Nursing Foundations Exam 1

within normal limits

The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

Place a surgical mask on the client and transport to the CT department at the specified time.

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply.

Risk for Poisoning related to poor eyesight and the inability to read medication labels

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

handwashing

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?

Use a sterile cotton-tipped applicator to apply the prescription to the site

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

applying a new dressing with the gloves that were used to remove the old dressing

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?

Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

Encourage exercise that improves balance and muscle strength

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

into a private room

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

an older adult client with a history of heart failure

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

Discard the sterile field and the supplies and start over.

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

the 2-year-old leaning against the screen of a window in a classroom

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

"Don't forget to put on your gloves."

The nurse observes a colleague performing the action above while preparing to care for a client with bacterial meningitis. What is the nurse's most appropriate statement to the colleague?

antibody

immunoglobin produced by the body in response to a specific antigen

airborne transmission

spreading of microorganisms that are less than 5 mcm when an infected host coughs, sneezes, or talks, or when the organism becomes attached to dust particles

VAP

ventilator associated pneumonia

1. preventing infections, thereby preventing the spread of resistance 2. tracking 3. improving antibiotic prescribing/stewardship 4. developing new drugs and diagnostic tests

what are the core actions from the CDC to fight resistant strains?

Surgical asepsis technique

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

active immunity

A nurse instructs a new mother on immunizations. An immunization produces:

Complete a fall-risk assessment

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority?

The nurse should question the client about the source of the bruises.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

Wear a mask when providing care within 3 ft. of the client Place a surgical mask on the client if transportation to another department is unavoidable Wear a gown when performing care that might result in contamination from secretions

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

Wash the hands with soap and water for at least 15 seconds Use a clean paper towel to turn off hand faucets

A nurse is reviewing hand hygiene techniques with a group of assistive personal (AP). Which of the following instructions should the nurse include when discussing handwashing?

keeping medications in clearly labeled containers

A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching?

Prodromal stage.

A school nurse is performing an assessment of a student who states, "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection?

Most people who die in fires die of smoke inhalation Fire-related injury and death have declined due to the availability and use of smoke alarms Fires are more likely to occur in homes without electricity or gas

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan?

Hepatitis B Hepatitis C HIV

A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply.

A 65-year old patient who has an indwelling urinary catheter in place

The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

Hypotension, tachycardia, hot, dry skin, dyspnea

What are s/s of heat stroke?

CRE

carbapenem-resistant enterobacteriaceae

antigen

foreign material capable of inducing a specific immune response

MRSA

methicillin-resistant staphylococcus aureus

endemic

something that occurs with predictability in one specific region or population and can appear in a different geographical location

SSI

surgical site infection

synthetic antibiotic (i.e. linezolid)

what is the drug of choice for health care-associated MRSA if resistant to vancomycin?

Activate external disaster protocol

A client arrives at the emergency department after an industrial explosion involving an unknown chemical contaminant. What is the nurse's priority action?

exposure to the pathogen nonspecific symptoms positive laboratory tests return of appetite

A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.

Avoid contact with mosquitoes

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?

Identifying his door with his picture and a balloon.

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints?

pathogen.

Any microorganism capable of disrupting normal physiologic body processes is a:

Making sure patients rooms are decluttered.

Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home?

Carry the soiled items away from the body to prevent them from touching the clothing and NEVER place the soiled items on the floor as it is highly contaminated.

Following medical asepsis technique, what should the nurse do when handling contaminated items in a room?

A patient diagnoses with rubella A patient diagnosed with diphtheria A patient diagnosed with adenovirus infection

In addition to standard precautions, the nurse would initiate droplet precautions for which patients?

eustachian tube is shorter and straighter.

Otitis media occurs in children because the:

absence of all microorganisms.

Surgical asepsis is defined as:

The nurse ensures that two fingers can be inserted between the restraint and patient's ankle.

The joint commission issues guidelines regarding the use of restraints. In which case is a restraint properly used?

encourage the colleague to remove the glove by grasping the cuff

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response?

Consider the outer 1 in of the sterile field as contaminated

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate?

respiratory infection

The nurse notes that the client's temperature is 101.2°F (38.4°C) at 8 a.m. Elevated temperature may be due to several factors. What could be the reason for this?

Perform hand hygiene.

The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?

The nurse keeps fingernails less than 1/4 in (0.63 cm) long.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene?

fomite

a physical object that serves to transmit an infectious agent from person to person.

asepsis

absence of disease-producing microorganisms; using methods to prevent infection

antimicrobial

antibacterial agent that kills bacteria or suppresses their growth

bundles

evidence-based best practices that have proven positive outcomes when implemented together to prevent infection

contact with feces, urine, or blood of an infected or colonized person

how is VRE spread?

medical asepsis

practices designed to reduce the number and transfer of pathogens; synonym for clean technique

bacteria

the most significant and most commonly observed infection-causing agents

sterilization

the process by which all microorganisms, including spores, are destroyed

droplet transmission

transmission of particles greater than 5 mcm

VRSA

vancomycin-resistant Staphylococcus aureus

1. prevention of inappropriate short-term urinary catheter use 2. timely removal of catheters that is nurse-driven 3. catheter care during placement

what are the initiatives to prevent CAUTIs?

Placing the client in a bed with a bed alarm

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

fill out an incident report, with the goal of preventing a similar event in the future.

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

The hospital must bear any costs incurred for treating the client's injury.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

"Your white blood cells have increased in the area."

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?

The client's vital signs must be assessed every hour.

A health care provider has ordered restraints for an older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints?

intravenous antibiotic administration

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?

Pull the fire alarm lever.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

decreased cellular immunity.

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

Hand hygiene is needed after contact with objects near the client.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

Healthcare-associated infection (HAI)

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection?

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

streptococci staphylococci

Nursing students are reviewing the different types of bacteria. The students demonstrate understanding of the information when they identify which of the following as Gram-positive bacteria? Select all that apply.

When hands are visibly soiled

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

A= Assessment

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?

The new nurse touches 1.5 in (4 cm) from the outer edges.

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?

"I will rescue clients from harm before doing anything else."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

removes gloves and walks out of the room

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

Surgical asepsis

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

Incentivizing health care workers to utilize hand hygiene

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?

Assess client's pain level and manage pain accordingly.

The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?

drugs that are used to control behavior and are not included in the person's normal medical regimen

What are chemical restraints?

The line of gravity should fall within the base of support Lower the center of gravity for more stability and balance Spread feet apart to increase and widen the base of support Hold an object as close to the body as possible when lifting Move rear leg back when pulling on an object

What are proper body mechanics?

Request Assistance when repositioning a client Avoid twisting spine or bending at the waist Use smooth movements when lifting and moving clients Keep knees slightly higher than the hips to decrease strain on the lower back when sitting for long periods of time Take a break every 15-20 minutes from repetitive movements to flex and stretch joints and muscles

What are the guidelines for preventing injury with staff nurses?

Class C fire extinguisher

What fire extinguisher is used for electrical fires?

Before direct contact with patients After direct contact with patient skin After contact with body fluids if hands are not visibly soiled After removing gloves Before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement Before donning sterile gloves prior to an invasive procedure If moving contaminated body site to a clean body site After contact with objects contaminated by the patient EXCEPT C. diff infection.

When is it recommended to use an alcohol-based handrub?

Discard the bottle and get a new one because the saline has expired.

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?

Gloves

Which piece of personal protective equipment (PPE) should be removed first?

"I will go to the nurse's station for assistance"

a nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by the nurse requires further instruction?

iatrogenic

infection that occurs as a result of a treatment or diagnostic procedure

surgical asepsis

practices that render and keep objects and areas free from microorganisms; synonym for sterile technique

colonization

presence of an organism residing in an individual's body but with no clinical signs of infection

disinfection

process used to destroy microorganisms; destroys all pathogenic organisms except spores

gloves, blood pressure cuffs, electrode pads, stethoscopes, IV tubing, urinary catheters, tourniquets, syringes, surgical masks, baby bottle nipples and pacifiers

what are frequently used products that contain latex?

skin prick test

what is a diagnosis technique for latex allergies?

people who have bladder or venous catheters in place, those who required ventilator assistant to breath, those taking antibiotics for a lengthy period of time, or people who have frequent hospitalizations or long-term care facility stays

who is at risk for developing CRE?

patients who have surgery, invasive devices, or are immunocompromised

who is at risk for developing a health care associated MRSA strain?

it is a vaccine given to booster antibodies towards the tetanus pathogen.

A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is:

Avoid unattended baths for the toddler.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Hold sterile objects above waist level to prevent inadvertent contamination.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

"These barriers help prevent the transmission of infection to you or other people."

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

Binds with hemoglobin in the body. Impairs the body's ability to use oxygen but the lungs are not damaged. Cannot be seen, smelled or tasted. Water heaters, gas-burning furnaces, and appliances should be inspected annually.

What are the dangers of carbon monoxide poisoning?

Mostly caused by bacteria such as E. coli. Immunocompromised individuals are at increased risk for complications. Clients at high risk should eat or drink only pasteurized dairy products. Healthy individuals usually recover in a few days. Handle raw and fresh foods separately.

What are the dangers of food poisoning?

Side rails, geriatric chairs with attached trays, and appliances tied at the wrist, ankle, or waist

What are types physical restraints?

A patient of small stature is at increased risk for injury from entrapment.

What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

oral diphenhydramine, cool compresses, and hydrocortisone 1% cream

what is the treatment for localized reactions to latex?

"All visitors who enter the room must wear N95/surgical masks."

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

Discard the supplies and prepare a new sterile field with another person holding the patient's hand

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate action in this situation?

Nail polish should not be used near a client who is receiving oxygen. A "No Smoking" sign should be placed on the front door. A fire extinguisher should be readily available in the home.

A nurse is providing discharge instruction to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include?

clear mucus

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?

"Help me understand your thoughts about vaccinations."

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?

Create an area for sterile field and opening packages

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

the individual, the environment, and specific risk factors

what does a safety assessment involve?

irritant contact dermitits

what is the most common reaction to latex that is usually restricted to hands that have made contact? s/s: dry, irritated skin associated with pruritis

bacteria.

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

handwashing before leaving the client's room

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply.

Tuberculosis

A nurse caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?

Planning and evaluating control and prevention stages Determining public health priorities Ensuring proper medical treatment Monitoring for common-source outbreaks

A nurse caring for a client who has sever acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rational for reporting?

Place wet paper towels along the base of the door to the client's room.

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been take to safety and the alarm has been activated. Which of the following actions should the nurse take?

"Once my infant starts to push up, I will remove the mobile from over the crib"

A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statement made by a participant indicates understanding?

Make sure that the client's call light is within reach Provide the client with nonskid footwear Complete a fall-risk assessment

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

The nurse records the circumstances and effect on the patient in the medical record.

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately?

Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?

The nurse moves the patient table away from the nurse's body when wiping it off after a meal.

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines?

Washes hands to 1 in above the wrists Uses approximately one teaspoon of liquid soap Uses friction motion he washing for a least 20 seconds Rinses thoroughly with water flowing toward fingertips

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly?

The use of clean technique is safe for the home setting

A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

Pour the solution from a height of 4 to 6 in (10 to 15 cm)

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task?

Wash the exposed area with warm water and soap

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the first action of the nurse following the exposure?

Call the PCC (Poison Control Center) immediately before attempting any home remedy. Ipecac no longer recommended because vomiting can be dangerous.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What be the nurse's best response?

reaches down to the bed to pick up a sterile drape

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?

prodromal

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

helps to determine prescribed antibiotic therapy

A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

contact precautions

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?

The alternative measures attempted before applying the restraints

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

change to airborne precautions

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?

Use a sterile intravenous catheter.

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?

Refrain from using extension cords.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Brush the chemical off the skin and clothing

What intervention should the nurse take when caring for an employee who was exposed to an unknown dry chemical resulting in a chemical burn?

Providing prompt recognition of the potential or actual threat to safety

What is the primary role of the nurse in the care of clients who experience domestic violence?

Inflammation

What is the second line of defense in microbial invasion?

Rescue the patient

When a fire occurs in a patient's room, what would be the nurse's priority action?

Cleanse and disinfect the sphygmomanometer.

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?

The fact that sterile technique was used for a given procedure

Which should be documented by the nurse?

klebsiella species and e. coli

what are examples of Enterobacteriaceae normally found in the human intestine? (these bacteria are carbapenem resistant)

bacteria (i.e. C. diff, E. coli, S. aureus)

what are most HAI caused by?

handwashing and a septic technique

what are the central line insertion maintenance guidelines?

Implement drowning prevention strategies.

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Determine the client's ability to help with the transfer.

A nurse is caring who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

A client who has partial-thickness and full-thickness burns to his face, neck, and chest. (At risk for airway obstruction)

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's priority?

Blood and body fluids are major reservoirs for microorganisms.

The nurse is caring for a client that requires a dressing change. When applying the principles of asepsis, what aspect of care should the nurse include?

Providing a bed bath for a patient Removing gloves when patient care is completed Inserting a urinary catheter for a female patient Removing old magazines from a patient's table

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate hands?

Fever Malaise Increase in pulse and respiratory rate

A charge nurse is reviewing with a newly hired nurse the difference in a manifestations of a localized versus systemic infection. Which of the following are manifestations of a systemic infection?

Survival adaptation

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:

The nurse moistens a cotton ball with sterile normal saline in places it on sterile field The procedure is delayed 1 hour because the provider receives an emergency call The nurse turns to speak to someone who enters through the door behind the nurse.

A nurse had prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field?

The flap farthest from the body

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

18,000 cells/mm

A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection?

A toddler playing with his 9-year-old brother's construction set

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating?

urinary catheter

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

The nurse places the client in a private room with monitored negative air pressure.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

Illness

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the follow stages of infection?

Infection

A nurse is caring for an obese 62-year old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient?

Wash hands thoroughly and then don sterile gloves. Utilize isolation precautions including donning gloves, gowns, and face mask. Ensure family visitors know they cannot bring flowers or fresh fruit to the client. Keep nails short with no polish. Practice good personal hygiene including showering before each shift.

A nurse is changing the dressings of a client in the burn unit. Which action(s) should the nurse perform to maintain asepsis and client comfort? Select all that apply.

Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 pounds.

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan?

The nurse works from "clean" areas to "dirty" areas during bath

A nurse is using PPE when bathing a patient diagnosed with C. diff. Which nursing action related to this activity promotes safe, effective patient care?

The inner wrapping of an item on the sterile field An irrigation syringe on the sterile field One glove hand with the other gloved hand

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique?

perform hand hygiene before and after entering the client's room

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?

Move clients who are nearby

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following action is the nurses priority?

Explain how to operate the call bell.

A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine?

Least soiled areas first to prevent having the cleaner areas soiled by the dirtier ones.

Following the principles of medical asepsis, should the nurse clean lightly soiled or heavily soiled items first?

respiratory.

The most common infection in children is:

urinary

The most lethal infection in an older adult is;

All patients receiving care in hospitals

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?

A patient who has already fallen twice A patient who experiences postural hypotension A 70-year old patient who is transferred to long-term care

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category?

contact

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection?

Pour the liquid into a sterile container within the sterile field.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

age of the client history of a drug that caused suppression of the immune system the intravenous catheter

The older adult client received chemotherapy for cancer 2 days ago and is now admitted for intractable vomiting. The client is receiving an antiemetic and intravenous fluids at 100 ml/hr. The client has a Purewick female external catheter for urinary incontinence. What data increase the client's susceptibility for systemic infections? Select all that apply.

immediately deposit uncapped needles into a puncture-proof plastic container.

To eliminate needlesticks as potential hazards to nurses, the nurse should:

Keep the caller on the line Do not evacuate clients unless directed Do not use elevators Ask questions for as much information as possible Listen for background noise

What actions should a nurse take in the event of a bomb threat by a phone?

Class A fire extinguisher

What fire extinguisher is used for combustibles (paper, wood, upholstery, rags, other types of trash fires)?

Class B fire extinguisher

What fire extinguisher is used for flammable liquids and gas fires?

The client lies supine with the head of the bed elevated 15-45 degrees.

What is Semi-Fowler's position?

Close all client doors Place blankets over clients who are confined to beds Move beds away from the windows Draw shades and close drapes Instruct ambulatory clients to go into the hallways away from windows

What is facility protocol in the event of a tornado?

Sitting up and leaning over a table to breathe.

What is orthopenic position?

Cover exposed wrist skin

What is the primary purpose for the demonstrated glove application?

Open the solution container according to directions and place the cap on the table away from the field with the edges up. Hold the bottle outside of the edge of sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4-6 in (10-15 cm)

What is the proper technique to add a sterile solution to a sterile field?

BLI (blast lung injury) is a serious consequence following detonation of an explosive device.

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack?

have a meeting place outside the home.

When educating families on fire safety, it is important to:

place a mask on the client to limit the spread of microorganisms into the surgical wound.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field.

Avoid exposing the child to sick individuals. Immunize the child against the Flu. Sleep at least 8 hours a day.

Which interventions protect children from acquiring infection? Select all that apply.

Risk for suffocation related to unfamiliarity with fire prevention guidelines

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for the patient?

CAUTI

catheter associated urinary tract infection; most common HAI

CLABSI

central line associated blood stream infection; have a high mortality rate

inform employer and other health care professionals, wear medical alert bracelet, follow dr's recommendations, inform all health care providers prior to injections/immunizations or procedure or surgery

how would you educate a patient who has a latex allergy?

1. avoiding the use of electronic equipment that is difficult to clean (electronic thermometers) 2. disinfecting the dedicated patient care items and equipment (stethoscopes) between patients 3. using full-barrier contact precautions (gown and gloves) 4. placing patients in private rooms; cohort patients with the same strand 5. performing meticulous hand hygiene 6. performing environmental contamination of rooms 7. educating health care providers (and patients/families) on clinical presentations, transmission, and epidemiology

what are the general strategies to reduce the indirect transmission of CDI?

compromised immune systems, recent surgery, invasive devices, prolonged antibiotic use (especially vancomycin), and prolonged hospitalization

what are the risk factors for VRE?

good handwashing, PPE, and disinfection/sterilization of equipment by health care providers who come into contact

what are treatment options for s. aureus?

bloodstream infections, wound infections, ventilator-associated MRSA, and multidrug resistance

what can MRSA be responsible for?

pathogens gain access to a patient's lungs via either an endotracheal or tracheostomy tube

what causes ventilator associate pneumonia (VAP)?

RAST (radioallergosorbent test)

what is a blood test for IgE antibodies to latex?

immediate hypersensitivity

what is a latex reaction that happens within minutes of exposure and is life-threatening? s/s: rhinitis, conjunctivitis, angioedema, bronchospasm, shock, and/or systemic anaphylactic reactions (rarely first reaction)

allergic contact dermatitis or delayed hypersensitivity

what is a latex reaction that is displayed as dry, crusty bumps, erythema, pruritis, scaling vesicles, papular lesions at the site of contact, including the palms s/s usually appear in 24-96 hours

IV vancomycin

what is the drug of choice for health care-associated MRSA?

direct contact with the contaminated hands of health care personnel or indirect contact with equipment

what is the main mode of transmission for health care-associated MRSA?

1. gather necessary supplies; do not let clothing touch sink 2. remove jewelry 3. turn on water and adjust force; warm temperature 4. wet hands and wrist area, keep hands lower than elbows 5. dispense soap and lather thoroughly, cover all areas of hands 6. with firm rubbing and circular motions, wash palms, back of hands, each finger, in-between, knuckles, wrists, forearms 7. wash for at least 20 seconds 8. use fingernails on the opposite hand and clean under fingernails 9. rinse thoroughly with warm water flowing towards fingertips 10. pat hands dry with paper towel beginning with the fingers and moving upwards to forearms; discard and use another clean towel to turn off faucet

what is the proper handwashing technique?

epinephrine subq, systemic steroids, antihistamines, transport to the ED

what is the treatment for systemic reactions to latex?

those with a history of kidney disease or diabetes, a previous MRSA infection , presence of an invasive catheter, or recent exposure to vancomycin

what patients are at risk for developing VISA or VRSA?

nasal mucous membranes, on the skin, and in the respiratory and gastrointestinal tracts

where are s. aureus bacteria normally found?

healthcare workers who wear latex gloves, people with allergic tendencies, people with food allergies (specifically bananas, papaya, avocado, potatoes, kiwi, chestnuts, pineapples), latex-industry workers, and people with asthma, spina bifida, or a history or multiple surgical procedures or exposure to latex

who is at risk for a latex allergy?