting room around other clients at this time.)

The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which action by the nurse indicates that further instruction on transmission of this disease is needed? 1. Instructs the new mother that she should not kiss the newborn. 2. Wears gloves during the perineal and lochia assessment. 3. Washes hands before and after each client contact. 4. States that the newborn may contract herpes from the birth canal.

4. States that the newborn may contract herpes from the birth canal. (4. Correct: Oral herpes simplex type I is more often manifested by lesions on the lips or nose (cold sores/fever blisters) and is contagious, but not through the birth canal. Genital herpes type 2 can be transmitted to the newborn during child birth. 1. Incorrect: The newborn can contract herpes simplex 1 through direct skin contact with the lesions or oral secretions such as kissing. This is an appropriate instruction. 2. Incorrect: Wearing gloves during the assessment is not related to the mother's diagnosis of oral herpes simplex type These are standard precautions and are appropriate. 3. Incorrect: Washing hands prior to and after each client contact are standard precautions and are appropriate.)

The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first? 1. Apply warm compresses. 2. Slow the infusion. 3. Inspect the IV site. 4. Stop the infusion.

4. Stop the infusion. (4. Correct: Stop the infusion in order to stop the damage now. 1. Incorrect: The infusion is burning and this is a sign of the drug in the tissues. Apply an ice pack. 2. Incorrect: Stop the infusion before the arm becomes necrotic. 3. Incorrect: Trust what the client is telling you, and stop it now before too much damage is done.)

A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. Extinguish the fire. Obtain the fire extinguisher. Activate the fire alarm. Remove the client from the room. Close the door to the client's room.

Remove the client from the room. Activate the fire alarm. Close the door to the client's room. Obtain the fire extinguisher. Extinguish the fire. (Remember RACE: Rescue the client; activate the alarm; contain the fire in the client's room; extinguish the fire. This standard process ensures safety for the client first and then the remaining people in the facility next. First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire.)