SAFETY AND INFECTION CONTROL
While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action? Report the error and request a private meeting with the unit manager. Contact the physician and follow their instructions. Administer the medication immediately and chart it as given on time. Report the error, complete the proper paperwork, and meet with the unit manager.
Report the error, complete the proper paperwork, and meet with the unit manager. Explanation: Making an error can be very stressful and a nurse may feel great pressure to hide the mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, the nurse must still report the error and complete the proper paperwork. The nurse should contact the physician and follow their instructions, but shouldn't bypass proper protocol.
A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager? Ask the nurse whether the client refused the assessments. Review the nurse's malpractice insurance policy. Address the nurse's omissions as negligent behavior. Reprimand the nurse for being forgetful.
Address the nurse's omissions as negligent behavior. Explanation: Negligence refers to careless acts on the part of an individual who is not exercising reasonable or prudent judgment. It also refers to the failure to do something that a reasonable person (another nurse) would do.
An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next?
Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities The nurse should immediately compare the information on the mother's identification band with that of the neonate's and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.
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 Talking with the client's family about his angry feelings Performing an assessment for tardive dyskinesia Learning to effectively express needs to staff and others
Demonstrating control over aggressive behavior Explanation: The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting. A discussion of angry feelings with the family can occur at a later time. Performing an assessment for tardive dyskinesia isn't a priority in the situation described. If the client were taking neuroleptic medication, a baseline assessment for tardive dyskinesia would already have been performed. The client's learning of effective communication and coping skills is a later goal, but not of primary importance.
A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate? Teach rules of the road for bicycle safety. Always make the toddler wear a seat belt when riding in a car. Make sure all medications are kept in containers with childproof safety caps. Never leave a toddler unattended on a bed.
Make sure all medications are kept in containers with childproof safety caps. Explanation: Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline, because poisoning accidents are common with toddlers owing to the child's curiosity, increasing mobility, and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not restrained by a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a health care provider's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers should not be allowed in the road unsupervised.
A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics? The nurse keeps feet as close together as possible. The nurse keeps knees straight and stiff and bends at the waist. The nurse uses a rocking motion while helping the client to stand. The nurse stands an arm's length away from the client.
The nurse uses a rocking motion while helping the client to stand. Explanation: 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.
An infection control nurse is reviewing the care of a client diagnosed with Clostridium difficile infection. The nurse determines that the staff is adhering to appropriate infection control precautions based on implementation of which measure?
contact precautions For a client with Clostridium difficile infection, it is imperative to institute contact precautions for the duration of the illness when providing care to the client to minimize the risk of disease transmission. Airborne precautions would be used for a client with an infection, such as tuberculosis, that is transmitted by small droplets that can remain suspended and widely dispersed by air currents. Droplet precautions would be used for a client with an infection, such as diphtheria or rubella, that is transmitted by large-particle droplets that are dispersed into air currents. Protective precautions would be used for a client with compromised immunity as evidenced by a significantly reduced neutrophil count, such as from chemotherapy or immunosuppressive agents.
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? notifying the proper authorities after saying nothing until the client has actually completed the call explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP) warning the client that his telephone privileges will be taken away if he abuses them offering to disregard the client's plan if he does not go through with it
explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP) Explanation: The priority is to explain to the client that this information has to be shared immediately with the staff and the HCP because of its serious nature. Safety of all is crucial regardless of whether the client follows through on his plan. It is possible that the client is asking to be stopped and that he is indirectly pleading for help in a dysfunctional manner. Bargaining with the client, such as warning him that his telephone privileges will be taken away if he abuses them, or offering to disregard his plan if he does not go through with it, is inappropriate. Saying nothing to anyone until the client has actually completed the call and then notifying the proper authorities represent serious negligence on the part of the nurse.
A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which problem?
fainting Explanation: Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower.
A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which problem? hygiene needs fainting diuresis fatigue
fainting Explanation: Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower.
The nurse is caring for a preschooler. Which technique will the nurse apply as most effective in preventing hospital-acquired infections in this population? hand hygiene personal protective equipment disinfection of environmental surfaces private hospital room
hand hygiene Explanation: Hand hygiene is the single most important measure for preventing infection transmission. Personal protective equipment and using infection-control precautions are required for certain diseases, such as varicella, diphtheria, mumps, pertussis, measles, and meningitis. A private room provides protection for high-risk clients and privacy for family members. When applicable, disinfecting medical equipment and surfaces is important to prevent infection transmission, and non-medical surfaces should be cleaned of visible dirt, but disinfection is not as universally important as hand hygiene.