Safety, asepsis, infection Prep U

An anxious son asks the nurse how he can keep his older adult father safe in his home. He tells the nurse that his father lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the best statement by the nurse? "Small, thick area rugs provide lower extremity warmth in cold weather. He may have temperature deficits in his feet." "If you tried hiding his car keys and he keeps finding them, why don't you disconnect the car battery?" "Put some blocks on his Internet service so he cannot subscribe to disreputable websites." "A good idea is to get a weekly medicine tray at the pharmacy. This will keep him from missing medication doses or taking the wrong pill by accident."

"A good idea is to get a weekly medicine tray at the pharmacy. This will keep him from missing medication doses or taking the wrong pill by accident."

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces." "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition."

"I will use conditioner so that the lice eggs will slide off my hair."

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how she could help her family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections? "Make sure your family has all of their childhood immunizations." "Encourage your family to stop smoking." "Make sure your family has regular checkups." "Encourage your family to adopt a healthy diet and exercise regimen."

"Make sure your family has all of their childhood immunizations."

A client the nurse is caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for 2 weeks. The client's family asks the nurse how the client got this infection. What would be the nurse's best response? "People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." "People in hospitals sometimes exhibit signs of infections they had prior to being admitted." "Sometimes people in hospitals get exposed to microorganisms that their visitors bring in." "People in hospitals are surrounded by infectious agents, so they can get infections they didn't have before being admitted."

"People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital."

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate? "Stress leads to increased secretion of cortisol, which suppreses your immune response." "Stress causes the body's normal immune response to turn on itself." "Stress causes body fluids to accumulate, which leads to bacterial growth." "Stress leads to a deterioration in the skin's barrier line of defense."

"Stress leads to increased secretion of cortisol, which suppreses your immune response."

The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response? "For 2 days as you get settled onto the unit." "When your sputum culture is negative." "Only until you begin to feel better." "Until you leave the hospital."

"When your sputum culture is negative."

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use? 34-year-old male who does not use a seat belt 25-year-old female who just accepted her first job 40-year-old female who is working two jobs 19-year-old male college student majoring in physics

19-year-old male college student majoring in physics

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days

Which client is most at risk for foot difficulties? 80-year-old man with coronary artery disease 34-year-old woman who is paraplegic 45-year-old woman with type 2 diabetes 91-year-old man with renal insufficiency

45-year-old woman with type 2 diabetes

A nurse is caring for an 18-month-old client after a tracheostomy. The is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate? dominos a rocking horse marbles a beaded bracelet

A rocking horse Rationale: All of these toys present a choking hazard except for the rocking horse, they are great for development of leg muscles

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate? administration of an antipsychotic agent to alter the client's behavior asking the unlicensed assistive personnel (UAP) to sit with the client application of devices that reduce the client's ability to move arms articulating the reason for use of a physical restrictive device to the client's spouse

Administration of an antipsychotic agent to alter the client's behavior Rationale: Chemical restraints are medications used to manage behavior or freedom of movement. These are generally used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others. Physical restraints are devices that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head. Articulation of rationale for using a physical restraint is part of nursing teaching. Asking the UAP to sit with the client is a diversion method.

A nurse is caring for an older adult client at risk of injury due to confusion. The client has a stable gait. Which method of restraining should the nurse use? vest restraint alarm-activating bracelet locking lap tray chair waist restraint

Alarm-activating bracelet Rationale: The nurse should use an alarm-activating bracelet for the client because the client has a stable gait. This prevents unnecessary confinement to bed, and the client can move freely without getting off the premises

A nurse caring for the skin of clients of different age groups should consider which accurately described condition? The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. An infant's skin and mucous membranes are protected from infection by a natural immunity. Secretions from skin glands are at their maximum from age 3 on.

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular

A nursing instructor is describing the phases of a febrile episode. What would the instructor describe as happening first? Crisis Chill Fever Flush

Chill Rationale: 2.) Fever phase 3.) Flush/ Crisis phase

Microorganisms that are present on the human body without host interference or interaction refers to: disease. infection. inflammation. colonization.

Colonization

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention? Clean under the toenails with a wooden orange stick. Clip the toenails with large clippers. Use a handheld electric rotary file to reduce the length of the toenails. Contact a podiatrist to care for toenails.

Contact a podiatrist to care for toenails.

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate? Discard it in the waste can. Disinfect it with alcohol swabs. Sterilize it by placing it in the autoclave. Do nothing; it can be used again immediately.

Disinfect it with alcohol swabs

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is the priority?

Evacuate the client

A nurse is educating a mother about caring for a newborn baby. What should the nurse teach the client as a precautionary measure to protect the infant from burns? Monitor the activities of the infant closely. Keep hot substances on the table. Keep hot substances away from the baby. Keep the infant away from the kitchen.

Keep hot substances away from the baby Rationale: Infants are not very mobile and depend on their parents

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide? Lesions should be squeezed gently to release pus. Apply cortisone to this reddened rash. There would be no intervention, as this chronic skin disorder is noninfectious. Launder gowns, linens, and towels separate from other clients' items.

Launder gowns, linens, and towels separate from other clients' items.

The nurse manager is preparing to educate newly hired nurses about fingernail hygiene. Which education is appropriate? Gel polish is an acceptable method of polishing nails. Use fingernail polish instead of artificial nails. Acrylic nail treatments help strengthen nails since nurses wash hands often. No nail treatments can be utilized. Clean under the fingernails when washing hands.

No nail treatments can be utilized. Clean under the fingernails when washing hands.

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the client's risk for a fall? Orient the client to the room and environment upon admission. Place the client in a shared room with a client who is stable and oriented. Provide the client with a bedpan to reduce ambulating to the restroom. Administer pain medications sparingly in order to minimize any cognitive side effects.

Orient the client to the room and environment upon admission.

A nurse is assigned to care for a hospitalized toddler. Which activity should be the highest priority for the nurse? Provide medications on time. Spend time with toddler in the play room. Protect the toddler from injury. Provide health education to parents.

Protect the toddler from injury

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agent. What is an appropriate consideration when assisting the client with morning hygiene? Do not allow the client to shower. Avoid massaging the client's back with lotion. Provide the client with a firm-bristled toothbrush. Provide the client with an electric shaver.

Provide the client with an electric shaver. Rationale: Electric shavers are recommended when a client is receiving anticoagulant therapy. In addition, the nurse should not provide a firm-bristled toothbrush because the client is more prone to bleeding, and the firm bristles may lead to bleeding. The client should be allowed to shower, unless there are other contraindications. A back massage will provide an ideal time to perform a skin assessment for bruising or breakdown.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? Extinguish the fire. Evacuate the unit. Confine the fire. Pull the fire alarm lever.

Pull the fire alarm lever

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes? Contact the facility's information technology department to delete abbreviations. Correct the abbreviations in the EHR. Ask another nurse to fix the abbreviations. Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

The nurse works on a long-term care unit. In the last 2 weeks, more than half the clients on the unit have been diagnosed with gastroenteritis. What is the best explanation for this phenomenon on the unit? The infection is being transmitted by health care personnel. Clients are in too small an area and are passing around diseases. Visitors are bringing the disease into the unit. Clients are not washing their hands after going to the bathroom.

The infection is being transmitted by health care personnel.

A nurse needs to send the blood and urine specimen of a client with acute diarrhea to the pathology laboratory. Which precaution is the priority when collecting and delivering the specimens to the laboratory? use disposable cover gowns and goggles use a particulate air filter respirator use thoroughly washed gloves use sealed containers in a plastic biohazard bag

Use sealed containers in a plastic biohazard bag

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup? Virus Parasites Bacteria Fungi

Virus

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the WBC in the chart. Which result supports this concern? WBC of 5,500 mcL WBC of 10,500 mcL WBC of 7,500 mcL WBC of 25,000 mcL

WBC of 25,000 mcL Rationale: Leukocytes (WBCs) and the inflammatory response make up the 2nd line of defense to microbial invasion. A normal WBC count is 5,000 to 10,000 cells/mm3. A count above this range is indicative of infection.

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify: decreased susceptibility to infection. decreased cellular immunity. increased effectiveness of phagocytosis. increased humoral immunity response.

decreased cellular immunity.

A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.

exposure to the pathogen nonspecific symptoms positive laboratory tests return of appetite

A nurse is preparing a sterile field and has removed the sterile drape from the outer wrapper. The nurse places the inner drape in the center of the work surface with the outer flap facing in which direction? facing away from the body toward the right side facing toward the body angled to the left side

facing away from the body

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include: peeling paint and easy access to the backyard pool. risky behaviors and cyberbullying. polypharmacy and use of multiple extension cords. household cleaners stored under the sink and hanging cords on window blinds.

polypharmacy and use of multiple extension cords.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy? raising one bed rail to offer stabilization when standing placing the client in a bed with a bed alarm raising all side rails while the client is in bed providing a bed that is low to the floor

raising all side rails while the client is in bed Rationale: Raising all side rails on the bed would be a restraint and may increase the client's risk of falling if he climbs out of bed.