NUR 204 ATI Safety and Infection Control Ch. 10-15
A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?
Wear a mask when providing care to the client
A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?
"As long as I change my gloves between clients, it is not necessary to wash my hands."
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask for the client?
"Do you have difficulty staying awake when you are driving?"
A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
"I can detect the presence of carbon monoxide by a metallic odor."
A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?
"I will cover the catheter so he cannot see it."
A nurse is teaching a client who has a history of falls about home safety. Which of the following statement should the nurse identify as an indication that the client understand the instructions?
"I will place a bath seat in my shower to use when I bathe."
A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?
"I will tie a restraint to the portion of the bed that moves when the head of the bed is moved."
A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching?
"I will use ink pens for writing."
A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?
"I will wear gloves and a gown when bathing a client who has open skin lesions."
A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching.
"I will wear synthetic clothing and woolen socks when using my oxygen."
A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
"It is a good idea to use handrails in the bathroom."
A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?
"Move both crutches forward while standing on the unaffected leg, then life and swing your body past the crutches."
A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
A nurse is providing home safety information for an older adult who uses a cane. Which of the following statements should the nurse include in the teaching?
"Should should advance your weak leg forward to the cane, then move your strong leg."
A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?
"The client was lying on the floor next to his bed."
A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record?
"The provider was notified."
A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the client's use of a cane?
"When the client moves, he should move the cane forward first."
A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room?
-A protective mask -A closed door -A puncture-proof sharps container -Hand hygiene
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection?
-An increase in neutrophils -Localized edema
A nurse caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? SATA
-Assist the client with toileting at frequent intervals -Use an electronic position-sensitive device -Provide diversionary activities for the client -Involve the family in the client's care
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching?
-Check the cannula position on a regular basis -Check the tops of the ears for skin breakdown -Post "no smoking" signs in a prominent location in the home
A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? SATA
-Client's full name -Facility-assigned identification number
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan?
-Document restraint checks and client status every 2 hr. -Educate the client's family about restraint use -Implement passive range-of-motion exercises
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? SATA
-Emptying urine from an indwelling urine collection bag -Providing oral care -Changing an ostomy pouch
A nurse is planning care for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physical restraints? SATA
-Ensure effective pain management -Attend to the client's needs for toileting -Assign the client to a room near the nurse's station -Orient client frequently to the environment
A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? SATA
-Irrigating a client's abdominal wound -Suctioning a client's new tracheostomy tube
A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.
-Perform hand hygiene -Place package on work surface -Open the outermost flap away from self -Open the side flap, pulling to the side -Open innermost flap toward self. -Use inner surface of package as sterile field
A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution?
-Perform hand hygiene -Remove the bottle cap -Place the bottle cap face-up on a clean surface -Pick up the bottle with the label facing toward the palm -Pour 1 to 2 ml into receptacle -Pour the solution onto the gauze
A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?
-Relief of urinary retention -An open perineal wound
A nurse is assisting a provider with a sterile procedure and prepares to pour a solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution.
-Remove the bottle cap -Place the bottle cap face-up on a clean surface -Pick up the bottle with the label facing toward the palm -Pour 1 to 2 ml into receptacle -Pour the solution onto the gauze
A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room.
-Remove the gloves -Remove the eyewear -Remove the gown -Remove the mask -Perform hand hygiene
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? SATA
-Teach the client to use the call light -Keep the client's bed in the lowest position -Place a fall-risk identification band on the client's wrist
A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? SATA
-Water heater temperature 54.4 C (130 F) -Throw rugs
A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? SATA
-bid -30 mL
A charge nurse is planning a room assignment for client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is private, negative-pressure airflow room; room 212 is semi=private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?
208
A nurse is caring for four clients. The nurse should identify which of the following clients as having a contraindication to receiving moist heat?
A client who broke his ankle 2 hr. ago and has swelling of the lower extremity
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions?
A client who has measles
When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?
Contact the provider to question the dosage.
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?
Airborne
A client receive a wrong medication. The nurse who made the medication error should take which of the following actions first?
Assess the client.
A nurse is having difficulty reading the provider's writing when transcribing a prescription for a client's medication. Which of the following actions should the nurse take?
Contact the provider to clarify the prescription
A clinical nurse educator is preparing an education program about transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized clients. Which of the following information should the nurse include in the program?
Bathe clients with water and chlorhexidine gluconate
A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?
Bend at the knees when picking up an object.
A nurse is admitting a client who has a wound infection with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?
Contact
A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?
Discard the tablet and obtain another dose of medication
A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?
Dispose of the dressing in a biohazardous waste container
A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take?
Dispose of the needle uncapped.
A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?
Droplet
A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?
Mask
A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?
Hold a bottle of solution with the label away from the palm of the hand
A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching?
Washes hands with soap and water before the procedure
A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following action?
Include any relevant statements the client made about the ulcer
A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first?
Gloves
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?
Gloves
The nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should be removed first?
Gloves
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
Have the client wear a mask
A nurse needs to lift a box in a supply room. Which of the following actions should the nurse take to prevent injury due to lifting?
Keep the box close to his body as he lifts.
A nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. Which of the following actions should the nurse take?
Keep the padded portion of the restraints against the wrists
A nurse caring for an older adults client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?
Leave a nightlight on in the client's room
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
Lock the wheels of the bed and the wheelchair
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
Lower the client to the floor
A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment should the nurse remove last?
Mask
A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?
Move any clients in the immediate vicinity.
A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?
Nonantimicrobial soap
A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?
Opening a sterile package over the middle of the sterile field
A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?
Perform hand hygiene before, during, and after direct contact with the client.
A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse should take?
Perform the Heimlich maneuver
A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?
Performing hand hygiene frequently and consistently
A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?
Place a seat alarm in the client's chair
A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?
Place the client on contact precautions
A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?
Places clean linen that touched the floor in the soiled linen bag
A nurse is caring for a client who is confused and has pulled out her peripheral IV catheter three times. Which of the following actions should the nurse consider?
Plate mitten restraints on the client's hands
A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?
Protective
A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?
Provide the appropriate PPE to the AP
A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?
Purulent drainage is noted from the site.
A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?
Reach around the pack and open the top flap away from the body
A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?
Reaches over the bed to straighten the fitted sheet
A nurse is wearing personal protective equipment and is preparing to leave a client's room after providing care. After untying the ties at the waist of the gown, which of the following actions should the nurse take?
Remove gloves. Remove the protective eyewear. Remove the gown. Remove the mask.
A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take.
Remove the clients from the room. Activate the fire alarm. Close the door. Extinguish the fire.
A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. Which of the following actions should the nurse take first?
Rescue the client from immediate danger
A newly license nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Secure the restraints with a quick-release tie
A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?
Standard
A nurse manager is preparing to take disciplinary action for a staff nurse's substance use disorder. The manager should identify which of the following as having the authority to revoke a nurse's license?
State board of nursing
A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting his goal?
The client faces the direction of movements when sliding an object across the floor
A nurse is reviewing the medical record for a client who has health care-associate infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?
The client is 71 years old
A nurse is assessing a client's ability to ambulate with crutches using a three-point gait Which of the following actions should the nurse identify as a risk to the client's safety?
The client places partial weight on the affected leg
A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?
The client's hand is cool and pale
A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?
The nurse has already considered alternatives to restraints.
A nurse manager is observing AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?
The padding of the restraints is against the client's bony prominences.
A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include?
Tie linen bags securely at the top.
A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?
Two nurses using a friction-reducing device
A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene?
Washes and rinses her hands for 10 seconds
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take?
Use a gait belt to stand and pivot the client
A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?
Use sterile forceps to move the sterile items on the sterile field.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
WBC count
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
Wait 30 min and return to measure the oral temperature
A nurse accidentally stick her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?
Wash the area of the puncture thoroughly with soap and water.
A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?
Wear an N95 respirator mask
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?
Wear clean gloves