Funds- Hygiene and Safety

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action? 1. call for help 2. extinguish the fire 3. activate the fire alarm 4. confine the fire by closing the room door

3 the order of priority in the event of a fire is to rescue the clients who are in an immediate danger. the next step is to activate the fire alarm. the fire is then confined by closing all doors. finally, the fire is extinguished

The nurse enters the nursing lounge and discovers that a chair is on fire. the nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. the nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform? 1. aim at the base of the fire 2. squeeze the handle on the extinguisher 3. sweep the fire from side to side with the extinguisher 4. sweep the fire from top to bottom with the extinguisher

1 Rationale: a fire can be extinguished by using a fire extinguisher. to use the extinguisher, the pin is pulled first. the extinguisher should then be aimed at the base of the fire. the handle of the extinguisher is squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? SATA 1. wearing gloves when emptying the client's bedpan 2. keeping all linens in the room until the implant is removed 3. wearing a film (dosimeter) badge when in the client's room 4. wearing a lead apron when providing direct care to the client 5. placing the client in a semiprivate room at the end of the hallway

1, 2, ,3, 4 Rationale: a private room with a private bath is essential if a client has internal radiation implant. this is necessary to prevent the accidental exposure of other clients to radiation. the remaining options identify interventions that are necessary for a client with a radiation device

The nurse obtains a prescription from the health care provider to restrain a client using a jacket (safety) restraint and instructs the UAP to apply the restraint. Which observation, if made by the nurse, should indicate unsafe application of the restraint? 1. a safety knot is made in the restraint straps 2. the restraint straps are safely secured to the side rails 3. the jacket restraint strap does not tighten when force is applied against it 4. the jacket restraint is secure, and two fingers can easily slide between the restraint and the client's skin

2 Rationale: a half bow or safety knot should be used when applying a restraint, because it does not tighten when force is applied against it and allows for the quick and easy removal of the restraint in case of an emergency. the restraint strap is secured to the bed frame (never to the side rail) to avoid accidental injury in case the side rail is released. the jacket restraint should be secure, and one to two fingers should easily slide between the restraint and the client's skin

The nurse should institute which type of precaution for a client diagnosed with Cdiff? 1. droplet 2. contact 3. airborne 4. neutropenic

2 Rationale: contact precautions are necessary for colonization or infection with a multidrug resistant organism. this includes enteric infection with Cdiff. droplet or airborne precautions are not necessary because the organism is not transferred via the resp route. neutropenic precautions are used when the client needs protection from contracting an infection from others

The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands? 1. every 2 hours 2. every 3 hours 3. every 4 hours 4. every 30 mins

4 Rationale: the nurse needs to assess restraints and skin integrity every 30 mins. therefore, options 1, 2, and 3 are incorrect. agency guidelines regarding the use of restraints should always be followed

The nurse is caring for a client with a health care associated infection caused by MRSA who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which protective items will be required to perform this procedure? 1. gloves and a gown 2. gloves and goggles 3. gloves, gown, and a goggles 4. gloves, gowns, and shoe protectors

3 Rationale: goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, bodily fluids, secretions, and excretions. in addition, contact precautions require the use of gloves, and a gown should b worn if direct client contact is anticipated. shoe protections are not necessary

A mother calls a neighborhood nurse and tells the nurse that her 3 year old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 1. induce vomiting 2. call an ambulance 3. call the poison control center 4. bring the child to the emergency department

3 Rationale: if a poisoning occurs, the poison controls center should be contacted immediately. Vomiting should not be induced without instructions to do so if the victim is unconscious or the substance ingested is a strong corrosive or petroleum product. bringing the child to the ED or calling an ambulance would not be the initial action because this would delay treatment. the poison control center may advise the mother to bring the child to the ED

The community health nurse has completed a teaching session about anthrax with members of the community. The LPN reinforcing the teaching tells those attending that anthrax can be transmitted via which routes? SATA 1. skin 2. kissing 3. inhalation 4. gastrointestinal 5. direct contact with an infected individual 6. sexual contact with an infected individual

1, 3, 4 Rationale: anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. it cannot be spread from person to person

The ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the ED. Which should be the initial nursing action? 1. prepare the triage rooms 2. activate the agency emergency response plan 3. obtain additional supplies from the central supply department 4. obtain additional nursing staff to assist with treating the casualties

2 Rationale: during a widespread disaster, many people will be brought to the ED for treatment. although options 1, 3, and 4 may be components of preparing for the casualties, the initial nursing action should be to activate the emergency response plan