NCLEX-PN INFECTION CONTROL, NURING PROCESS

Absence of reflexes Diminished ability to communicate Loss of pain sensation

An intraoperative nurse is applying interventions that will address surgical patients' risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.

While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take?

Notify the physician upon arrival at the operating room.

A nurse is caring for a client who received pain medication before leaving the post anesthesia care unit (PACU). Upon returning to the room, the client reports pain and requests more pain medication. Which action is most appropriate for the nurse to take?

Obtain the client's vital signs.

The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?

Place a hand under the child's head for support.

The physician orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions?

Place an isolation cart containing gloves and gowns outside the client's room.

Evidence-based practice

Prior to a patient's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patient's care. What is the main rationale for organizing perioperative care in this collaborative manner?

The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents.

Restrict exercise.

Restrain the patient.

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?

Performing documentation

The OR nurse acts in the circulating role during a patient's scheduled cesarean section. For what task is this nurse solely responsible?

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

compromised skin graft

The patient may be at risk for malignant hyperthermia.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?

An older adult man who will undergo an inguinal hernia repair

The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control?

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority?

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.

Latex allergy

The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit?

The nurse preceptor is discussing Standard Precautions with a graduate nurse. The preceptor should include which measures when discussing Standard Precautions? Select all that apply.

>wear gloves when administering intramuscular (IM) medication >wash hands after removal of gloves

Which statement by a client demonstrates to the nurse that the client understands the best time to perform a self-breast exam?

"I'll examine my breasts a week after my menstrual period starts."

A newly hired graduate nurse asks her preceptor, "What is a common goal of discharge planning in all care settings?" How does the preceptor correctly respond?

"The goal is teaching the client how to perform self-care activities."

Intubating

A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the team's next step in the care of this patient?

A 74-year-old woman with a low body mass index

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?

The nurse just received the shift report on her group of clients. Based on the information she received, which client should she assess first?

A client who underwent a right nephrectomy yesterday and is complaining of pain

Keep the patient positioned supine.

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?

By implementing an interdisciplinary approach to care

A patient is scheduled for surgery the next day and the different phases of the patient's surgical experience will require input from members of numerous health disciplines. How should the patient's care best be coordinated?

The tube provides an airway for ventilation.

A patient waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe?

Trendelenburg

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patient's nerve damage. What surgical position places the patient at highest risk for nerve damage?

The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse?

A stable 6-month-old infant with pneumonia

Sterile surfaces or articles may touch other sterile surfaces.

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?

Mask covering the nose and mouth

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR?

The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called?

statute of limitation

The nurse educator is presenting information about Standard Precautions to a group of newly hired nurses. Hand hygiene is a necessity in Standard Precautions. Which true statement about hand washing would the educator include in her teachings?

Frequent hand washing reduces transmission of pathogens from one client to another.

By maintaining each of your patients' privacy

As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?

A client with end-stage pulmonary hypertension tells his physician that he doesn't want any heroic measures should his heart stop and that he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is a nurse upholding by supporting the client's decision?

Autonomy

A nurse is working with the team to develop a neonate's plan of care. Which action would be the highest priority in regulating the neonate's temperature?

Block sources of radiant, convective, conductive, and evaporative losses.

In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene?

Calling a security guard and another staff member for assistance

Which nursing action is appropriate when performing wound care for a client who has a diabetic foot ulcer?

Change the sterile field after sterile water is spilled on it

A client suspected of having a pulmonary embolus is scheduled for a lung scan. What is the most important action for the nurse prior to the procedure?

Check all allergies of the client.

A client who returns to the surgical floor after undergoing transurethral resection of the prostate complains of pain. Which action should the nurse take first?

Check the client's medical record for postoperative orders.

A clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours?

Client will demonstrate ability to bottle-feed the neonate.

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions?

Consider all body substances potentially infectious

A nurse is caring for a client who had abdominal surgery 3 days ago. The client states, "I haven't moved my bowels, but I am passing gas." What nursing action is appropriate for this client?

Encourage the client to ambulate.

A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy?

Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart.

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?

Make arrangements for the client to receive information about advance directives

A client with a full-term, uncomplicated pregnancy comes into the labor and delivery unit in early labor states, "I think my water has broken." Which action by the nurse would be the priority?

Note the color, amount, and odor of the fluid.

A client recovering from back surgery tells a nurse that she's concerned about going home. She explains that she has many stairs to navigate and household responsibilities she must perform. How can the nurse help ease this client's concerns?

Notify the charge nurse of the client's concerns, and request a team meeting to discuss the client's discharge planning.

A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?

Notify the charge nurse so she can notify the physician of the missed dose.

A client newly diagnosed with diabetes mellitus is experiencing difficulty with self-administration of insulin. Despite further teaching, the client shows little improvement. What action by the nurse is most appropriate?

Notify the physician of the client's lack of progress and request a diabetes education department consult.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access. Which action would be most appropriate for the nurse to take?

Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client

A nurse monitors members of the healthcare team for the use of interventions to reduce the occurrence of methicillin-resistant staphylococcus aureus (MRSA) and other nosocomial infections. Which finding demonstrates to the nurse that the team members understand infection control measures?

Performing hand hygiene before and after contact with every client

A nurse implements standard precautions when caring for a client. Which action best demonstrates proper use of these precautions?

Performing hand hygiene immediately after removing gloves

After a physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond?

Provide the information requested

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the plan of care?

Putting on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA) respirator when entering the client's room

A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety?

Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.

A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do?

Sign the consent only if she sees the client sign it.

After completing a course on infection control, a licensed practical nurse (LPN) demonstrates knowledge of the use of standard precautions based on which statement?

Standard precautions are mandatory for use with all client care.

A nurse is reviewing infection-control measures with a group of unlicensed assistive personnel (UAP). Which statement made by one of the group members indicates learning goals have been met?

Standard precautions should be used when performing client care.

A nurse caring for a client with acquired immunodeficiency syndrome (AIDS) is working with a nursing student. The student does not attempt to suction or assist with care of the client. Which action by the nurse is appropriate?

Talk to the student to determine the issue.

The nurse suspects that a client is not swallowing the administered dose of an anxiolytic medication and is concerned that the client may be disposing of it in the trash. Which action should the nurse take first?

Talk with the client about the concerns.

The patient must never be left unattended by the nurse.

The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia?

Use a tone that decreases the patient's anxiety.

The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement?

Pressure points should be assessed and well padded.

The circulating nurse will be participating in a 78-year-old patient's total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR?

A nurse enters the room of a client who had a left modified mastectomy 8 hours earlier. Which observation indicates that the unlicensed assistive personnel (UAP) assigned to the client needs further instruction and guidance?

The client is wearing a robe with elastic cuffs.

Discard the gauze packing and repack the wound with new Iodoform gauze

The nurse is packing a patient's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patient's abdomen 2 inches (5 cm) away from the wound. What should the nurse do?

Pouring solution onto a sterile field cloth

The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis?

Hypothermia

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient?

Anaphylaxis

The patient's surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication?

An 80-year-old client has an advance directive that states "do not keep alive by any heroic means." The client suffered a heart attack, and the family is requesting full code. Which nursing action taken by the nurse is correct?

Use only pain medication to keep the client comfortable.

Informed consent

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patient's accompanying documentation includes which of the following?

The nurse must administer a liquid medication to an infant. Which step should the nurse take first?

Verify the physician's order.

A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she sees that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do?

Voice her concerns about continuity of care with the charge nurse.

Discourage the colleague from making such comments.

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patient's weight. How should the nurse best respond?

Preventing the onset of a headache

You are caring for a male patient who has had spinal anesthesia. The patient is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the patient?

A licensed practical nurse (LPN) receives a report on several assigned clients at the beginning of the evening shift. The nurse would plan to collect data on which client first?

an older adult client with bacterial pneumonia experiencing periods of confusion

A child diagnosed with tetralogy of Fallot has been ordered to undergo testing. Which test would the nurse prepare the child for that will indicate the direction and amount of shunting in this child?

cardiac catheterization

A nurse is implementing standard precautions when caring for all assigned clients, regardless of their diagnosis or infection status. The nurse demonstrates adherence to the guidelines for standard precautions by which action?

disposing of sharps into a puncture-resistant container

When collecting data on a child with cellulitis, which symptoms would the nurse expect to find?

fever, edema, tenderness, and warmth at the site

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?

frequent respiratory infections

The nurse complies with a client's request to administer his medication at 9 p.m. instead of 10 p.m. so he can go to sleep earlier. Which type of nursing intervention is the nurse utilizing?

independent

Which procedure performed by the nurse will require the use of sterile technique?

inserting an indwelling urinary catheter

The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the:

risk manager.

Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?

signs of increased intracranial pressure (ICP)

A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure that the client is placed:

on contact isolation

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator?

pain level 3/10 one hour after administration of pain medication

The nurse is caring for a child with a Harrington rod placement. Which data gathered by the nurse would be of greatest concern 2 days postoperatively?

urine output less than 30 mL/hr

The nurse is assigned to care for a client with amnesia. When preparing to deliver care, which action will best meet the needs of this client?

use short, simple commands when providing instruction

A nurse is changing a client's dressing and providing wound care. Which activity should the nurse perform first?

wash hands thoroughly

A nurse is working at a local emergency department. A nearby building explosion has occurred, and many of the victims involved are being brought to the facility. Which client would the nurse expect to be triaged first?

a 62-year-old with tachypnea

Ensure that the patient has had a current cross-match.

A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patient's safety if a blood transfusion is required?

The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care?

promoting bowel rest

A nurse is providing care to a client after surgery. The nurse must practice surgical asepsis when performing which procedure?

Insertion of an indwelling urinary catheter

Four clients on an orthopedic unit are scheduled to attend physical therapy at the same time. Facility policy dictates that each client be escorted to therapy in a wheelchair or on a stretcher. When it's time for therapy, only three wheelchairs are available. One of the four clients is learning crutch-walking and is scheduled for discharge in the morning. What should the nurse do to ensure the clients' safety and timely arrival to physical therapy?

Request that a physical therapist accompany the client to therapy while he uses the crutches.

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care?

The client entered a clinical trial through the National Cancer Institute.

A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which child is treated first?

a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling

Which of the following clients should the nurse question about their signed consent form for surgery?

a 54-year-old client with a fractured femur committed to a mental health unit

A client undergoes rhinoplasty to repair a nasal fracture. Postoperatively, the client swallows frequently and requires frequent changes of the mustache dressing, which is soiled with bright-red blood. Which is the best action for the licensed practical nurse (LPN) to take?

check the pharynx with a penlight for bleeding, and confer with the registered nurse (RN)

During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on his forearms. What is the most appropriate way for the nurse to respond?

"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

A nurse is caring for a client who is 6 hours postpartum. The nurse observes a moderate amount of blood clots in the pad, a boggy uterus, and blood pressure of 90/60 mmHg. Which actions should the nurse take? Select all that apply.

>Massage the fundus. >Notify the health care provider. > Give prescribed Methergine. >Ask the client to empty her bladder.

The health care provider orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions?

place an isolation cart containing gloves and gowns outside the client's room.

A nurse must obtain the blood pressure of a client in airborne isolation. Which method is best to prevent transmission of infection to other clients by the equipment?

Leave the equipment in the room for use only with that client

The nurse is teaching a group of client-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

Washing hands

The nurse is teaching a group of unlicensed assistive personnel (UAP) about standard precautions. What information should the nurse include that best describes standard precautions? Select all that apply.

>Wear gloves when there is the potential for contact with a clientj's body fluid; >Wear gloves, a face shield, and a gown when contact with body fluids is possible