Copy of NCLEX Prep: Client Needs: Safety & Infection Control (I)

The nurse is caring for a hospitalized immunosuppressed client. Which interventions will be beneficial for safe and effective care of this client? Select all that apply.

Supplies from common areas should not be used for neutropenic clients to prevent contracting infection. Physical activity at a level appropriate for client's condition should be encouraged to promote health. Alcohol-based hand rubs should be used before touching the client to decrease the risk of infection. Immunosuppressed clients should avoid eating raw fruits and vegetables; they should eat low-bacteria diet. Gauge-containing wound dressings should be changed on a daily basis, not on alternative days, to prevent infection.

The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation?

Place in a sitting position Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high blood pressure. The first step in this situation is to assist the client into a sitting position because it naturally reduces blood pressure. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure ulcers after stabilizing the client. The nurse should monitor client's blood pressure every 10 to 15 minutes after stabilizing the client.

A client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implemented when the client arrives on the unit? Select all that apply.

Obtaining vital signs and inspecting the bandages for bleeding are interventions that must be performed in this situation; physiologic stability must be maintained. Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress. A therapeutic relationship must be developed so the client can trust the nurse to provide a safe environment and aid emotional recovery. Telling the patient that their life isn't that bad and that they have much to live for does not promote therapeutic communication and is not appropriate.

Which diseases can be transmitted from client to client by droplet infection? Select all that apply.

Pertussis Diphtheria Pertussis and diphtheria are infectious diseases that are known to be transmitted by droplet infection. Shingles and measles are infectious diseases that are known to be transmitted by air. Scabies is an infectious disease that is transmitted by direct contact.

A registered nurse is evaluating the statements of a client after teaching the client measures to decrease the risk for antibiotic-resistant infections. Which statements made by the client indicate a need for more education? Select all that apply.

"I should skip doses when I am completely well." "I should save unfinished antibiotics for later emergency use." Antibiotics should not be stopped even if the client is feeling better. Skipping doses may allow antibiotic-resistant bacteria to develop. Antibiotics should not be saved for later emergency use because old antibiotics can lose their effectiveness and in some cases can even be fatal if taken. Hand washing is necessary to prevent infections. Antibiotics are effective against bacterial infections but not viruses, which cause the common cold. Antibiotics should be taken only after asking the physician.

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply.

A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving patient care at the bedside.

For which illness should airborne precautions be implemented?

Chickenpox Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

A visitor comes to the nursing station and tells the nurse that a client and a relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take?

Ask security to make sure the room is safe Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and ensured that any other people in the room are safe.

A nursing student is educating a client about the use of tampons. Which statement made by the nursing student indicates a need for correction?

"Use a superabsorbent tampon during the daytime." Organisms such as Staphylococcus aureus and Streptococcus pyogenes may cause toxic shock syndrome (TSS) due to tampon use. Therefore the client should not use a superabsorbent tampon. The client should wash his or her hands before inserting a tampon to maintain good hygiene. Limiting tampon use reduces TSS to a great extent; the client should use sanitary napkins at night. High temperatures, vomiting, and diarrhea are manifestations of TSS due to tampon use. These symptoms should be reported immediately to the primary healthcare provider.

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program?

Explain ways to prevent physical trauma from occurring during a seizure The client may become injured in many ways during a seizure, and trauma prevention is a priority. Anticonvulsants can cause gastrointestinal disturbances, especially early in therapy, and should be taken with food. Seizures and seizure disorders are not similar; they vary greatly. Others should understand the condition and be taught how to help in case of a seizure.

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms?

Friction Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply

Identifying the causative agent for neutropenia is important for starting treatment. Therefore the priority nursing intervention is to obtain blood cultures immediately and administer antibiotic STAT as prescribed to the client. The nurse can monitor for rashes and pruritus after administering the medication. The nurse can prepare a diet plan and teach hygiene measures after stabilizing the client.