Lacharity Chapter 5: Safety and Infection

22. You are preparing to insert a PICC line in a client's left forearm. Which solution will be best for cleaning the skin prior to the PICC insertion? 1. 70% isopropyl alcohol 2. Povidone-iodine (Betadine) 3. 0.5% chlorhexidine in alcohol (Hibistat) 4. Betadine followed by 70% isopropyl alcohol

3. 0.5% chlorhexidine in alcohol (Hibistat) The current Institute for Healthcare Improvement guidelines indicate that chlorhexidine is more effective than the other options at reducing the risk for central line-associated bloodstream infections (CLABSIs). The other solutions provide some decrease in the number of microorganisms on the skin, but are not as effective as chlorhexidine. Focus: Prioritization

12. You are the charge nurse on the medical unit. Which infection control activity should you delegate to an experienced UAP? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4. Disinfecting blood pressure cuffs after clients are discharged The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses. Focus: Delegation

4. A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? (Select all that apply.) 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

Ans: 2, 3, 4 2. N95 respirator 3. Gown 4. Gloves Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and will not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions. Focus: Prioritization

13. You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? (Select all that apply.) 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

Ans: 1, 2 1. Gown 2. Gloves A gown and gloves should be used when coming in contact with linens that may be contaminated by the client's wound secretions. The other PPE items are not necessary, because transmission by splashes, droplets, or airborne means will not occur when the bed is changed. Focus: Prioritization

21. You are caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the client's position. 5. Provide oral care with chlorhexidine solution at least daily.

Ans: 1, 2, 5 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 5. Provide oral care with chlorhexidine solution at least daily. The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential in preventing VAP. Focus: Prioritization

26. The LPN/LVN whom you are supervising comes to you and says, "I gave the client with myasthenia gravis 90 mg of neostigmine (Prostigmin) instead of the ordered 45 mg!" In which order should you perform the following actions? 1. Assess the client's heart rate. 2. Complete a medication error report. 3. Ask the LPN/LVN to explain how the error occurred. 4. Notify the physician of the incorrect medication dose.

Ans: 1, 4, 3, 2 1. Assess the client's heart rate. 4. Notify the physician of the incorrect medication dose. 3. Ask the LPN/LVN to explain how the error occurred. 2. Complete a medication error report. The first action after a medication error should be to assess the client for adverse outcomes. You should evaluate this client for symptoms such as bradycardia and excessive salivation. These may indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The physician should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report. Focus: Prioritization

3. You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. 4. Take off gown. 5. Perform hand hygiene.

Ans: 3, 2, 4, 1, 5 3. Remove gloves. 2. Take off goggles. 4. Take off gown. 1. Remove N95 respirator. 5. Perform hand hygiene. This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients. The correct method for donning and removal of personal protective equipment (PPE) has been standardized by agencies such as the CDC and the Occupational Safety and Health Administration. Focus: Prioritization

2. You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will you implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/hr. 3. Administer first dose of oseltamivir (Tamiflu). 4. Obtain blood and sputum specimens for testing.

1. Start oxygen using a nonrebreather mask. Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems.

24. Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing physician before administration? 1. Warfarin (Coumadin) 1.0 mg by mouth (PO) 2. Morphine sulfate 2 to 4 mg IV 3. Cephalexin (Keflex) 250 mg PO 4. Heparin infusion at 900 units/hr

1. Warfarin (Coumadin) 1.0 mg by mouth (PO) The Institute for Safe Medication Practices (ISMP) guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose (in this case, 10 mg). The order should be clarified before administration. The other orders are appropriate, based on the client's diagnosis. Focus: Prioritization

28. You are checking medication orders that were received by telephone for a client with rheumatoid arthritis who was admitted with methotrexate toxicity. Which order is most important to clarify with the physician? 1. Administer chlorambucil (Leukeran) 4 mg PO daily 2. Infuse normal saline at 250 mL/hr for 4 hours 3. Administer folic acid (Folacin) 2000 mcg PO daily 4. Give cyanocobalamin (vitamin B12) 10,000 mcg PO

1. Administer chlorambucil (Leukeran) 4 mg PO daily Leukeran is an antineoplastic drug used to treat cancer. The medication used to treat methotrexate toxicity is leucovorin (Wellcovorin), a reduced form of folic acid. Leukeran and leucovorin are "look-alike, sound-alike" drugs that have been identified by the ISMP as being at high risk for involvement in medication errors. All treatment prescriptions that are communicated by telephone should be reconfirmed with the health care provider; however, the most important order to clarify is the Leukeran order, which is likely an error. Focus: Prioritization

25. A client with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells you, "I feel really dizzy." Which action should you take first? 1. Help the client to sit down. 2. Check the client's apical pulse. 3. Take the client's blood pressure. 4. Have the client breathe deeply.

1. Help the client to sit down. The first priority for an ambulating client who is dizzy is to prevent falls, which could lead to serious injury. The other actions are also appropriate but are not as high a priority. Focus: Prioritization

5. You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? 1. 3-year-old who has paroxysmal coughing and whose sibling has pertussis 2. 5-year-old who has a new pruritic rash and a possible chickenpox infection 3. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

2. 5-year-old who has a new pruritic rash and a possible chickenpox infection Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. Focus: Prioritization

1. A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? 1. Infuse normal saline at 75 mL/hr. 2. Obtain blood, urine, and sputum for cultures. 3. Place the client on airborne and contact precautions. 4. Give methylprednisolone (Solu-Medrol) 1 g IV.

3. Place the client on airborne and contact precautions. Current Centers for Disease Control and Prevention (CDC) guidelines indicate that rapid implementation of standard, contact, and airborne precautions are needed for any client suspected of having SARS in order to protect other clients and health care workers. If an airborne-agent isolation (negative-pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room. The other actions should also be taken rapidly but are not as important as preventing transmission of the disease.

23. You have received a needlestick injury after giving a client an intramuscular injection, but you have no information about the client's HIV status. What is the most appropriate method of obtaining this information about the client? 1. You should personally ask the client to authorize HIV testing as soon as possible. 2. The charge nurse should tell the client about the need for HIV testing. 3. The occupational health nurse should discuss HIV status with the client. 4. HIV testing should be performed the next time blood is drawn for other tests.

3. The occupational health nurse should discuss HIV status with the client. The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about obtaining a client's HIV status and/or ordering HIV testing is the occupational health nurse. Performing unauthorized HIV testing or asking the client yourself would be unethical. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health). Focus: Prioritization

8. A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first? 1. Notify the physician about the loose stools. 2. Obtain stool specimens for culture. 3. Instruct the client about correct hand washing. 4. Place the client on contact precautions.

4. Place the client on contact precautions. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be to place him on contact precautions to prevent the spread of C. difficile to other clients. The other actions are also needed and should be taken after placing the client on contact precautions. Focus: Prioritization

16. In your role as the hospital infection control nurse, which policy will you implement to most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? 1. Limit the use of indwelling urinary catheters in all hospitalized clients. 2. Ensure that clients with catheters have at least a 1500-mL fluid intake daily. 3. Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria. 4. Require the use of antimicrobial/antiseptic impregnated catheters for catheterization.

1. Limit the use of indwelling urinary catheters in all hospitalized clients. According to the CDC, CAUTIs are the most common health care-acquired infection in the United States. Primary CDC recommendations include avoiding the use of indwelling catheters and the removal of catheters as soon as possible. Although a high fluid intake will also help to reduce the risk for CAUTIs, 1500 mL may be excessive for some clients. The CDC recommends against routine screening for asymptomatic bacteriuria. Antimicrobial catheters are a secondary recommendation and may be appropriate if other measures are not effective in reducing CAUTI incidence. Focus: Prioritization

18. Which information about a client who has meningococcal meningitis is the best indicator that you can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100° F (37.8° C).

2. Appropriate antibiotics have been given for 24 hours. Current CDC evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the client's condition is improving but does not indicate that droplet precautions should be discontinued. Focus: Prioritization

15. As the infection control nurse in an acute care hospital, which action will you take to most effectively reduce the incidence of health care-associated infections? 1. Require nursing staff to don gowns to change wound dressings for all clients. 2. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. 3. Screen all newly admitted clients for colonization or infection with MRSA. 4. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug-resistant organisms.

2. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. Because the hands of health care workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use. Wearing a gown to care for clients who are not on contact precautions is not necessary. Although some hospitals have started screening newly-admitted clients for MRSA, this is not considered a priority action according to current national guidelines. Because administration of antibiotics to individuals who are colonized by bacteria may promote development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection. Focus: Prioritization

9. A client who states that he may have been contaminated by anthrax arrives at the ED. Which action included in the ED protocol for possible anthrax exposure will you take first? 1. Notify hospital security personnel about the client. 2. Escort the client to a decontamination room. 3. Give ciprofloxacin (Cipro) 500 mg by mouth (PO). 4. Assess the client for signs of infection.

2. Escort the client to a decontamination room. To prevent contamination of staff or other clients by anthrax, decontamination of the client by removal and disposal of clothing and showering is the initial action in possible anthrax exposure. Assessment of the client for signs of infection should be performed after decontamination. Notification of security personnel (and local and regional law enforcement agencies) is necessary in the case of possible bioterrorism, but this should occur after decontaminating and caring for the client. According to the CDC guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax. Focus: Prioritization

19. You are administering vancomycin (Vancocin) 500 mg IV to a client with a MRSA wound infection when you notice that the client's neck and face are becoming flushed. Which action should you take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the client's temperature.

2. Slow the rate of the vancomycin infusion. "Red man" syndrome occurs when vancomycin is infused too quickly. Because the client needs the medication to treat the infection, the vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes. Although the client's temperature will be monitored, a temperature elevation is not the most likely cause of the client's flushing. Focus: Prioritization

27. You are caring for a confused and agitated client who has wrist restraints in place on both arms. Which action included in the client plan of care can you delegate to an LPN/LVN? 1. Determining whether the client's mental status justifies the continued use of restraints 2. Undoing and retying the restraints in order to improve client comfort 3. Reporting the client's status and continued need for restraints to the health care provider 4. Explaining the purpose of the restraints to the client's family members

2. Undoing and retying the restraints in order to improve client comfort Hospital staff who have been trained in the appropriate application of restraints may reposition the restraints. Evaluation of the continued need for restraints, communication with the provider about the client's status, and teaching of the family require RN-level education and scope of practice. Focus: Delegation

14. A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse delegate to an LPN/LVN? 1. Performing ongoing assessments to determine the client's hydration status 2. Explaining the purpose of ordered stool cultures to the client and family 3. Administering the ordered metronidazole (Flagyl) 500 mg PO to the client 4. Reviewing the client's medical history for any risk factors for diarrhea

3. Administering the ordered metronidazole (Flagyl) 500 mg PO to the client LPN/LVN scope of practice and education include administration of medications. Assessment of hydration status, client and family education, and assessment of client risk factors for diarrhea should be done by the RN. Focus: Delegation

11. A 23-year-old client comes to the outpatient clinic reporting increasing shortness of breath, diarrhea, abdominal pain, and epistaxis. Which action should you take first? 1. Assist the client to pinch the anterior nares firmly for 5 minutes. 2. Call an ambulance to take the client immediately to the hospital. 3. Ask the client about any recent travel to Asia or the Middle East. 4. Determine whether the client has had recommended immunizations.

3. Ask the client about any recent travel to Asia or the Middle East. The client's clinical manifestations suggest possible avian influenza ("bird flu"). If the client has traveled recently in Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. The other actions may also be appropriate but are not the initial action to take for this client, who may transmit the infection to other clients or staff members. Focus: Prioritization

6. You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection? 1. Client with an implanted port in the right subclavian vein 2. Client who has a midline IV catheter in the left antecubital fossa 3. Client who has a nontunneled central line in the left internal jugular vein 4. Client with a peripherally inserted central catheter (PICC) line in the right upper arm

3. Client who has a nontunneled central line in the left internal jugular vein According to CDC guidelines, several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, jugular vein lines are more prone to infection, and the line is nontunneled. Peripherally inserted IV lines such as PICC lines and midline catheters are associated with a lower incidence of infection. Implanted ports are placed under the skin and are the least likely central line to be associated with catheter infection. Focus: Prioritization

17. You are admitting four clients with infections to the medical unit, but only one private room is available. Which client is it most appropriate to assign to the private room? 1. Client with diarrhea caused by C. difficile 2. Client with a wound infected with VRE 3. Client with a cough who may have TB 4. Client with toxic shock syndrome and fever

3. Client with a cough who may have TB Clients with infections that require airborne precautions (such as TB) need to be in private rooms. Clients with infections that require contact precautions (such as those with C. difficile and VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. Standard precautions are required for the client with toxic shock syndrome. Focus: Prioritization

10. A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the UAP who is assisting with the client's care? 1. Teaching the client and family members about means to prevent transmission of VRE 2. Communicating with other departments when the client is transported for ordered tests 3. Implementing contact precautions when providing care for the client 4. Monitoring the results of ordered laboratory culture and sensitivity tests

3. Implementing contact precautions when providing care for the client All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data. Focus: Delegation

7. You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which nursing action can you delegate to an LPN/LVN? 1. Planning ways to improve the client's oral protein intake 2. Teaching the client about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown

3. Obtaining wound cultures during dressing changes LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN. Focus: Delegation

20. A healthy 65-year-old woman who cares for a newborn grandchild has a clinic appointment in May. The client needs several immunizations, but tells you, "I hate shots! I will only take one today." Which immunization is most important to give? 1. Influenza 2. Herpes zoster 3. Pneumococcal 4. Tetanus, diphtheria, pertussis

4. Tetanus, diphtheria, pertussis Individuals who have contact with infants should be immunized against pertussis in order to avoid infection and to prevent transmission to the infant. The influenza and pneumococcal vaccines can be administered later in the year, prior to the influenza season. The herpes zoster vaccine is important, but does not need to be administered today. Focus: Prioritization