Safety and Infection

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 Perform hand hygiene 2 Remove gloves 3 Remove N95 respirator 4 Take off goggles 5 Take off the gown

2 Remove gloves 4 Take off goggles 5 Take off the gown 3 Remove N95 respirator 1 Perform hand hygiene

A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? A. Gloves B. Gown and gloves C. Gown, gloves, and mask D. Gown, gloves, mask, and eye goggles or eye shield

D. Gown, gloves, mask, and eye goggles or eye shield

Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation? A. Absence of intercostals or substernal retractions B. Oxygen saturation of 95% C. Mild work of breathing D. History of steroid-dependent asthma

D. History of steroid-dependent asthma

The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to: A. Bananas B. Color dyes C. Kiwifruit D. Latex

D. Latex

Which action will you take to most effectively reduce the incidence of hospital-associated urinary tract infections? A. Ensure that clients have enough adequate fluid intake B. Teach assistive personnel how to provide good perineal hygiene C. Perform dipstick urinalysis for clients with risk factors for UTI D. Limit the use of indwelling foley catheter (IFC)

D. Limit the use of indwelling foley catheter (IFC)

An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant? A. Encouraging the infant to hold a bottle B. Keeping the infant on bed rest to conserve energy C. Rotating caregivers to provide more stimulation D. Maintaining a consistent, structured environment

D. Maintaining a consistent, structured environment

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do first? A. Assess vital signs B. Institute seizure precautions C. Assess neurologic status D. Place in respiratory isolation

D. Place in respiratory isolation

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 a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? A. Obtain blood, urine, and sputum for cultures B. Infuse normal saline at 100ml/hr C. Administer methylprednisolone (Solu-Medrol) 1 gram/IV D. Place the client on contact and airborne precautions

D. Place the client on contact and airborne precautions

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

A. A client who has nontunneled central line in the left internal jugular vein.

Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is: A. Correct illumination of the environment B. Amount of regular exercise C. The resting pulse rate D. Status of salt intake

A. Correct illumination of the environment

The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age: A. Is highly sensitive to criticism B. Rebels against scheduled activities C. Still depends on the parents D. Loves to tattle

A. Is highly sensitive to criticism

While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topics in the teaching session? A. Safety guidelines B. Preparation for surgery C. Toilet Training D. Nursery schools

A. Safety guidelines

An eighty-five-year-old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is: A. Speak soothingly and provide quiet music B. Encourage family phone calls C. Limit visits by staff D. Position in a bright, busy area

A. Speak soothingly and provide quiet music

When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following? A. Tachypnea B. Shallow respirations C. A reduced white blood cell count D. A decreased platelet count

A. Tachypnea

Nurse Betina should begin screening for lead poisoning when a child reaches which age? A. 3 months B. 12 months C. 24 months D. 30 months

B. 12 months

The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? A. The nurse puts on a mask, a gown, and gloves before entering the room of a client in strict isolation. B. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. C. The nurse aide is not wearing gloves when feeding an elderly client. D. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.

B. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.

Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What is the nurse's best recommendation for helping the mother increase her child's nutritional intake? A. Use specially designed dishes for children - for example, a plate with the child's favorite cartoon character B. Allow the child to feed herself C. Only serve the child's favorite foods D. Allow the child to eat at a small table and chair by herself

B. Allow the child to feed herself

An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching? A. Apply hydrocortisone cream under the cast using sterile applicator B. Apply cool air under the cast with a blow-dryer C. Use sterile applicators to scratch the itch D. Apply cool water under the cast

B. Apply cool air under the cast with a blow-dryer

A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler's fontanels, what should the nurse expect to find? A. Open anterior and fontanel and closed posterior fontanel B. Closed anterior and posterior fontanels C. Closed anterior fontanel and open posterior fontanel D. Open anterior and posterior fontanels

B. Closed anterior and posterior fontanels

The nurse is finishing her shift in the pediatric unit. Because her shift is ending, which intervention takes top priority? A. Restocking the bedside supplies needed for a dressing change on the upcoming shift B. Documenting the care provided during her shift C. Emptying the trash cans in the assigned client room D. Changing the linens on the clients' beds

B. Documenting the care provided during her shift

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 A. Goggles B. Gown C. Gloves D. Shoe covers E. N95 respirator F. Surgical face mask

B. Gown C. Gloves E. N95 respirator

A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority? A. Impaired urinary elimination related to fluid loss B. Ineffective airway clearance related to edema C. Disturbed body image related to physical appearance D. Risk for infection related to epidermal disruption

B. Ineffective airway clearance related to edema

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? A. Obtain stool specimens for culture B. Place the client on contact precaution C. Notify the physician about the loose stools D. Instruct the client about correct handwashing

B. Place the client on contact precaution

Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure? A. She says to her husband, "Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food." B. "I understand it will be several weeks before all the radiation leaves my body." C. "I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital." D. "I brought several craft projects to do while the radium is inserted."

C. "I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital."

Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis? A. "If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled." B. "If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline." C. "If I question the sterility of any dressing material, I should not use it." D. "I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s."

C. "If I question the sterility of any dressing material, I should not use it."

Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause: A. Dehydration B. Hypovolemic shock C. Cerebral edema D. Heart failure

C. Cerebral edema

A 26-year-old client is diagnosed with scarlet fever. Which of the following is the most appropriate type of isolation for this client? A. Airborne B. Contact C. Droplet D. Standard

C. Droplet

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 A. N95 respirator B. Surgical Mask C. Gloves D. Goggles E. Gown

C. Gloves E. Gown

Which of the following is the first priority in preventing infections when providing care for a client? A. Wearing gowns and goggles B. Using a barrier between client's furniture and nurse's bag C. Handwashing D. Wearing gloves

C. Handwashing

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client's care? A. Monitor the results of the laboratory culture and sensitivity test. B. Educate the client and family members on ways to prevent transmission of VRE. C. Implement contact precautions when handling the client. D. Collaborate with other departments when the client is transported for the ordered test.

C. Implement contact precautions when handling the client.

A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? A. Obtaining history information from the parents B. Administering acetaminophen (Tylenol) C. Instituting droplet precautions D. Orienting the parents to the pediatric unit

C. Instituting droplet precautions

The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to: A. Discuss dressing change technique with the nurse at a later date. B. Congratulate the nurse on the use of good technique. C. Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves. D. Interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing.

C. Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.

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 of these nursing actions can you delegate to an LPN/LVN? A. Assess risk for further skin breakdown B. Plan ways to improve the client's oral protein intake C. Obtain wound cultures during dressing changes D. Educate the client about home care of the leg ulcer

C. Obtain wound cultures during dressing changes

A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? A. Place a urine collection bag and specimen cup at the bedside B. Order a stat admission CBC C. Pad the side rails of his bed D. Place a cooling mattress on his bed

C. Pad the side rails of his bed

A young adult is being treated for second and third-degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement? A. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bathwater." B. "I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours." C. "I must wear my Jobst elastic garment all day and can only remove it when I'm going to bed." D. "If any healed areas break open I should first cover them with a sterile dressing and then report it."

D. "If any healed areas break open I should first cover them with a sterile dressing and then report it."

After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching? A. "We'll follow these instructions until our child has completely grown and developed." B. "Well follow these instructions until our child's symptoms disappear." C. "Our child must maintain these dietary restrictions until adulthood." D. "Our child must maintain these dietary restrictions lifelong."

D. "Our child must maintain these dietary restrictions lifelong."

The nurse is evaluating whether a nonprofessional staff understands how to prevent the transmission of HIV. Which of the following behaviors indicates the correct application of universal precautions? A. An aide wears gloves to feed a helpless client. B. A pregnant worker refuses to care for a client known to have AIDS. C. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood. D. An assistant puts on a mask and protective eyewear before assisting the nurse to suction a tracheostomy.

D. An assistant puts on a mask and protective eyewear before assisting the nurse to suction a tracheostomy.

Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first? A. Call an ambulance immediately B. Administer ipecac syrup C. Punish the child for being bad D. Call the poison control center

D. Call the poison control center

Shane tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor for the nurse to stress to the mother is: A. Developmental level of the child's peers B. Consistency in approach C. The mother's positive attitude D. Developmental readiness of the child

D. Developmental readiness of the child

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? A. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms. B. Screen all newly admitted clients for colonization or infection with MRSA. C. Require nursing staff to don gowns to change wound dressings for all clients. D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.

D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.

An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure? A. The nurse-manager B. The registered nurse caring for the infant C. The social worker who placed the infant in the foster home D. The foster mother

D. The foster mother