Safety and infection control - Client needs

A young adult was told that he had a significant reaction to the Mantoux test. The client asks the nurse what is the meaning of this significant reaction. How does the nurse appropriately respond?

"You have been exposed to tuberculosis." A reaction to the Mantoux test for tuberculosis means that the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction doesn't mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.

A nurse finds a suicidal client trying to hang themself with a belt. In order to preserve self-esteem and safety, what action should the nurse take?

Assign a nursing staff member to remain with the client at all times. Implementing a one-to-one, staff-to-client ratio is the nurse's highest priority. Doing so allows the client to maintain self-esteem and keep them safe. Seclusion would damage the client's self-esteem. Forcing the client to stay with the group and refusing to let the client in a private room will not guarantee safety.

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?

Hold the medication and report the information to the physician to ensure client safety. The nurse should report the information to the physician because the client's safety may be endangered. The nurse shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

A nurse is reinforcing education with parents on how to reduce the spread of impetigo. What should the nurse encourage the parents to do?

Teach children the importance of proper hand washing. The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing will not prevent its spread. Currently, no vaccine exists to prevent a child from contracting impetigo. Isolating a child with impetigo is unnecessary.

The nurse is preparing to administer an injection from an ampoule. To avoid injury, how should the nurse open the ampoule?

Using a pad, break ampoule away from the body. Using a pad and breaking the ampoule away from the nurse protects the nurse from cutting from the sharp edge of the broken ampoule. Gloves are thin and can easily be cut by a broken glass. Using a syringe without a needle puts the nurse's fingers in direct contact with the broken glass. Asking the technician to open the ampoule without the proper technique puts the technician at risk of injury.

A client received chemotherapy 24 hours ago. Which intervention is the priority to include in the plan of care?

Wear personal protective equipment when handling blood, body fluids, or feces. Chemotherapy drugs are present in the client's waste and body fluids for 48 hours after administration. The priority in this scenario is to prevent the nurse from exposure to the chemotherapeutic agent. The nurse should wear personal protective equipment, including a face shield, gown, and gloves when exposure to blood, body fluid, or feces is likely. Gloves alone offer minimal protection against exposure. Placing incontinence pads in a biohazard bag and using a urinal or bedpan would be implemented, but are not the priority as they do not protect the nurse from exposure.

A nurse is caring for a client with an acute head injury and is ready to begin rehabilitation. When transferring the client from the bed to a chair, what should the nurse do to ensure client safety?

lock the brakes on the bed Locking the wheels of the bed (and wheelchair, if one is used) helps to prevent the bed (and chair) from sliding away, thus preventing injuries. The side rail on the side of the bed where the nurse is standing should be lowered to facilitate the transfer. Positioning the chair alongside the bed, rather than 2 feet away, helps the client to pivot into the chair. The nurse should place shoes or slippers with nonskid soles on the client's feet to help prevent slipping during the transfer.

A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition?

orthostatic hypotension The rapid decrease in intra-abdominal pressure occurring after birth causes splanchnic engorgement. The client is at risk for orthostatic hypotension when standing due to the blood pooling in this area. Breast engorgement is caused by vascular congestion in the breast through lactation. The client shouldn't experience separation of the episiotomy incision or chest pain when standing. None of these conditions are risks related to the need to assist the client out of bed.

A student nurse is performing wound care while the instructor observes. Which observation by the instruction requires immediate intervention of the student nurse's action?

pouring solution directly onto a sterile field barrier Pouring solution onto a sterile field barrier violates surgical asepsis because moisture penetrating the barrier can carry microorganisms to the sterile field via capillary action. The other practices help ensure surgical asepsis.

The nursing team is caring for clients on a clinical unit when the fire alarm sounds. Which nurse on the team acts most appropriately to contain a fire?

the nurse who closes all the inside doors Closing doors helps keep the fire confined to its location of origin and slows or prevents its spread into other areas. It is important to assemble with others at the nurses' station to await instructions, but this activity is appropriate only after the environment is secured. Searching for smoke takes valuable time better spent closing doors. Staying with an immobile client is admirable, but nurses have a responsibility to ensure the protection of all clients, not just one who may be difficult to evacuate.