Safety/Infection Control: Review

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? x isolation gown and surgical mask

(just the surgical mask). Rationale: This is done to protect others from the respiratory secretions. _____________________ Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed?

*"I walk in my stockinettes at home because it helps to relieve my bunion pain."

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the nurse's priority response? x Call the poison control center. I will give you the number.

*"What is your child doing right now?"* Rationale: When a child accidentally ingests a poisonous substance, it is most important to assess the child's condition, including physical signs and symptoms, mental status, and behavior. Based on the condition of the child, the nurse can provide guidance and instructions to contact the appropriate agency (eg, emergency services, poison control center).

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely?

*1 person safety standby with walker.* Rationale: Criteria: 1. Weight Bearing 2. Mental Status The client has both of these;

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client?

*Complications, including death could result.*

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? x PICC line that is occluded and was placed 2 weeks ago. (PICC lines can be inserted for weeks to months; occulsion doesn't necessarily mean removal). x Subclavian line with *redness at the anchor site* (necessitates looking at) but is not on the insertion site. = okay x Internal jugular 6 days ago = stable.

*Femoral line inserted in the emergency department post-cardiac arrest 48 hours ago.* Rationale: - Access in the *inguinal*/femoral area can easily be contaminated by feces and urine and should be removed immediately.

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC). The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

*Flush unsued lumens of the CVC with 1,000 units of heparin every 12 hrs.* Rationale: *Most CVCs require intravenous heparin flushes to maintain patency and prevent clotting. Single-dose vials of 2-3 mL of 10 units/mL or 100 units/mL are the standard of care. A dose of 1000-10,000 units is given for cases of thromboembolism.*

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? x Lorazepam for alcohol withdrawal and agitation = okay x Olanzepine for schizophrenia and violent aggressive behaviors = okay x Propofol for mechanical ventialation to prevent extubation = okay.

*Haloperidol for a client with a fall history who keeps getting out of bed without assistance.*

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery?

*I didn't take my clopidrogel yesterday or today."* Rationale: The client d/c the blood thinner only within the last 48 hrs. ago. The surgery would most likely have to be rescheduled.

Misconceptions vs. Known Facts

*Look for possible misconceptions before selecting true facts as erroneous.*

TPN can be given via a CVC or PICC line.

*TPN should be administered through a CVC. Because of its viscosity and high glucose, lipids, electrolytes, vitamins and minerals, it is safest when administered through a CVC or peripherally inserted central catheter.*

The nurse at the radiological imaging center is admitting a client for an *MRI of the right knee*. Which information obtained by the nurse should be *reported immediately to the prescribing health care provider*?

*The client has an implantable cardioverted defibrillator.* Rationale: The large magnet can damage or interfere with their function.

Propofol: (Diprivan)

*class*: general anesthetic *Indication*: anesthesia, induction, sedation *Action*: hypnotic, produces amnesia *Nursing Considerations*: - use cautiously with CVD, lipid disorder, increased ICP - can cause apnea, bradycardia, hypotension - burning and pain at insertion site - *can turn urine green* - assess respiratory status and hemodynamics - maintain patent airway - assess level of sedation

Strategies to Prevent Falls:

- *EXERCISE PROGRAMS TO INCREASE MUSCULAR STRENGTH & FLEXIBILITY*- regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore, decreasing fall risk.* - *Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double-sided tape) .* - *Using grab bars and non-skid bath mats in the bathroom.* - *Wearing shoes or slippers with non-skid soles, both inside and outside of the home.* - *Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care provider (HCP).* - *Getting regular vision exams.* - *Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of knowing help is available immediately if a fall occurs.*

A nurse prepares a client for knee arthroscopy requiring general anesthesia. Which actions should the nurse complete? Select all that apply. x Replace the 20 gauge catheter with an 18 gauge.

- *Encourage the client to void prior to surgery.* - *Ensure that the client has been on NPO status.* - Place signed informed consent into the client's chart. - *Witness the correct surgical site is marked by the surgeon.* ______________ https://www.medicalnewstoday.com/articles/322099.php#recovery

Bariatric Patients: Do we really need a whole team to assist them

- *ONLY IF THE CLIENT IS UNABLE TO BEAR WEIGHT, SHOULD THE NUMBER OF STAFF BE INCREASED TO PROVIDE SAFETY.* - *ASSISTIVE DEVICES SHOULD BE ASSESSED TO ENSURE THAT THEY CAN ACCOMMODATE THE SIZE & WEIGHT.* - *CLIENT DIGNITY should be given throughout the process.*

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

- *Step slightly behind the client with feet apart, extend one leg, and let client slide against it to the floor.*

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? Select all that apply. *(NCSBSN - SAFETY & INFECTION CONTROL)* x IN NCLEX LAND YOU DON'T NEED TO SHAKE THE FIRE EXTINGUISHER PRIOR TO USE.

- Aim the nozzle at the base of the fire. - Pull the pin on the handle. - Sweep from side to side. - Squeeze the handle.

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate order. All options must be used. *(ORDERED STEPS)*:

- Assess for presence of adequate pulse. - Inspect the client for injuries. - Get help and move the client to the bed. - Notify the HCP - Complete an incident report. Rationale: *Establish the ABC's PRIORITY before any other step for a client who has suffered a fall & might be UNCONSCIOUS first!* In this case, if they need CPR, resuscitative measures will be taken. Then check client injuries, move the client to safety, and follow protocol.

x Full padded side rails that are *RAISED* for a client during a seizure. x Long leg immobilizer for a fractured tibia. x Elbow restraints for a toddler during a blood draw.

- Belt restraint for a confused client who keeps trying to get out of bed, but is on *bed rest.* - *Soft ankle restraint to prevent bleeding following a cardiac catheterization*.

MRI Contraindications:

- Claustrophia & extreme cases of anxiety - (sometimes) pregnancy Absolute: - Pacemakers - *Aneurysm Clip* - *Cardiac Defibrillators* - Shrapnel or foreign metallic objects in the body - *Hearing Aids* - (other electronic devices)

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. Rationale: Option 2 is a treatment error. Option 4 is a communication error as well as inadequate follow-up. Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals.

- Client receives 1 mg of morphine instead of the prescribed 0.5mg. - Nurse does not report a Hbg of 6 to the oncoming nurse. - Provider was not notified of the client's positive blood culture test.

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.

- Ensure bed alarms are activated. - *Intiate hourly rounding.* - Moving client to a room closer to the nurse's station.

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply.

- Hand washing - N95 particulate NOT THE GOWN

Do not use alcohol based gels:

- If hands are *visibly soiled* - C.Difficle patients (a contact precaution)

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. x Ensure that the *CLIENT* wears an N95 respirator at all times. x *Remove both pairs of gloves before doffing the gown and mask.*

- Keep the door of the client's room closed at all times. - Maintain a log of everyone who enters and exits the client's room. - *Restrict visitors from entering the client's room.*

Nursing Responsibilities prior to surgery:

- NPO & (NO Cigarette Smoking) - Void before surgery - Informed Consent - Verify Site Marking (witness and document preoperatively that the surgeon has chosen the correct site w/ a permanent marker and *verify this with the client*.)

To Brace a patient during a fall:

- SLIDE DOWN THE LEG (from behind) 1. Step behind client with feet apart. 2. Move one foot back and extend the leg. 3. Lower the client to the floor.

On a triple lumen, which port should be used for CVP monitoring (Central Venous Pressure)?

- The *DISTAL PORT* of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. (i.e. the short middle one typically with the rubber-padded tubing).

Ebola Virus Precautions:

- private room - standard, contact, droplet & airborne precautions - double gloved PPE: - impermeable gown, coveralls, N95 respirator, full-face shield, double-gloved with extended cuffs, single use boot covers, single use apron. - Outer gloves cleaned first with DISINFECTANT then REMOVED. - *INNER GLOVES WIPED BETWEEN EVERY REMOVAL OF PPE and then the gloves are discarded LAST.* NO Visitors - except extentuating circumstance: a parent visiting an infected child. - Disease Surveillance: A log must be kept of all of those who enter and leave the room (to check for symptoms). - Use of needles and sharps are LIMITED as MUCH as POSSIBLE.

Assist from bed to wheelchair transfer:

- step in front of a client, brace client's knees to yours and assist in a wheelchair transfer.

IV Pumps and High Risk Medications:

-Heparin - Insulin - KCL - Vancomycin

PRIORITY - PRECAUTIONS

1st: *Airborne* 2nd: Droplet 3rd: Contact

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BLOOD THINNERS NEED TO BE D/C at LEAST

5 - 7 DAYS BEFORE ELECTIVE SURGERY (i.e. Cholecystectomy, CABG (probably more), major abdominal surgery).

Occlusive dressing can be changed... every

7 days Rationale: According to the CDC, an occlusive dressing should be changed every 7 days.

The emergency department nurse receives report on 4 clients. Which client will the nurse *prioritize* for *placement in an isolation room*? x 4 year-old with *scabies* (only from direct contact) x 12 year-old with *influenza* (droplet precautions - 2nd priority). x 14 year-old with MRSA (only from direct contact)P

7 year-old diagnosed with measles who has a fever, conjunctivitis, and a maculopapular rash. Rationale: Infectious agents that are spread via the AIRBORNE ROUTE are among the MOST CONTAGIOUS. Therefore: *Measles, Tuberculosis, Varicella, SARS (severe acute respiratory syndrome) should be isolated first among airborne precautions. - These clients are placed into a *NEGATIVE PRESSURE ROOM* with high rates of air exchange or negative particulate filtration systems.

Incident Report:

A report documenting an incident and the response to the incident; also known as an occurrence report or event report.

TREATMENT GOALS: BED BUGS

ALLEVIATE THE ITCHING AND SCRATCHING. - Use hot water to wash linens, clothes, etc. - Exterminate the house to eradicate of the bugs. - Bed bugs are NOT contagious. - Bed bugs aren't necessarily found because of a DIRTY ENVIRONMENT. They can HITCH a RIDE anywhere within the environment. = *(common misconception)*

NCLEX TIP/STRATEGY:

ALWAYS READ THE MODIFYING PHRASE.

Who is greatest at RISK for FALLS:

Adults age >65+ (senior citizens)

Smoking before surgery???

All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems.

High Falls Risk:

Bed alarm High fall risk signs Room close to nurses' station Color-coded socks & wristbands

CENTRAL VENOUS CATHETER:

D/C THE MOST DISTAL ACCESS SITE (i.e. Femoral or Dorsal = has the highest incidence for contamination: fecal, urine, environmental). - UPPER CVC sites are PREFERED (i.e. back of hand, subclavian, internal jugular) x antecubital fossa

Remember: NCLEX loves to play with...

DISTANCE & TIME - when in doubt, *Leave it Out!*

MENIERE'S DISEASE - NURSING ACTIONS/PRIORITY

FALL RISK, AMBULATE SAFETY, AVOID DISTRACTIONS AND FLASHING LIGHTS

Standard Falls Risk:

Fall risk precautions Standard Orientation to room & call light Call light within reach Bed in lowest position Uncluttered room Nonslip socks or shoes Well-lit room Belongings within reach

A nurse is caring for a client who is intubated and has a subclavian central venous catheter. Which nursing intervention is *most important* to prevent the spread of infection to this client? x Use of chlorohexadine bath wipes.

Frequent Hand Hygiene Rationale: The nurse should use chlorhexidine to bathe clients who are critically ill, have central venous catheters, or are scheduled for surgery; and for indwelling catheter care. However, the risk for infection transmission would remain high if the nurse implements client care without performing hand hygiene.

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first?

Gloves

Vastus Lateralis

IM injection site for < 7 mos of age. - Gluteal muscles are not developed enough;

Implied Consent:

Implied consent in emergency situations includes the following criteria: - There is an emergency! - Treatment is required to protect the client's health. - It is impractical to obtain consent - It is believed that the client would want treatment if able to consent. - In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed.

Look at the modifying phrase. Order the steps from greatest physiological need/risk to least.

Look at the modifying phrase. Order the steps from greatest physiological need/risk to least.

Other Ways to Prevent Transmission of Infection w/ Biohazard Bags:

Meticulous hand hygiene (Option 3) Use of disposable gloves during collection and handling of specimen Cleaning the specimen bag with a disinfecting wipe Proper and immediate transport of specimen to the lab Avoiding placing specimen in clean areas (eg, nursing station)

The nurse should consider which of the following client reports as an indication of an allergic reaction?

My lips swell when I eat broccoli or avocados.

NCLEX TIP: Try to use some of the prioritization nursing action questions as *"ordered steps". Be sure to start with the most pertient: PHYSIOLOGICAL SAFETY RISK (to the client, you, or others first) + (MASLOW'S / ABC if applicable).

NOTE: Med-Surg questions will use another format than ABC and use the *"MOST-LIFE SAVING TECHNIQUE" before the "LEAST LIFE-SAVING TECHNIQUE".

Alcohol-Based Solution:

OKAY... for MRSA *NOT OKAY... for C. DIFFICLE*

*Informed Refusal*

Occurs when the patient refuses treatment after he/she has been fully educated regarding the consequences of not receiving the treatment. - *Is documented in the patient record* - *is a last resort after attempts to get even partial or alternative compliance.*

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement?

One-on-one supervision from a sitter.

Opening a Sterile Package:

Opening the sterile package with *clean, ungloved hands is acceptable.*

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently *asymptomatic*, and the *telemetry monitor indicates sinus rhythm*. *Which of the following critical values is most likely due to laboratory error*?

Potassium of 7.0 mEq/L

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action?

Pours sterile, NS solution into a sterile basin *from a bottle opened 30 hours ago.* = STERILITY IS NOW QUESTIONABLE OF THE N/S BOTTLE. - CAN USE ONLY AN OPENED BOTTLE WITHIN THE LAST 24 HRS.

Propofol (DIP- Ri- Van): general anesthesia for clients receiving surgery, but also for *mechanical ventilation to prevent extubation.*

Propofol (Diprivan) is considered standard treatment to sedate the client receiving *mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort.*

preventing a fall:

Step slightly behind the client and place the arms under the axillae or around the client's waist Place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back injury to the nurse Place one foot behind the other and extend the front leg - allows the nurse to bring the client backward by using the leg muscles to rock backward while supporting the client's weight Let the client slide down the extended leg to the floor - lowers the client gently to the floor while keeping the client's head protected from injury

WHEN IN DOUBT...

THROW IT OUT !!!

CVC and ports

The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. The distal end of the CVC is in reverse as regards the client; therefore, the distal end is at the tip of the catheter in the superior vena cava vein, closest to the right atrium of the heart.

The General Steps for Preparing the Sterile Field for a *Wet-to-Damp* Dressing Change:

The general steps for preparing the sterile field for a wet-to-damp dressing change include: Perform hand hygiene. Open a sterile gauze package with ungloved hands. Hold the inverted opened gauze package 6" (15 cm) above the sterile field. Place the sterile gauze dressing more than 1" (2.5 cm) from the edge of the sterile field. Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits).

*An unconscious client is brought to the emergency department by the paramedics after being hit by a car*. An *emergency craniotomy* is required. The client has no identification. *What action should be taken next*? x Court Order = would cause a delay - risk on life x Contact the police to find possible family or contacts - would be done, but would require time. x national database of health care proxy = doesn't exist!

Transport the client to the operating room under implied consent.

The P's of Hourly Rounding:

Typically staff checks on the "Ps": potty, position, pain, and placement/proximity of personal items (eg, bed height, call light, water, tissues, urinal

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate?

Use long-handled forceps to secure the implant into a lead container.

If an IV line has not already been started...

a 20 gauge is used *(in case the client needs blood products)*

Surgery: If an IV line has already been started...

an 18 gauge is sufficient

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)?

an 80 year-old who has COPD and is on a ventilator. - older - immunocompromised - *abx / corticosteroid therapy* - intubation (IV catherter; tracheostomy, NG, Foley Cather, mechanical ventilator) - prolonged hospital stay (HAI)

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? x Apply a mitt on the right hand x Apply a soft restraint on the right wrist x Apply an arm board to the left arm.

apply a gauze wrap and elastic stockinette around the IV site. NCLEX RULE: "LEAST RESTRICTIVE before MOST RESTRICTIVE"

NCLEX hates...

arm boards

Gingko Biloba should be d/c...

at least 2 weeks before elective surgery.

NSAID's should be d/c...

at least 7 days before elective surgery.

MRI uses:

gadolinium (not IV contrast dye or Iodine)

Sterlie gloves

protect the client from YOU not the other way around.

IV Potassium (KCL):

should never be administered via a gravity drip because it can cause: LETHAL DYSRHYTHMIAS if instilled TOO FAST.

The nurse should NOT DELAY a BATH:

unless the client is UNSTABLE.

Codes of Transfer:

Client should use as much of his or her own weight as possible. - Assistive devices should be used when transferring > 35 lbs. of weight at any given time.

The nurse is educating a client recently diagnosed with anaphylactic allergy to latex. Which statement made by the client indicates that the client understood the condition correctly? x I should take better care of myself and eat *bananas and chestnuts*. x I just need to read labels to check if products have latex.

"I should always carry my Epi-Pen in case I have difficulty breathing." Tx: Epinephrine (pen) + Benadryl (anti-histamine symptoms)

A nurse in the *surgical admitting unit* is preparing a client for *elective coronary artery bypass surgery*. Which statement by the client should the nurse report *immediately* to the health care provider (HCP)?

"I took my *plasurgrel* this morning with a tiny sip of water." = a BLOOD THINNER --> RISK FOR BLEEDING. Rationale: Clients about to receive CABG surgery MUST D/C ANTI-PLATELET, ANTI-COAGULANT, or BLOOD THINNERS (NSAID'S) AT LEAST 5-7 DAYS BEFORE SURGERY TO PREVENT BLEEDING RISK.

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle this situation?

"Let the family member stay and assign a staff person to explain what is happening." Rationale: The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls?

"Remove all area rugs and install grab bars in the bathroom."

PPE for Droplet Precautions:

- *Surgical Mask* - most important - gown - gloves - *Private Room*

Absolute Contraindications to MRI:

- Cardiac PACEMAKER - DEFIBRILLATOR - FOREIGN METAL OBJECTS - COCHLEAR IMPLANTS

Additional Measures to Prevent Aspiration:

- Have the client sit upright with the chin *FLEXED FOWARDS TOWARDS the CHEST* (not hyperextended) - *Monitor for wet or garbled sounding voice* - *Monitor for SIGNS of FEVER* = aspirated food gets stuck in the airways; body fights pathogen.

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the *most important for the nurse to do before the client leaves the building*? x Insist that he sign the AMA form. x Provide the client with a copy of the hospital results.

- Remove the intravenous catheter Rationale: It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter.

Cultural Practices/ Anomalies that may look like suspected child abuse:

- The nurse should also be aware of cultural health practices (eg, *cupping, coining*) and physiologic conditions (eg, *hemophilia*, *Mongolian spots*) mimicking maltreatment.

Most Common Nosocomial Infections:

- UTI (catheters or others) - Surgical Wounds - Blood Streams - Pneumonia (VAP)

Irrigating a Wound Care: PPE

- gown, gloves, face shield (to protect from splashes). Also: same for *suctioning a wound* or tracheostomy.

An inflated tracheostomy cuff:

- intended purpose: to prevent aspiration risk. - However, it may not prevent entire "slippage" down the oropharyneal pathway. - Is difficult to talk and swallow with - best use: aspiration risk for a client who is unconscious, high risk.

A client is *able to partially bear weight* and *(can) follow the nurse's instructions*. Which would be the most appropriate method for the nurse to use to safely transfer this client?

1 person stand and pivot with gait belt and walker.

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle. The client has HIV infection. Place in order the steps the nurse should take.

1. Remove the gloves 2. *Wash area with soap and water.* 3. Notify Nursing Supervisor 4. Go to employee health clinic 5. Take *post-exposure* prophylaxis = *EFFECTIVE WHEN TAKEN WITHIN 2 HRS. OF THE INCIDENT.*

Accidental Toxin/Poisoning of Child:

1st: What is the substance? 2nd: How is the child behaving/doing? (assessment) 3rd: How long will it take for the toxic effects to occur? / What type of toxic effects might happen? --> Call 911. / Call Poison Control Center. 4th: Take Activated Charcoal (if able to) 5th: Evaluation by Hospital ___________________ If the solution is absolutely harmless... (rare for NCLEX) Monitor symptoms at home (if harmless toxin w/ NO SERIOUS SIDE EFFECTS).

Neutropenic Precautions:

A private room Strict handwashing Avoiding exposure to people who are sick Avoiding all fresh fruits, vegetables, and flowers Ensuring that all equipment used with the client has been disinfected.

PRIORITY CONCEPT:

ANXIOUS FAMILY MEMBERS CAN STAY IN THE EMERGENCY OR ICU ROOM OF A FAMILY MEMBER (as long as they are out of the way of care) and can receive support and explanations from ongoing staff.

Appropriate vs. Inappropriate Use of Indewlling Catheter:

Appropriate uses include the following: - Clients with *urinary obstruction or retention*, or a need for - *STRICT I'S & O'S for CRITICALLY ILL PATIENT. *PERIOPERATIVE use for SURGICAL W/ LOTS OF DIURETICS ONBOARD DURING SURGERY* ( such as urologic surgery or prolonged surgeries, or when *large doses of fluid or diuretics are given during surgery*) - *prolonged immobilization* when bedrest is essential To improve *end-of-life comfort* - *To facilitate healing of an open perineal or sacral wound in incontinent clients*

A client is receiving *IV potassium*. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the *IV flushes easily without symptoms of infiltration*. Which action should the nurse take next? x Use another IV site x Instill the medication using a gravity drip. x Discard the potassium and document as a partial dose.

Exchange the pump with a different one.

A client is *seen in the clinic for the third time* for a *non-healing, infected diabetic foot ulcer*. The *client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home*. What intervention does the nurse prioritize to promote proper self care? x Assess the client's feelings about going to a skilled nursing facility. x Educate the client on the risks of tissue death = *threatening & non-therapeutic* .... scolding!!! x Provide the client with supplies = this is not the barrier

Explore the client's abilities and motivation to perform care at home. Rationale: The nurse must assess a client's knowledge, skills, and motivation to identify barriers to self care. Through this identification, the nurse can help develop an individualized plan to meet health care needs.

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse?

Place the bed in the lowest position with *all side rails up.* = false imprisonment; RISK for INJURY Rationale: Safety is a priority for the client experiencing an acute attack of Meniere disease. *Fall precautions include: - Placing the bed in low position - Raising 2 or 3 side rails - Assisting the client with arising and ambulating.* Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights.

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate?

Please go directly to the emergency department for evaluation. *TCA: CARDIAC DYSRHYTHMIAS* Toxicity, neurological, and cardiac developments can occur much later.

The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention?

Provide assistance with ambulation. Rationale: Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation.

To determine whether or not a client can be transferred safely:

The nurse should assess the following aspects : 1. *Ability to bear weight* - a) Neurological Status - paralysis, paresis b) Decreased Muscle Strength - *prolonged immobility*, Multiple Sclerosis, Muscular Dystrophy c) Trauma - *amputee, hip fracture* 2. Whether the client is cooperative or able to follow instructions. a) *Altered Mental Status* - Delirium, drug intoxification b) Decreased Cognitive Ability - *Dementia, Head Injury*

Recommended Bed to Chair Transfer Method:

Weight Bearing: 1. *Full* - independent, no assistance required; one person standby or assistance for clients who are *uncooperative or at high risk for falls*. 2. *Partial* - one person standby, or *pivot transfer* with gait belt or motor-operated assistive device; 2 person with body sling if uncooperative. 3. *None* - motor-assisted device if client is cooperative or has *upper body strength*; *full-body sling* if client is uncooperative or has NO upper body strength.

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client?

a gown, gloves, N95 mask, and eye protection. Rationale: Coronavirus (MERS-CoV) S&S: fever, cough, shortness of breath. Spread: *via AIRBORNE PRECAUTIONS* Tip: The PPE should include at least gloves. If it's respiratory droplets, it may be just: gloves, gown, and surgical mask. However, this is an *airborne precaution, so it's the 'most complete answer'.

One of these things is...

not like the other. - Try to look for patterns - What could the topic of this question be about???

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse?

Facilitate immediate removal of people from the area. Rationale: Safety is the priority when violence occurs. People should leave the area and call security immediately

Risk for Infection via IV Sites:

Higher Risk: Lower Peripheral IV sites (i.e. leg, foot, thigh) Lower Risk: Upper Peripheral IV sites __________ Higher Risk: Upper arm or wrist Lower Risk: *Back of the Hand* (unless the client is VERY OLD/VERY YOUNG)

Inappropriate Use of Indwelling Urinary Catheter:

Inappropriate uses include the following: Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently (Options 2, 3, and 4) For obtaining a urine culture when the client can follow instructions and void voluntarily Postoperatively for prolonged periods when other appropriate indications are not present

Other correct techniques when taking a Central Line Sample:

(Option 1) When drawing a blood specimen from a central line, the *nurse should discard the first blood drawn to prevent an inaccurate lab result*, but this will not prevent the transmission of infection. (Option 2) *Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting.* Neither action prevents infection transmission. (Heparin Lock).

A nurse is caring for a group of clients on a medical surgical unit. Which client is most *at risk for contracting a nosocomial infection*? x 51 years-old with pacemaker put in 48 hours ago. = one risk = surgical incision...not age..not time frame. x 75 years-old, Dementia, and IV catheter. = 2 risks = age, IV catheter (but not as great as indwelling urinary catheter).

*A 74 year-old client with a stroke and an indwelling urinary catheter for 3 days.*

*A 2-year-old who swallowed an overdose of adult cough syrup* is being discharged from the emergency department. The parent says to the nurse, *"From now on, I'm going to store all medicines in my top dresser drawer."* Which is the *best response* by the nurse? x *advise that all of the medicines have childproof caps.*

*Can you lock your dresser drawer?*

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions. The *registered nurse intervenes when the student performs which action*? x Uses an alcohol-based solution after doffing gloves.

*Cleans the DISPOSABLE stethoscope with chlorohexadine solution before reuse with another client.* Rationale: Single-use equipment should be used when working with clients on *Contact Precautions*. (Prevent the spread of MRSA).

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first?

*Don Personal Protective Equipment*

Other protocols for safety during a violent situation:

*Staff members should call security immediately and/or institute a back-up staff/takedown protocol.* The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team.

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches? Select all that apply. *(SAFETY & INFECTION CONTROL) - NCSBN x Look down at feet when walking.

- Keep a clear path to the bathroom - Remove scatter rugs from floors - Use a *small backpack* or *shoulder bag* to carry personal items. - Wear rubber soled shoes preferably with laces. Rationale: Wear a small shoulder bag or backpack to keep hands free when walking.

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply.

- Keep dedicated equipment for the client. - Perform hand hygiene before exiting the room. - Wear an isolation gown when providing direct care.

The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply. x hx of epilepsy x hx of angioedema w/ lisinopril. - NOT RELATED

- Known allergies to avocadoes and bananas - Lip swelling when blowing up balloons.

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse?

- Maintaining the affected leg flat on the bed. = can WORSEN EDEMA/ the AFFECTED EXTREMITY SHOULD BE ELEVATED to PROMOTE LYMPHATIC DRAINAGE. (Caused by Bacterial MRSA infection: staph A, insect bite, cut, or abrasion).

Latex Allergy:

- Must use latex-free gloves; - Schedule surgery first thing in the morning; - Label O.R. as "latex free"; - tape up cords - clients w/latex allergy usually have an allergy to foods such as bananas, kiwis, and avocados _____________ exposure to plastic products, condoms, and all other medical products containing latex.

Common Indications for Droplet Precautions:

- Neisseria Meningitidis - Haemophilus Influenza B - Diptheria (often found in contaminated water) - Mumps = wet - Rubella = *Umbrella...ella...* - Pertussis = *wooping cough* - Group A Strep* (throat) - *wet/ sneezy/ cough* - *Viral* Influenza (flu)

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. *Which intervention should the nurse carry out first*? x *Administer the pain medication.* x Call the HCP to meet with the family to obtain the informed consent. x Complete the preoperative checklist.

Perform the morning assessment. In order of steps: 1st: Perform the morning assessment. 2nd: Administer the pain medication (as prescribed and needed by 0730). 3rd: Call the HCP to meet with the family to obtain the informed consent. 4th: Complete the preoperative checklist.

Prevention of Infection with Urinary Catheters:

Wash hands thoroughly and regularly Perform routine perineal hygiene with soap and water each shift and after bowel movements. Keep drainage system off the floor or contaminated surfaces. Keep the catheter bag below the level of the bladder. Ensure each client has a separate, clean container to empty collection bag and measure urine. Use sterile technique when collecting a urine specimen. Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder. Avoid prolonged kinking, clamping, or obstruction of the catheter tubing Encourage oral fluid intake in clients who are awake and if not contraindicated. Secure the catheter in accordance with hospital policy (tape or Velcro device). Inspect the catheter and tubing for integrity, secure connections, and possible kinks.

The unconscious client requires a thorough *head-to-toe assessment* on admission to assess for *foreign objects, devices, or belongings that have potential for harm*.

x *MEDICATION PATCHES SHOULD NOT BE REMOVED WITHOUT FIRST CONSULTING THE HCP.* - Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client.

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? x Antecubital Fossa = good for emergency or short term use; bending arm can cause dislodgement, friction, or infiltration. x Dorsum of Foot = not typically used; venous are deep; harder to access (if burn injury requires it ... i guess so). x Radial side of Wrist = risk for nerve injury

*Dorsal surface of the hand.* Rationale: The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed.

A client with a *tracheostomy* is *alert and oriented and able to tolerate oral intake*. Which action would be appropriate to reduce the client's risk of aspiration pneumonia? *(REDUCTION OF RISK POTENTIAL) - NCSBN*

*Partially or fully deflate the cuff.* Rationale: A tracheostomy cuff is used for client who are AT RISK FOR ASPIRATION PNEUMONIA (i.e. those who are on mechanical ventilation or unconscious). - However, a tracheostomy cuff is difficult to swallow or talk. - Once the client is: *awake, alert, determined not to be at risk for aspiration, and has an improving condition* the cuff can be DEFLATED. - The client is then asked to COUGH to EXPECTORATE MUCOUS, is SUCTIONED, and then the cuff is DEFLATED.

The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a *priority for this client*? Click on the exhibit button for additional information. x Sequential compression stockings x Administer Erythropoietin injections. (Hgb 8) x Avoid venous and Im injections (78,000 = not dangerously low)

*Provide a private room and neutropenic precautions.* Rationale: - LEUKEMIA with LOW NEUTROPHIL COUNT... NEUTROPENIC PRECAUTIONS.

A *3-month-old infant* is treated in the emergency department for a *spiral femur fracture*. The parent reports that the infant *sustained the injury after rolling off the bed*. What is the priority nursing action? (PYSCHOSOCIAL INTEGRITY) - NCSBN

*Report the injury per facility protocol.* Rationale: 3 month old's cannot roll or turn over from side-to-side until they are about 5 months old. - Injuries in a nonambulatory child, especially fractures, warrant suspicion. The nurse has a duty to report suspected child maltreatment to the appropriate authorities as required by law.

Syrup of Ipecac vs. Charcoal

*Syrup of ipecac is no longer routinely recommended for oral poisonings.* - *The uncontrolled vomiting and vagal response induced can be harmful after ingestion of toxic substances*. - Treatments such as *oral activated charcoal may be used in the inpatient setting* to remove the ingested toxin if the client presents immediately after the ingestion.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? x confused and incontinent x elderly and at risk for falls x receiving iv diuretics

*The client has acute urinary retention.*

The nurse cares for a child with bed bug bites. Which parent statement indicates that *further teaching is required*?

*This must've happened because I did not wash the bed sheets this week.*

Warfarin & Pregnancy:

*Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy).* - *It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception.*

The nurse is preparing to transfer a client from the bed to the chair for the first time. The client has generalized weakness and is unable to follow instructions. Which would be the most appropriate method for the nurse to use to transfer this client safely?

*mechanical lift* (illustration)

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. x Age of 50

- *Age of 65 - 75* - Lying pulse 80, standing pulse 110/min. = *orthostatic hypotension* - osteoarthritis of knees - takes Carbidopa/Levodopa = dizziness, involuntary movements - Uses a cane to ambulate

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply. x Smooth soled shoes = need non-slip, rubber soled

- *Exericse Programs* - Good lighting - Handrails in stairwells - Staff hourly rounds Rationale: - General exercise programs, especially those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries from falls.

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply. x Locate and remove any medication patches. = Check for foreign objects that could cause harm: - jewelry/rings - tampons = Toxic Shock Syndrome - diaphragms - contact lenses (to prevent corneal damage) - medical alert band: status or code

- *Locate possible medical alert band or necklace.* - *Remove rings or jewelry* and lock in a secure location. - *Remove tampon* and replace with menstrual pad. - *Take out contact lenses if no presence of trauma.*

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply.

- *Requests that the client be assigned to a single-room.* - Use disposable, single-use gown during client care.* ____________ *Also: DEDICATED MEDICAL EQUIPMENT STETHOSCOPE that stays in the room & bleach!*

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection? x anti-bacterial soap = useful in the home setting where *betadine* is not available. x a new cloth for each area = only good if the bath water contained *chlorohexadine*. x wait until client has received abx for 24 hrs.

- *Use packaged premoistened cloths containing chlorohexadine to bathe the client.*

Risk Factors for a NOSOCOMIAL INFECTION:

- > 48 hrs after admission - > 90 days after discharge - "Extremes of Age": infants, children, elderly - *Immuno-compromised* - long hospital stays - being in the ICU - use of *indwelling urinary catheters* - use of *mechanical ventilators* - failure of workers to wash their hands - *overusage of ABX* ---> UTI meds. Cipro.

A client who has been prescribed several medications asks, "Can I take over-the-counter (OTC) medications with my prescriptions?" Which of the following statements by the nurse is appropriate? Select all that apply. x It is best to avoid OTC medications, but herbal supplements are *usually safe*.

- Always ask the HCP before taking OTC medications. - Some OTC medications may interact with your prescription medicines. - Remember to discuss *all medications, herbs, supplements you take with your HCP*. - *Taking OTC medications can sometimes mask symptoms of a serious illness.*

A client with suspected foot osteomyelitis is scheduled for an MRI. Which findings should the nurse notify the health care provider about before the test? Select all that apply. *(REDUCTION OF RISK POTENTIAL)*

- Aneurysm Clip - Pacemaker - Retained Metal Foreign Object in the Eye Rationale: Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, or fentanyl) are not a contraindication for MRI. - However, the nurse should REMOVE the CLIP BEFOREHAND due to the RISK for BURNS.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply.

- C. Difficle - MRSA (Methicillin-Resistant) - *VRE* (Vancomycin-Resistant Enterococcus Staph A.) - *VRSA - *Herpes Simplex* (contact - oral sores) - *Herpes Zoster* (airborne and contact unless lesions are dry and crusted).

Which of the following drug administrations should be reported as a practice error? Select all that apply.

- Cephalexin administered; client has a hx of penicillin allergy. - Immunization for 3 month old administered via *ventral-gluteal site* = muscle and nerve damage. - Warfarin therapy for a client who is 12 weeks pregnant. = *TERATOGENIC*

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply. x Wear a face shield. = not necessary x Wash hands with alcohol-based solution. = X WON'T KILL IT! WASH HANDS WITH SOAP AND WATER & RUB THOROUGHLY.

- Disinfect surfaces with *DILUTED BLEACH*. - Wear a protective gown. - Wear non-sterile gloves.

The nurse is caring for a client with *bacterial meningitis*, identified as *Neisseria meningitidis* who has a *stage 4 pressure injury*. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply. x N95 respirator

- Disposable gown - Face shield - Gloves - Surgical Mask

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply.

- Don gown, gloves, and N95 respirator when entering the room. - Ensure that pregnant staff members are not assigned to this client. - Place single use, disposable thermometer and stethoscope in the room. - *Place the client in a private room with negative air pressure.* - Request discontinuation of isolation precautions once the lesions have dried and crusted.*

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply. x *Cleanse peri-urethral area once every shift.* (MORE AS NEEDED) x *Routinely irrigate the catheter with anti-microbial solution.* (IS NOT RECOMMENDED)

- Ensure each client has a separate container bag to empty collection. - *Keep catheter bag BELOW the level of the BLADDER.* - *Use STERILE TECHNIQUE when COLLECTING A SPECIMEN.* = protects the client from the environment.

After reporting suspected maltreatment, the nurse should:

- Facilitate a *complete physical evaluation* (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination). - *Document facts and observations objectively*, using medical terms when possible. - Include the history provided by the parent or caregiver and the time period from injury occurrence to evaluation. - *Perform a review of child-care practices with the caregiver.*

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply. x name of HCP x room #

- First and Last Name (although you should also include...) - Date of Birth - Medical # (most accurate) Rationale: - *An identifier should be permanent and unique to the client.* - *2 Identifiers is best.*

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply. x Gown, gloves, and face shield for *every client encounter*. = more appropriate for a client giving a 'vaginal delivery'. x N95 mask and face shield. = not droplet or airbourne transmission.

- Gloves when contact with bodily fluids is anticipated. - Gloves when starting an intravenous line. - Hand hygiene, before and after providing client care.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply. x tongue blades x physically restrain the client

- Guide the client to the floor and gently cradle the head. - Move objects that cause injury to the client away from the client. - Place the client in the *LEFT LATERAL POSITION* = to prevent aspiration of the tongue. - Remain with the client, observe, and record the seizure activity.

The nurse is *drawing a blood specimen* from a *client's central line*. *Identify the steps necessary to *PREVENT TRANSMISSION OF INFECTION* while performing this procedure*. Select all that apply. x Discard the first 6-10 ml withdrawn from the line. x Flush the line with normal saline before and after use.

- Perform hand hygiene - Place the specimen in the biohazard bag. - Scrub the catheter hub with anti-septic prior to use. *(SEVENTY 70% PERCENT ALCOHOL)* See: https://journals.lww.com/nursing/Fulltext/2004/02000/Drawing_blood_through_a_central_venous_catheter.27.aspx

The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used.

- Place the call light within the client's reach. - Remove the gown and gloves without contaminating hands. - Discard the gown and gloves and perform hand hygiene. - Exit the negative pressure room and close the door. - Remove the N95 pressure mask and wash the hands. = *(take this one off last because you don't want to contaminate YOURSELF with the client who is on AIRBORNE PRECAUTIONS).*

Relative Contraindications: MRI

- Prosthetic heart valve - *Metal plate, pin, brain aneurysm clip, or joint prosthesis* - Some of these devices have nonferrous MRI-safe materials and should be verified. - *Implanted device (eg, insulin pump, medication port)* - Clostrophobia - Pregnancy - Uncontrolled Movements

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? Select all that apply. x attach the wrist restraints to the upper side rails (instead the moveable side of the bed). x LAY THE CLIENT SUPINE = ASPIRATION RISK; BEST = TURN SIDE LYING OR SEMI-FOWLER'S to drain emesis.

- Release restraints at regular intervals and assess behavior. - Use gauze to pad bony prominences under restraints.

Meningitis

droplet precaution (large; can spread 6 feet away) - laughing, talking, sneezing, coughing.