HESI Module #6 Safety and Infection Control

A home care nurse is instructing a client in the use of ice packs to treat an eye injury. What does the nurse instruct the client to do? a. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye b. Avoid the use of commercially prepared ice bags c. Place the ice pack directly on the eye d. Keep the ice pack on the eye continuously for 24 hours

a

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the *least restrictive*? a. ambularm b. elbow c. belt d. wrist

a

A nurse caring for a 9-month-old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request? a. Remove a restraint from one extremity b. Tell the mother that the restraints may not be removed c. remove both restraints d. Loosen the restraints after telling the mother that they may not be removed

a

A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client's plan of care? a. Wearing gloves when emptying the client's bedpan b. Placing used linen in double bags and sending a bag to the laundry room every evening c. Allowing the client to ambulate in the hall only once a day d. Placing the client in a semiprivate room at the end of a hallway

a

A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precautions does the nurse understand are most appropriate to help ensure the safety of this client? *Select all that apply* a. switching injection sites b. Applying a pressure bandage to the site after each IM injection c. Decreasing the sizes of the needles used for the IM and SC injections d. Applying prolonged pressure to the sites of the IM and SC injections e. Doubling the dose of anticoagulant

a and d

An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? *Select all that apply* a. A victim who is dazed and staggering around the other victims b. A victim with burns of both arms c. A victim who is alert but complaining of loss of vision d. A victim with a limb amputation e. A victim who has sustained minor bruising of an arm and the lower legs

a and d

A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain? *Select all that apply* a. gown b. face shield c. gloves d. mask e. shoe protectors

a, b and c

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? *Select all that apply* a. Wear a dosimeter film badge when in the client's room b. Wear a lead shield when in the client's room. c. Keep all bed linens and dressings in the client's room until the implant is removed. d. Allow children to visit the client as long as they are at least 12 years old. e. Limit visits from family to 60 minutes per day.

a, b and c

According to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, what are the components of actions in the mitigation phase? *Select all that apply* a. Determining available resources for the care of infants, older clients, the disabled, and people with chronic health problems b. Actions that can prevent the occurrence of a disaster c. Measures that can reduce a disaster's damaging effects d. Putting disaster-planning services into action e. Actions taken to return to normal after the disaster f. Actions that plan for rescue, evacuation, and care of disaster victims

a, b, and c

At the beginning of the 7 am-3 pm shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L), notifies the primary health care provider, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? *Select all that apply* a. The primary health care provider was contacted b. The blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L). c. An IV solution of 5% dextrose in water was infusing at 7 am. d. A solution of 5% dextrose in water was infusing instead of the prescribed 0.9% normal saline solution. e. A 5% dextrose in water solution is not usually prescribed for clients with diabetes, and the solution was changed immediately on its discovery.

a, b, and c

Which of the following statements reflect the principles of sterile technique? *Select all that apply* a. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated. b. Sterile objects that come in contact with unsterile objects are to be considered contaminated. c. The clients over-bed table is wiped with chlorhexidine. d. When a sterile field becomes wet, it remains sterile as long as the items on the field are not touched. e. If a package is not labeled as sterile, it should be considered unsterile. f. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched.

a, b, and e

A community health nurse is asked to assist in developing a community disaster plan identified by Federal Emergency Management Agency (FEMA). The nurse knows that the preparedness phase of the plan includes what components? *Select all that apply* a. training of disaster personnel b. planning for rescue c. caring for disaster victims d. putting disaster planning services into action e. evacuation f. Actions to prevent the occurrence of a disaster or reduce the damaging effects

a, b, c, and e

A nurse educator is providing in-service sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needle-sticks? *Select all that apply* a. the use of needleless devices b. disposal of needles in special puncture-resistant containers c. the use of latex gloves d. the use of shielded needles e. the use of recessed needles

a, b, d, and e

The nurse plans to wear a protective surgical mask when caring for clients with certain disorders. What are these disorders? *Select all that apply* a. Meningococcal pneumonia b. hepatitis A c. Pharyngeal diphtheria d. Streptococcal pharyngitis e. Tuberculosis f. scabies

a, c and d

A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? *Select all that apply*. a. using tongs to collect any broken glass b. placing the pieces of broken glass in a plastic bag c. disinfecting the area of the blood spill with a dilute bleach solution d. blotting up the spill with a face cloth or cloth towel e. wearing gloves for the cleanup procedure

a, c, and e

A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? *Select all that apply* a. Identifying and training personnel for disaster response b. Developing a federal disaster response plan c. Educating the public about ways to prepare for disasters d. Declaring a disaster e. Providing disaster relief f. Activating disaster medical assistant teams

a, c, and e

A physician writes a prescription for the application of a heating pad to a client's back. Which of the following actions should the nurse take when implementing this prescription? *Select all that apply*. a. Assessing the client's medical history and risk factors for burns b. Adjusting the heating pad to the high setting c. Assessing the heating pad periodically for proper electrical function d. Placing the heating pad under the client e. Frequently assessing the client's skin for signs of burns

a, c, and e

Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? *Select all that apply* a. Changing dressings that become wet or soiled b. Placing capped needles and syringes in puncture-resistant containers c. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin d. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician e. Placing tissues and soiled dressings in paper bags f. Keeping bedside table surfaces clean and dry

a, c, d, and f

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3 (0.5 x 109/L). Which of the following interventions does the nurse implement on the basis of this finding? *Select all that apply* a. Monitoring the client's oral temperature b. Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure c. Requiring the client to use an electric shaver rather than a razor d. Maintaining sterile occlusion of intravenous (IV) catheters e. Providing a soft toothbrush for oral care f. Performing meticulous skin decontamination before venipuncture

a, d, and f

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. What is the *most appropriate* initial action for the nurse to take? a. Implementing a child safety program b. Determining the appropriateness of the planned health activity c. Performing an analysis of health problems related to child safety d. Planning a focused child safety program

b

A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action? *SATA* a. Explaining to the client that the oral route will not permit the medication to exert an adequate effect b. Verifying the primary health care provider's prescription c. Sitting and talking to the client to alleviate his concern d. Letting the client know that most medications are administered by way of the IV route when a client is hospitalized

b

An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted? a. respiratory droplets b. close intimate contact c. airborne particles d. fecal-oral

b

An older client in a long-term care facility is at risk for injury because of confusion. Which of the following devices would be the *best* choice to help prevent injury while the client is in bed? a. mittens b. bed alarm c. wrist restraints d. belt

b

What is an example of the nurse using surgical asepsis? a. Applying a gown and gloves b. Maintaining objects and areas free from pathogenic microorganisms c. Handling hazardous and infectious materials d. Reducing the number of organisms and preventing their spread

b

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of signs/symptoms and injury. Which instructions should the nurse provide to the client? *Select all that apply* a. "Use public transportation as much as possible." b. "Change positions slowly." c. "Remove clutter from your home." d. "Drive your car only if you're not feeling dizzy." e. "Turn your head slowly when someone speaks to you."

b and c

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? *Select all that apply* a. Anthrax can be transmitted from person to person. b. One way that anthrax can be contracted is through the skin. c. Anthrax is never fatal d. A blood test is available for the detection of anthrax. e. No vaccine to prevent anthrax is available

b and d

A nurse is preparing a sterile field to change a client's sterile dressing. What are some sterile techniques the nurse must adhere to? *Select all that apply*. a. Cuff the top of the disposable paper bag, and place it within reach of the work area. b. Do not turn your back to the sterile field at any time. c. A half-inch border of the sterile field is considered contaminated. d. Make sure to use sterile gloves when opening up sterile gauze packages to place on the sterile field. e. Maintain the sterile field and gloved hands above the level of the waist.

b and e

A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? *Select all that apply*. a. a victim with a fractured humerus b. a victim with respiratory distress c. a victim with a forehead laceration that is not bleeding d. A victim with multiple non-bleeding bruises of the arms and legs e. a victim with partial amputation of the foot

b and e

A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client understands the directions? *Select all that apply*. a. "I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner." b. "I need to follow the oxygen prescription exactly." c. "I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator." d. "I can use my electric razor while I'm using oxygen." e. "I have to keep the oxygen concentrator out of direct sunlight."

b, c, and e

After discussing the use of restraints with a client and family, the primary health care provider has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? *Select all that apply* a. The restraints have been tied to the side rails of the bed. b. The call light has been placed within reach of the client c. A safety knot has been used to secure the restraints. d. The restraints are applied tightly. e. The restraints are being released every 2 hours

b, c, and e

An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? *Select all that apply* a. keep visitors to a minimum b. Allow the client to have as many choices regarding his care as possible c. Acknowledge the client's feelings d. Keep the door open and the room lights on at all times e. put the client in a room far from the nurses' station f. provide information about hospital

b, c, and f

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? *Select all that apply* a. Have a firearm or other weapon available. b. Have an adequate supply of prescription medications. c. Obtain a 1-day supply of water (1 gallon per person). d. Plan a meeting place for family members. e. Have a first aid kit available. f. Have a battery-operated radio and a flashlight and batteries available.

b, d, e and f

A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? a. Wearing an oxygen mask at all times b. Staying secluded in the bedroom c. Disposing of contaminated tissues in a container with a leak-proof bag d. Keeping the house closed up to minimize the spread of disease

c

An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin? a. a weeping blister b. a black skin area of skin c. an itchy bump d. an open ulcer

c

Which event would require a nurse to complete and file an incident report? a. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. b. a client has a seizure. c. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment. d. The nurse determines that a client would benefit from the use of a walker to ambulate.

c

The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? *SATA* a. through open wounds b. enteric c. inhalation d. direct contact e. gastrointestinal f. handling of contaminated materials

c, d, and f

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is *most important*? a. The name of the person from whom the client contracted TB, so that the person may be reported for follow-up care b. What medications have been prescribed and what the client knows about his or her side effects c. The religious affiliation or church of preference d. The names of close friends and family members

d

A nurse is assisting with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? a. secondary b. primary c. initial d. tertiary

d

A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin's disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? a. Wearing gloves and a mask b. Wearing gloves and a gown c. Wearing gloves, a mask, and a head covering d. Wearing gloves, a mask, and eye protection

d

A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? a. The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client's skin. b. The assistant applies a tie knot in the restraint strap. c. The assistant attaches the restraint straps securely to the side rails. d. The assistant applies the restraint so that the strap does not tighten when force is applied against it.

d

A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client's safety? a. wrist b. mitten c. elbow d. belt

d

A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client's primary health care provider does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is *best*? a. Asking a family member to sit with the client b. Telling the family that the application of wrist restraints is critical in preventing injury to the client c. Asking a nursing assistant to monitor the client d. Staying with the client and consulting with the nurse manager about the situation

d