Safety and Infection Control

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?

"I won't donate blood, because I don't want to get AIDS."

After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom the student nurse has been assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response?

Ask the student to provide a photo ID for comparison with the names on the assignment sheet.

A client presents to the emergency department (ED) with suicidal thoughts and a long-standing history of major depression. The nurse completes a mental status assessment and deems that the physician needs to see the client immediately. Which action would be most appropriate for the nurse to take next?

Call the physician from a phone in the examining room.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do?

Check on the client at regular intervals to ascertain the need to use the bathroom.

A nurse is administering a newly prescribed I.V. antibiotic to a client who suddenly develops wheezing and dyspnea. Which is the nurse's priority action?

Discontinue the antibiotic infusion.

Which nursing action best addresses the outcome: The client will be free from falls?

Encourage use of grab bars and railings in the bathroom and halls. To address the client outcome of being free from falls, it is best to place assistive devices of grab bars especially in the bathroom and railings in the halls and on the stairs to promote balance. Focusing on how to transfer a client is a nursing-focused action, not a client-focused action. It is important to place an emergency contact number close by and have an emergency monitoring system; however, they will not prevent falls. Although limiting the use of stairs decreases the potential of falls, any time that stairs are used creates a fall possibility.

The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child?

Maintain a tidy environment around the child.

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

Use a night-light in the bathroom.

Which client has a greater risk for latex allergies?

a woman who is admitted for her seventh surgery

Which behaviors from a client with dementia would prompt nursing intervention?

attempting to hit others Attempting to hit others would need to be corrected immediately. Yelling and attempting to exit doors would need to be addressed; however, safety is the primary concern. Clients with dementia can be redirected and should be addressed calmly.

When teaching parent workshops about measures to prevent lead poisoning in children, the nurse should identify which preventive measure as being the most effective?

educating the public on common sources of lead

One evening, the client takes the nurse aside and whispers, "Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight." Which action is the priority?

explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP)

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask:

is appropriate

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used?

handling of the dislodged radiation source.

When the client is involuntarily committed to a hospital because the client is assessed as being dangerous to himself or others, which client rights are lost?

the right to leave the hospital against medical advice

The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to PPE use?

"PPE should be used when you risk exposure to blood or bodily fluids."

A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate?

Make sure all medications are kept in containers with childproof safety caps.

The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence?

"How safe do you feel in your home?" The act of screening for intimate partner violence is a key intervention to help open doors for at risk women to discuss ways to improve their safety and well-being. Asking clients how safe they feel in their home open is an open-ended, nonjudgmental way to elicit perceptions of safety. Asking if a partner is excited about a pregnancy is not a good screening question because many couples are not excited to learn of an unplanned pregnancy. However couples with healthy relationships eventually adjust. Having an arrest record and gun ownership do not automatically equate to having a history of violence.

A nurse is caring for an infant who requires intravenous therapy. The nurse notes that the only available IV pump is in a toddler's room. In which order should the nurse complete the following actions?

1, 2, 3, 4 Properly cleaning the monitoring equipment is the correct infection control process. Best practices would include removing the pump from the toddler's room, cleaning the pump, taking the pump into the infant's room, and using the pump.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Institute isolation precautions.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand. Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to the nurse's body as possible when lifting — not at arm's length. The nurse should keep knees slightly bent and feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply.

taking small steps with feet shoulder length apart when walking on wet surfaces removing clients from the area where a fire is reported using tongs to place a dislodged radioactive device in a lead container

The nurse is placing a client with severe neutropenia in reverse isolation. What should the nurse tell the client why this is necessary? Reverse isolation helps prevent the spread of organisms:

to the client from sources outside the client's environment.

A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep their leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take?

Ask the staffing coordinator to assign a nursing assistant to sit with the client.

The nurse completes an incident report after discovering and assessing a client sitting on the floor beside the bed. Which actions should the nurse take after completing the incident report? Select all that apply.

Notify the physician. Notify the nursing supervisor. Send a copy of the report to the risk management department. Document the client's condition

The nurse is developing a care plan for a client who has had radiation therapy for Hodgkin's lymphoma. What is the primary goal of care for this client?

Prevent infection.

A client with Alzheimer's disease is admitted to an inpatient setting and has memory loss, wandering, and disorientation. What nursing intervention should be the priority to initiate in the client's care plan?

Remove potential hazards from the client's environment. By removing potential environmental hazards, the nurse can help prevent injury to the client. For a client with Alzheimer's disease, some visual cues, such as the client's picture on the room door, can be helpful, but this is not a priority. Not all clients with Alzhiemer's disease are at risk for falls; since there is no evidence this client is at risk, there is currently no established need for standby assist or a walker. Routine reorientation is not recommended for clients in later stages of dementia and serves no useful purpose.

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Mothers can transmit gonorrhea during the birth process; untreated, it can cause serious eye damage to the neonate. A neonate whose mother has hepatitis B should receive hepatitis B immunoglobulin within 12 hours of birth, not eye prophylaxis. CMV doesn't require strict isolation; however, the neonate may be treated with I.V. antivirals. HIV is transmitted via blood and body fluids. Contact isolation, not strict isolation, is appropriate.

A 45-year-old client diagnosed with colon cancer states, "I don't want any treatment. I haven't seen any family members in 25 years. I'm a loner. Besides, I'll decide when and how I want to die." In which order of priority from first to last should the nurse perform the actions? All options must be used.

Ask the client about thoughts of suicide. Ask the client what methods of suicide are available. Express concern for the client's feelings and safety. Tell the client that the primary care provider will ask for a psychiatric consult. Even with such a blatant suicide clue, it is still important to confirm that he is truly suicidal. Then it is crucial to know what methods of suicide are available to him. Before asking for a psychiatric consult, the client needs to understand that the nurse cares, is empathetic, and will take actions to protect him from harm.

The nurse is providing discharge instructions to a client newly diagnosed with the hepatitis C virus (HCV). When evaluating the teaching, which statement made by the client indicates a need for further teaching? Select all that apply.

"I will make sure that my family has had the vaccine against hepatitis C." "Having an occasional alcoholic beverage will not be a problem." Hepatitis C is the most common chronic liver disease. Hepatitis C clients may have no symptoms until later stages of the disease. There is no vaccine for the disease, and a client should not have alcoholic beverages due to the impact on the liver. Therefore, if the client believes there is a vaccine or that consumption of alcohol is OK, the client requires further teaching. Hepatitis C leaves the client fatigued after minimal exertion, so periods of rest are needed throughout the day. The primary mode of transmission is through blood exposure such as through bleeding from the oral mucosa or blood on razors, so meticulous care to prevent cross-contamination is needed. Epigastric pain is a common symptom due to the enlarging liver.

An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff?

"The client needs to be placed in a private, negative air pressure room."

After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which statement by the parents indicates effective teaching?

"We'll remove the restraints temporarily, one at a time, at least three times a day to check his skin, then put them right back on." Elbow restraints help to keep the child from placing fingers or any other object in the mouth that would cause injury to the operative site. The restraints are worn at all times except when they are removed to check the skin. Because of the risk for skin breakdown, the restraints are removed periodically during the day to assess the child's underlying skin. It is advisable to remove only one restraint at a time while keeping hold of the child's hand on the unrestrained side. Toddlers are quick and usually want to explore the area in the mouth that the surgery has made feel different. The restraints should be in place at all times during sleep and play to prevent inadvertent injury to the operative site. Taping the restraints directly to the skin is not advised because skin breakdown can occur when tape is reapplied to the same area over several weeks. The restraints can be fastened to clothing to keep them from slipping.

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take?

Determine that the procedures currently in place must be followed and direct staff to follow them without question.

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Help the client dangle his legs. After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse should help him sit on the edge of the bed and dangle his legs. The nurse should then face the client and place the chair next to and facing the head of the bed.

A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which action by the nurse is the best solution?

Hold the medication until speaking with the NP. The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication.

A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention?

Maintain the client on respiratory isolation

The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply.

Wash hands with soap and water. Wear a protective gown when in the client's room C. difficile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn.

A client is being assessed for multiple lacerations resulting from an assault by an unknown paid sexual partner. The nurse must recognize what as a priority for this client?

The client's safety should be provided in a secure and private environment. Regardless of the gender of the client or the attacker, a traumatic assault demands that safety and security are a top priority. The client may resist filing a police report because of the paid sex (prostitution), and because it was with a stranger. Testing for sexually transmitted diseases is not a priority until the wounds have been treated. The client's illicit behavior does not warrant being referred to a community free clinic.

A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority?

Use an organized, efficient team approach to apply and secure the restraints.

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). What should the nurse do first?

Verify the prescription to use the restraint.

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. Which actions would be appropriate for the nurse to take to address this situation? Select all that apply.

a communication plan for the family and client a thorough explanation of the isolation procedures acknowledgement of the family's concerns

Which nursing intervention is the highest priority when a client is placed in restraints?

monitoring the client every 15 minutes Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client's position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:

safety needs. The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

A parent of a 9-year-old child who is scheduled to have surgery expresses concern about the potential for a postoperative infection. Which information would be most important for the nurse to tell the parent?

"All visitors should wash their hands before they leave or enter the room." Hand washing upon entry and when leaving the client's room should be stressed to visitors to prevent the spread of disease. During the postoperative period, visitors could inadvertently bring in infectious agents to the client. Telling the family to cover their mouths and noses when coughing and sneezing does not decrease postoperative infection risks as much as hand washing would impact the client. Fresh flowers and fruit are restricted for neutropenia clients. Isolation gowns would not be necessary in a noninfected postoperative client.

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report.

During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which activity should the nurse perform related to documentation?

Include the time and date of the incident in the report. When completing an incident report, the nurse should include the date and time of the incident, the events leading up to it, the client's response, and a full nursing assessment. To control the risk of litigation, the nurse should not highlight the mistake in the client record or attach a copy of the incident report. Because the report is a legal document, it should not contain the name of the nursing assistant.

The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket?

The client is at risk for injury from fighting the restraints. A full-length restraint blanket is added when the client is at risk for injury from fighting the restraints. The increased degree of restriction is justified only when the risk of client injury increases. Feeling more secure is not a sufficient cause for using a more restrictive measure. Client statements that restraints are tight and uncomfortable require the nurse to assess the situation and adjust the restraints if necessary to ensure adequate circulation. Four-way restraints already provide adequate protection for the staff.

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask?

"Are you going to hurt yourself?" The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to cope with the voices and to assess the client's impulse control. The nurse's assessment will then determine the course of action to take regarding the client's safety. Asking when the client hears the voices and how long the client has heard them is important but not as important as determining whether the client will act on what the voices are saying. Asking, "Why are the voices starting again?" would be inappropriate because the client may not know why and may not be able to answer the nurse.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first?

Institute droplet precautions. The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.