Safety and Infection Control

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches?

"After advancing both crutches the length of one step, move your 'good' leg forward."

When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which restraint system would be safest?

A rear-facing infant safety seat in the middle of the back seat

A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?

Apply cool water to the burned area.

A cloth chest restraint has been presecribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols.

A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?

I.V. tubing with a volume-control chamber

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile.

Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)?

Restrict staff and visitors with active infections.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager?

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible.

A client with hepatitis B is visiting with a sibling when the client's I.V. catheter dislodges and bleeds onto the surface of the bedside table. Which action, if observed, would cause the nurse to intervene?

The nursing assistant uses tissue to blot up the blood.

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.

Which client has a greater risk for latex allergies?

a woman who is admitted for her seventh surgery

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain?

compressing it and then plugging it to establish suction

After administering an I.M. injection, a nurse should

discard the uncapped needle and syringe in a puncture-proof container.

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with his prescribed therapy

A nurse is caring for a client with diarrhea caused by Clostridium difficile. Which personal protective equipment should the nurse use? Select all that apply.

gGown gloves

A parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to:

place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum.

Which use of restraints in a school-age child should the nurse question?

to substitute for observation

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action?

wearing of sterile gloves to bathe a neonate at 2 hours of age

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?"

A child who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond?

"Wear gloves when you're likely to come into contact with the child's blood or body fluids."

A nurse is teaching a parent of a toddler diagnosed with conjunctivitis to administer the ophthalmic ointment. Which action by the mother indicates that further instruction is necessary?

The mother holds the eyelids open with her fingers.

The nurse is administering oxycodone for leg pain, as requested by the client. What priorityactions will the nurse implement? Select all that apply.

Verify the healthcare provider's order. Assess the client for allergies. Assess the client's respirations. Identify the client.

The nurse unit manager is making rounds on a team of clients and notices a client with a color-coded armband that indicates the client is at risk for falling walking down the hall unassisted. The client is at the end of the hallway farthest from the client's room, but is not tired. What should the nurse do first?

Walk with the client back to the room, and assist the client to get in bed or a chair.

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

The nurse is reviewing the content of a prescription before giving it to a client. The nurse determines that the prescription is accurately written when which information is included on the prescription? Select all that apply.

dose healthcare provider signature frequency

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

placing the client in respiratory isolation

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:

review the unit's procedure manual.

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care?

Bending and twisting while providing care may cause injury.

The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother?

Complete the hospital identification procedure with mother and infant.

A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute?

airborne precautions

The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?

airborne precautions

The student nurse is admitting an elderly patient with congestive heart failure and sets up the room with standard precautions. Which is noted by the nursing instructor as the best action?

considering all body substances potentially infectious

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

droplet precautions

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus?

droplet precautions

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

every 15 minutes

A parent tells the nurse that the parent's preschool-aged child with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently the child had an allergic reaction after eating kiwi fruit and bananas. Based on the parent's report, the nurse suspects that the child may have an allergy to

latex.

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

A nurse manager is implementing a plan to improve the use of standard precautions by the staff on the unit. After collecting observational data on the staff's use of personal protective equipment, which behavior would the nurse manager identify as an indication of the need for education? Select all that apply.

use of gowns when caring for any client use of sterile gloves for urine specimen collection recapping of needles after use

A nurse is caring for a client following a tonsillectomy and fails to routinely assess the back of the client's throat for signs of bleeding. The nurse manager reviews the client's chart and notices the omission of the assessments. Which is the best response to the nurse regarding the missing assessments?

"Failure to complete these assessments constitutes negligent behavior."

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions."

The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement?

"I cannot wait to get home to my cat!"

A young client develops a fever and rash and is diagnosed with rubella. The client's mother has just given birth to another child. Which statement by the mother best indicates that she understands the implications of rubella?

"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children."

A client diagnosed with schizophrenia for the last 2 years tells the nurse who has brought the morning medications, "That's not my pill! My pill is blue, not green." What should the nurse tell the client?

"I'll go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color."

Which telephone order is written correctly by the nurse?

8/18 2235 gabapentin 800 mg oral twice a day. D. Stark, MD/A. McCollum, RN T.O.R.B.

While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first?

Bathe the neonate.

A school nurse is conducting a seminar for parents of preschool children on the prevention of head injuries. What is the most appropriate information for the nurse to give the parents?

Children should always wear helmets when riding bicycles.

The nurse is preparing to administer an I.V. medication to an unconscious client. What is the best action by the nurse?

Compare the client's ID on the wristband to the medication administration record.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order.

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.

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 is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Increase the frequency of client observation.

The nurse is caring for a 5-year-old child with a femur fracture. The parent explains that the fracture occurred from a fall. The child's recollection of the event conflicts with the parent's explanation. What is the nurse's immediate responsibility?

Keep the child safe, and assess for abuse.

The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response?

Keep the individual on the line in order to gather more information about the details of the threat.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities.

The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse?

Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan.

A school-age child begins to have a seizure while walking to the bathroom after an appendectomy. The nearby staff do not have the child's medical history. What is the nurse's first action?

Position the child on the side.

A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first?

Provide one-to-one supervision of the client until detoxification treatment can begin.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients.

Which topic would be most important to include when teaching the parents how to promote overall toddler development?

Safety is a priority concern for this age group.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?

The client is able to refuse medications.

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions?

The client will show no self-harm or harm to staff.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then

advance both crutches

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the firstpriority of the nurse who witnesses this scene?

calling a security guard and another staff member for assistance

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that

enteric precautions must be continued.

When the nurse is preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain?

padding for the side rails