UWorld Safety and Infection Control Part 1

The school nurse is speaking w/parent of 4th grade student about bed bug that was found on child's sweater. Parent conforms that their home is infested but the issue is being resolved. Which is the best action by the nurse? 1. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags 2. Instruct teacher of child's classroom to use insecticide spray 3. Send letters home to all parents informing them about finding 4. Send child home and prohibit school attendance until infestation is resolved

1 Laundering clothing in hot water and using highest temperature setting on dryer will kill any bed bugs attached to clothes. Clothing should be then stored in tightly sealed plastic bags to prevent addtl infestation Notes about 2: Professional pest control company should be brought in to evaluate classroom/school for bed bugs; treatment w/insecticide may or may not be necessary Notes about 3: After professional pest control personnel eval classroom/school, letters can be sent to inform parents of findings--if needed--and any precautions that should be taken Notes about 4: Bed bugs do not inhabit humans as child is not infested as seen w/head lice

The practical nurse is collaborating with the RN to admit a client who will receive general anesthesia in the same-day surgery unit. The client has never had surgery before. Which question is the most critical for the nurse to ask the client during preoperative assessment and health history taking? 1. "Has any family member ever had a bad reaction to gen anesthesia?" 2. "Have you ever experienced low back pain?" 3. "Have you ever had an anaphylactic reaction to a bee sting?" 4. "Have you ever received opioid pain meds?"

1 Malignant hyperthermia is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and succinylcholine (anectine), a depolarizing muscle relaxant used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of Calcium from the muscles, causing sustained sustained muscle contraction and rigidity

A 2yo who swallowed an overdose of adult cough syrup is being discharged from the ED. The parent says to the nurse, "From now on, I'm going to store all meds in my top dresser drawer." Which is the best response by the nurse? 1. "Can you lock your dresser drawer?" 2. "Make sure all your meds have childproof caps." 3. "That sounds like a safe plan." 4. "You need to keep an eye on your child at all times."

1 Meds are the leading cause of child poisoning. The best preventive measures include placing all meds out of sight, placing them in a drawer or cabinet w/childproof lock, and putting them away after each use.

A client in mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurse's station. What is the most important intervention by the nurse? 1. Facilitate immediate removal of people from the area 2. Inform the client that the client cannot act that way 3. Pull the fire alarm to get additional immediate help 4. State that the nurse can see the client is upset

1 When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area and security should be called immediately. Notes about 2 and 4: When violence occurs, trying to defuse the situation verbally is no longer the priority. Notes about 3: Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to the fire department, which is not the type of help needed.

Nurse is caring for client who weighs 450lb 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. 1-person safety standby w/walker 2. 2-person full body sling lift 3. 2-person standing-assist lift 4. 4-person full-body sling lift

1 When determining most appropriate method to transfer client safely, nurse should assess (1) Whether client can bear weight (2) Whether client is cooperative. If meets both criteria, such as this client, they should be encouraged to do as much as they can for themselves--even if this client is heavy--as they are to anticipate discharge in near future. If client was unable to bear full weight, more assistance would be needed. Number of caregivers providing assistance during transfer of heavier client should be increased to promote safety for client and staff. With bariatric clients, equipment that has capacity to bear client's full weight and accommodate their size should be used while maintaining client's dignity throughout process. - Notes about 4: This is only appropriate for bariatric clients that cannot bear weight or cooperate with the transfer.

Which measures will help prevent falls in the elderly clients of LTC? SATA. 1. Exercise programs 2. Good room lighting 3. Handrails in stairwell 4. Smooth-soled shoes 5. Staff hourly rounds

1, 2, 3, 5 Falls are leading predictor of mortality and morbidity in older adults. General exercise programs, especially those including gait balance + strength training do not only reduce risk of falls but also prevent injuries from falls.

A home health nurse is supervising a home health aid who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? SATA. 1. Open a sterile container of 4x4's using the outermost corner to peel back the cover 2. Pull glove off over the soiled dressing to encase it before disposal 3. Save unused sterile 4x4's by taping original package shut for the next dressing change 4. Wash hands prior to putting on gloves and after removing them 5. Wrap soiled dressing in paper towels before disposing of it in the trash can

1, 2, 4 2: Contaminated used dressing should be placed in impervious plastic or paper bag before disposal in household trash Notes about 5: Paper towels are not impervious and infectious waste from dressing can seep through and into other items in the trash can

The nurse is caring for an older adult client who is confused and has high risk for falls. 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? SATA. 1. Ensuring bed alarm remains activated 2. Initiating hourly rounding schedules 3. Inserting indwelling urinary cath 4. Moving client to room close to nurse's station 5. Raising all side rails of client's bed

1, 2, 4 Fall risk increases with advanced age, incontinence, confusion, and presence of lines, tubes, and drains. Standard fall risk precautions include: Orientation to room and call light, ensuring call light is in reach, bed is in lowest position w/belongings within reach, room is uncluttered and well-lit, with nonslip socks/shoes High fall risk precautions include: Bed alarm, high fall risk signs, room close to nurses' station, color-coded socks & wristbands

A client has been admitted w/catheter-assoc, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? SATA. 1. Keep dedicated equipment for client 2. Perform hand hygiene before exiting room 3. Place "No Visitors" sign on the cilent's door 4. Wear a face mask when in the room 5. Wear an isolation gown when providing direct care

1, 2, 5 Place client in private room or semi-private room w/another client w/same infection and dedicate equipment for client, as it must be kept in client's room and disinfected when removed from room. Wear gloves when entering the room and perform excellent hand hygiene before exiting room (w/soap + water or alcohol-based hand rubs for MRSA + VRE & only soap + water for C.diff). Wear gown w/client contact and remove it before leaving the room. Place door notice for visitors. Ensure client leaves the room only for essential clinical reasons, such as tests and procedures. - Notes about 4: A face mask is required for droplet precautions.

A client w/suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? SATA. 1. Cardiac pacemaker 2. Colostomy 3. Retained metal foreign body in eye 4. Total hip replacement 5. Transdermal testosterone patch

1, 3, 4 Absolute contraindications include: cardiac pacemaker, implantable cardioverter defib, chochlear implant, retained metallic foreign body (especially in organs such as the eye). Relative contraindications include: Prosthetic heart valves, metal plates/pins/brain aneurysm clips/joint prosthesis, select nonferrous MRI-save devices, implanted devices (such as insulin pump or med port) Other factors: Inability to remain supine for 30-60 mins and claustrophobia (sedation or open MRI machine may be used)

The LPN is collabing w/RN to create a teaching plan for client rehabing after tibial fracture. Which instructions should be included to promote safety in the home when using crutches? SATA. 1. Keep clear path to bathroom 2. Look down at feet when walking 3. Remove scatter rugs from floors 4. Use small backpack/shoulder bag to hold personal items 5. Wear rubber-soled shoes preferably without laces

1, 3, 4, 5 Interventions to promote safety when using crutches in the home include: (1) Keep environment free of clutter and remove scatter rugs to reduce fall risk. (2) Look forward, not down at feet, when walking to maintain upright position, which will help prevent muscle and joint strain, maintain balance, and reduce fall risk. (3) Use small backpack, fanny pack, or shoulder bag to hold small personal items which will keep hands free when walking (4) Wear rubber or non-skid soled slippers/shoes without laces to reduce fall risk (5) Rest crutches upside down on axilla crutch pads when not in use to prevent them from falling abd becoming a trip hazard (6) Keep crutch rubber trips dry. Replace them if worn to prevent slipping

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? SATA. 1. Guide the client to the floor and gently cradle the head. 2. Insert a tongue blade to prevent client from swallowing the tongue. 3. Move objects that may cause injury away from the client. 4. Physically restrain the client to prevent injury. 5. Place the client in left lateral position. 6. Remain with the client, observe, and record the seizure activity.

1, 3, 5, 6 Before a seizure occurs, remove potential sources of injury, place padding, and keep oxygen at the bedside. Assess therapeutic level of antiepileptic drugs and identify seizure triggers, as well as areas for further client education. During a seizure, protect client's head from injury if possible, place client in left lateral rescue position, insert nothing into the mouth, and do not restrain limbs or torso. After a seizure, document timing and symptoms, remain with the client, and perform neurological assessments while assessing for physical injury. If necessary, the client may require maintenance of the airway via suctioning and oxygen admin.

The nurse is caring for a client who develops C.diff colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? SATA. 1. Disinfect surfaces w/diluted bleach solution 2. Hand hygiene w/alcohol based hand rub 3. Wear a face mask 4. Wear a protective gown 5. Wear nonsterile gloves

1, 4, 5 C.diff requires strict contact precautions in private rooms as this infection of the colon may develop/spread through contact w/organism or after prolonged antibiotic therapy alters normal bowel flora, allowing for C.diff overgrowth. Notes about 2: Hand hygiene using soap and water is the only effective method for removing C.diff spores. Notes about 1: Alcohol is not an effective agent for killed C.diff spores--a diluted bleach solution must be used to disinfect contaminated equipment and surfaces. Notes about 3: Contact precautions require gown and gloves. Face masks are only used if organism could be spread via droplets.

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 gloves 2. Go to employee health clinic 3. Notify the nurse's supervisor 4. Take postexposure prophylaxis 5. Wash area with soap and water

1, 5, 3, 2, 4 Following a needlestick injury, the nurse's immediate actions should be to remove their gloves and thoroughly wash the affected area with soap and water. Exposure should be reported to nurse's supervisor and facility exposure hotline ASAP to facilitate eval process. Once going to employee health clinic or ED, blood should be drawn for baseline testing and postexposure prophylaxis will be given based on risk of exposure. Ones for HIV infection is most effective when given within 2 hours of an exposure incident.

The male client had hemicolectomy. The client is refusing to wear prescribed SCDs. What is most important for nurse to communicate to client? 1. An appropriate form must be signed, verifying refusal 2. Complications, including death, could result 3. Client will be billed for equipment regardless 4. The surgeon will be informed of refusal

2 Just as there is informed consent, there is informed refusal, and this must be documented. The nurse should try to work w/client to get at least partial compliance when it's in the client's best interests (such as wearing the SCDs for a limited time).

The nurse at the radiological imaging center is admitting client for MRI of R knee. Which info obtained by nurse should be reported immediately to HCP? 1. The client ate a full breakfast that morning 2. The client has Implantable Cardioverter Defib (ICD) 3. The client is allergic to povidone-iodine 4. The client took all prescribed cardiac meds before arriving

2 MRI is contraindicated in clients w/aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel as the large magnet of MRI can damage ICD or interfere w/its function Notes about 1 and 4: MRI is noninvasive and does not require anesthesia, which makes NPO important as aspiration risk increases due to this. Client is not required to have anything by mouth and can take meds as normally indicated. Notes about 3: Betadine is not used during MRI, gadolinium contrast is used.

A client is being admitted with diagnosis of active shingles w/disseminated rash. Which room assignment is most appropriate for this client? 1. Private room w/contact & droplet precautions 2. Private room w/neg airflow & contact + airborne precautions 3. A private room w/pos airflow + airborne precautions 4. Semi-private 2 bed room w/standard precautions

2 Shingles (herpes zoster) is a reactivation of chicken pox (varicella zoster) virus. It is more likely to occur when client's immune system is compromised by disease--such as HIV infection--or treatments, such as chemo. Shingles lesions that are open may transmit infection by air and contact. Client w/disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of infection to others in hospital. - Notes about 3: Negative airflow pulls air from hospital environment into room and air from room goes directly outside rather than recirculating to rest of hospital. Positive airflow would pull fresh air from outside into hospital room then air from the room would circulate throughout rest of hospital--it is only for protective isolation for a client who is severely compromised. Notes about 4: Localized shingles require only standard precautions for clients w/intact immune sys & contained/covered lesions.

A female client is admitted to the ED after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? SATA. 1. Locate and remove any med patches 2. Locate possible med alert band/necklage 3. Remove rings/jewelry and lock in secure location 4. Remove tampon and replace w/menstrual pad 5. Take out contacts if no presence of eye trauma

2, 3, 4, 5 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. This includes: (1) Med alerts to indicate allergy status, emergency contact, or code status (2) Removing contact lenses to prevent corneal injury (3) Med patches should be located and identified to prevent drug interactions and determine conditions currently being treated, but should not be removed as patches are usually prescribed for chronic conditions and removing med patch w/o addtl info may harm client (4) Tampons are removed to prevent toxic shock syndrome or infection (5) Rings and jewelry are removed to prevent constrictive injury or vascular damage if edema develops

Client in med-surg unit has indwelling urinary catheter. Which actions should nurse implement to reduce incidence of catheter-assoc UTI? SATA. 1. Cleanse periurethral area w/antiseptics every shift 2. Ensure each client has separate container to empty collection bag 3. Keep catheter bag below level of bladder 4. Routinely irrigate catheter w/antimicrobial solution 5. Use sterile technique when collecting urine specimen

2, 3, 5 Wash hands thoroughly and regularly. Perform routine perineal hygiene w/soap + water at each shift and after BM. Keep drainage sys off floor or contaminated surfaces. Keep catheter bag below level of bladder. Ensure client has separate, clean container to empty collection bag and measure urine. Use sterile technique when collecting urine specimen. Facilitate urine drainage from tube to bag to prevent pooling of urine in tube/backflow into bladder. Avoid prolonged kinking, clamping, or obstruction of catheter tubing. Encourage oral fluid intake if not contraindicated. Secure catheter in accordance w/hospital policy (w/tape or velcro). Inspect catheter and tubing for integrity, secure connections, and possible kinks. - Notes about 4: Routine irrigation w/antimicrobial solution or systemic admin of antimicrobials is not rec for routine cath care + infection prevention.

The client is cheduled to have a cardiac cath. Which findings will cause the nurse to question the safety of the test proceeding? SATA. 1. Elevated C-reactive protein level 2. History of precious reaction to IV contrast 3. Prolonged PR interval on ECG 4. Serum Creatinine of 2.5 5. Took metformin today for DMII

2, 4, 5 Cardiac cath involves injection of iodine contrast using catheter to examine for obstructed coronary arteries. Complications include: (1) Allergic reaction where clients w/previous allergic reaction to IV contrast may require premedication with corticosteroids, antihistamines, etc. or another contrast medium. (2) Contrast nephropathy--or kidney injury--can occur from iodine-containing contrast, which can be reduced with adequate hydration but worsened for clients with renal impairment AEB lab values such as a Cr level above 1.3 (3) Lactic acidosis risk is increased when metformin is taken with IV iodine. It usually needs to be discont 24-48 hrs before exposure and restarted after 48hrs once stable renal fxn is confirmed - Notes about 3: 1st degree atrioventricular block (such as a PR interval above 0.20 second) may precede more serious conditions. However, clients are usually asymptomatic and do not require treatment except for stopping causative meds like beta bloxers and digoxin.

The nurse has Unlicensed Assistive Personnel (UAP) caring for a client w/acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? 1. Assist the client in ambulating to the bathroom. 2. Dim the room lights. 3. Place the bed in low position with all side rails up. 4. Turn off television.

3 Meniere disease results from excess fluid accumulation in inner ear. S/S: Vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be serve and is assoc w/nausea and vomiting. Clients report feeling being pulled to ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating, placing the bed in low position, and raising side rails. Notes about 3: Raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct UAP that 2 or 3 side rails lifted up would be sufficient. Notes about 2 and 4: Vertigo may be minimized by staying in quiet, dark room and avoiding sudden head movements. Client should reduce stimulation by not watching TV + not looking at flickering lights.

A nurse is caring for a group of clients on a med-surg unit. What client is most at risk for contracting noscomial infection? 1. 51yo client who received permanent pacemaker 48hrs ago 2. 60yo client who had MI 24hrs ago 3. 74yo client w/stroke and indwelling catheter for 3 days 4. 75yo client w/dementia and dehydration who is on IV fluids

3 Nosocomial, hospital-acquired infections are often caused by multidrug resistant organisms. These infections occur 48hr/+ after admission or up to 90 days after discharge. Clients at greater risk include young children, elderly, and those w/compromised immune systems. Other factors: long hospital stays, being in ICU, indwelling caths, failure of hand hygiene, and overuse of antibiotics. Most common nosocomial infection is UTI, followed by surg site infections, pneumonia, and bloodstream infections. - Notes about 1: Client does have surg incision that poses risk of infection. But is younger and does not have any chronic condition to compromise immune sys. Notes about 2: Client is technically not elderly and, other than possibly an IV cath, has no surg incision or indwelling cath. Notes about 4: Client at risk due to age and presence of IV cath, but not as high as elder w/cath.

The nurse is caring for a client w/active pulmonary TB. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? SATA. 1. Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask

3, 4 TB, chicken pox (varicella zoster), shingles (herpes zoster), measles (rubeola) all require airborne precautions. N95 respirator or powered air-purifying respirator and neg-pressure isolation room w/high-efficiency particulate air filter. Clean gloves, disposable gown, goggles/face shield as needed if contact w/body fluid is anticipated. For chicken pox, airborne + contact only when uncrusted lesions are present. For shingles, airborne + contact only when rash disseminated or client is immunocompromised - Notes about 1 & 2: Wearing gown + face shield would be necessary only if nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or med admin. Contact precautions may also be necessary if TB is extrapulmonary w/draining lesions, such as cutaneous TB. Notes about 5: Class N95 or higher respirator must be used in lieu of surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation.

The nurse recognizes which factors place client at increased risk for falls? SATA. 1. Age of 50 2. Diagnosis of ovarian cancer 3. Lying pulse 80/min, standing pulse 110/min 4. Osteoarthritis of knees 5. Takes caridopa/levodopa 6. Uses cane to ambulate

3, 4, 5, 6 Positive orthostatic VS, such as rise in pulse at or above 20bpm, indicate increased risk of syncope and falls. Osteoarthritis of the knees limits joint mobility, increasing risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat/bed height are factors that increase risk. Parkinson's increases risk of falls due to gait abnormality and sinemet may also cause dizziness, involuntary movement, orthostatic and hypoTN. Use of ambulatory aids indicates balance/gait prob & places client at higher risk of falling. - Notes about 1: Fall risk does not increase until age 65-75. Notes about 2: Ovarian cancer does not inherently affect cognition and neurologic/muscular fxn. Advanced disease w/weakness, perhaps from treatment, could constitute risk for fall.

The nurse is caring for a client who performs frequent urinary self-caths. Which of the following client assessments would indicate a potential for latex allergy? SATA. 1. History of angioedema w/lisinopril 2. History of epilepsy 3. Known allergy to avocados and bananas 4. Known allergy to shellfish 5. Lip swelling when blowing up balloons

3, 5 Latex is a natural rubber used in many med devices like gloves, catheters, and tape. Many people develop latex allergies from repeated exposures. Many food allergies--such as to avocados, bananas, tomatoes--also increase risk for latex allergy because food proteins are similar to those found in latex. Notes about 1: There are no cross-sensitivity reactions between ACE inhibitors in the -PRIL category and latex. Notes about 4: Shellfish was previously believed to be assoc w/allergy to iodine--which is a CT contrast material--which as now been disproved and shellfish allergies have no relationship to latex allergies.

The nurse cares for child w/bed bug bites. Which parent statement indicates that further teaching is required? 1. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." 2. "I should concentrate on alleviating scratching as it can cause further complications." 3. "My other family members and pets are at risk of bed bug bites." 4. "This must have happened because I did not wash the bed sheets this week."

4 Bed bugs can inhabit any environment--clean or dirty--and can travel + spread easily in clothing, bags, furniture, and bedding. Does not pose significant harm but can cause itchy, red rash that is uncomfortable and affects sleep. Notes about 1: Important to treat entire house for bed bugs. Washing a single pillowcase or blanket will not stop infestation as they multiply quickly and can hide in any crevice. Once pest control is complete, home will need to monitored for signs of lingering bugs. Notes about 2: Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. Notes about 3: Once home is infested, bugs can travel quickly and occupy spaces + crevices. All household members and pets will be afflicted.

The nurse is preparing to care for client w/AML who has been going through induction chemo. Client's lab results are as follows: >>WBC 1,100 >>Absolute neutrophil count 400 >>Hgb 8.2 >>Platelets 78,000 Which intervention would be a priority for this client? 1. Admin erythropoietin injection 2. Minimize venipunctures and avoid IM injections 3. Place SCDs on legs 4. Provide private room and neutropenic precautions

4 Client's lab results show reduce WBC and lowered neutrophils. Protection against infection is most important goal for this client, which indicates: (1) Private room (2) Strict handwashing (3) Avoid exposure to people who are sick (4) Avoid all fresh fruits, veggies, and flowers (5) Ensure all equipment used w/client has been disinfected Notes about 1: Client's lab results show moderate anemia. Erythropoietin injections are important but not priority as infections in immunocompromised clients are life-threatening. Notes about 2: Client's platelet count of 78,000 is decreased but not dangerously low, so it is not highest priority. Avoiding IM injections and minimizing venipunctures is most important when platelet count is below 50,000 as these can cause prolonged bleeding. Notes about 3: Client would need SCDs for prevention of DVT to legs as anticoags may not be used d/t risk of bleeding from borderline low platelet count. However, this is not priority over infection prevention.

The nurse caring for a client w/TB transports the client to the radiology department for a chest x-ray. Nurse ensures that the client uses which PPE when out of the neg-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves 2. Isolation gown and surgical mask 3. N95 respirator mask 4. Surgical mask

4 Clients w/airborne infections such as TB, measles, chickenpox (varicella) are confined to neg-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through HCF, the client on airborne transmission-based precautions wears surgical mask to protect HCW and other clients from respiratory secretions. Notes about 3: CDC and prevention recs that HCW who transports clients wear N95 respirator masks as protection against exposure to airborne droplets. These masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air.

The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection? 1. Assist client to the shower and provide directions to use antibacterial soap. 2. Delay bath until the client has received antibiotic therapy for 24 hours. 3. Use bath basin w/warm water and a new wash cloth for each body area. 4. Use package pre-moistened cloths containing chlorhexidine to bathe the client.

4 Current evidence supports drug-resistant organisms to be bathed w/pre-moistened cloths or warm water containing chlorhexidine solutions, which can significantly reduce MRSA infection. Notes about 1: This is appropriate for a client in a home setting. Notes about 2: It is not appropriate to delay bathing as the client's skin and incision need to be cleaned. Delay should only occur if the client is unstable. Notes about 3: This is only appropriate if bath water contained solution of chlorhexidine.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. LPN should notify RN about which assessment data ASAP before surgery? 1. Hgb 15, Hct 45% 2. INR 1.3 3. Platelet count 295,000 4. Temp of 100.4*F with cough

4 Low-grade temp and cough could indicate infection. Admin of anesthesia in a client w/fever + cough can exacerbate unknown viral or bacterial condition, increase risk for post-op pneumonia, & interfere w/post-op healing process. Depending on individual situation and type of surgery scheduled, HCP may prescribe further testing, consult anesthesia professional, or postpone/proceed surgery. Notes about 1, 2, 3: Hgb (13.2-17.3), Hct (39%-50%), and platelet count (150,000-400,000) are within normal ranges and do not indicate increased risk for bleeding. Normal range for INR is 0.75-1.25, so a value of 1.3 represents only borderline elevation and would not increase bleeding risk.

A client with MS is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time? 1. "Avoid excess stretching of your lower extremities." 2. "Build strength by increasing the duration of daily exercise." 3. "Let me speak with your HCP about getting a wheelchair." 4. "You should keep your feet apart and use a cane when walking."

4 MS is a progressive, demyelinating disease of the CNS that interrupts nerve impulses, causing a variety of symptoms. S/S: Muscle weakness, spasticity, incoordination, loss of balance, fatigue, impaired mobility, risk for falls and injury. Walking with feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of nerve fibers progresses. Notes about 1: ROM, strengtthening, and stretching exercises help limit spasticity and contractures in clients with MS. Notes about 2: Fatigue is common w/MS. Rather than increasing duration, clients should balance exercise with rest. Clients should also exercise when weather is cool and stay hydrated, dehydration and extremes in temp cause symptom exacerbation. Notes about 3: Wheelchairs are advise if exercise and gait training are not successful as clients should maintain mobility and independence as long as possible.

Client w/acute ST-elevation MI intends to leave hospital now Against Medical Advice (AMA) regardless of what is recommended. Client is determined to be competent to make personal decisions. Which of the following is most important for nurse to do before client leaves building? 1. Insist client sign AMA form 2. Provide client w/copy of hosp results 3. Reassure that client can return later 4. Remove intravenous catheter

4 Nurse should inform HCP immediately but if client decides to leave facility--even after HCP/nurse explain consequences--or cannot wait until HCP speaks w/client, they should be allowed to. Most important is that client's IV cath be removed to prevent complications (like infections) and misuse (like access for illicit drug injections). Nurse should document fluid infused, sites appearance, and integrity of IV catheter. Notes about 1: If client refuses to sign, client still allowed to leave. Nurse should have witnesses to events and clearly document in chart what happened + what client refused to signed. Notes about 2: Discharge instructions, results, prescriptions can be given despite client leaving AMA. However, not as essential as removing catheter. Notes about 3: Reassuring client can return is ethical as desire for client to receive needed care. However, not priority over removal of catheter.

The nurse is caring for a client w/bacterial meningitis who has been placed on droplet precautions. Which PPE is mandatory for the nurse when admining meds? 1. Face shield 2. Gown 3. N95 Respirator 4. Surgical mask

4 PPE for droplet precautions include surfical mask + private room, w/PRN if procedure includes risk of splash or body fluid contact: gloves, gown, goggles/face shield. Bacterial meningitis is transmitted through large droplets spreading by coughing/sneezing/talking. Droplets can land on surfaces up to 6ft away from client. Droplet precautions can be discont after client receive 24h of antibiotics. Nurse should also: proper hand hygiene, consider all surfaces w/in 3ft of bed contaminated, and dedicated medical equipment that should be kept in the room.

The nurse dons PPE before providing care for client in airborne transmission-based precautions. Place steps for donning PPE in appropriate sequence. 1. Gloves 2. Goggles or face shield 3. Gown 4. Hand hygiene 5. Mask ore respirator

4, 3, 5, 2, 1 2: Gown must fully cover torso from neck to knees, arms to end of wrists, and wrap around back with it fastened in back of neck and waist 3: Masks or respirators must be secured via ties or elastic bands at the middle of head and neck, fitting flexible band to nose bridge and snugly to face below the chin 4: Goggles or face shield must be placed over face and eyes then adjusted to fist; can be combined with mask or visor 5: Don gloves and extend cover wrist of isolation gown