Safety/Infection Control

The nurse cares for a confused client who continues to pull at the IV catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? 1. Apply a gauze wrap and elastic stockinette around the IV site 2. Apply a mitt on the right hand 3. Apply a soft wrist restraint on the right wrist 4. Apply an arm board to the left arm

1 Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? 1. The client has acute urinary retention 2. The client is confused and incontinent 3. The client is elderly and at risk for falls 4. The client is receiving IV diuretics

1 Catheter-associated UTIs are prevalent in hospital settings. Only indwelling urinary catheters should be used when appropriate Appropriate use include the following: -Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients -Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery -During prolonged immobilization when bedrest is essential -To improve end of life comfort -To facilitate healing of an open perineal or sacral wound in incontinent clients Inappropriate uses include: -Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently -For obtaining a urine culture when the client can follow instructions and void voluntarily -Postoperatively for prolonged periods when other appropriate indications are not present

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the HCP before the surgery? 1. "I didnt take the clopidogrel pill for my heart yesterday or today." 2. "I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today." 3. "I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk." 4. "I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead."

1 Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP Option 2: All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems Option 4: NSAIDs should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Tylenol can be taken to control pain up until surgery

The nurse on the IV therapy team is making rounds in the ICU on clients with central venous catheters. Which central line should be removed earliest to prevent infection? 1. Femoral line inserted in ED post cardiac arrest 48 hours ago 2. Internal jugular line inserted 6 days ago in operating room 3. Peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago 4. Subclavian line with slight redness at anchor suture sites inserted in ICU 72 hours ago

1 In adult clients, central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize the risk of infection. Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and is difficult to place an occlusive dressing over these sites. A CVC should be placed where aseptic technique can be applied Option 2: Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the operating room, where surgical asepsis was easily accomplished. The site can be used as long as there is a clinical need and no evidence of infection Option 3: Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter Option 4: The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture sites, it is not located at the insertion site

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer the client? 1. 1-person stand and pivot with gait belt and walker 2. 1-person standby assist with walker 3. 2-person motorized stand-assist lift 4. 2-person stand and pivot with gait belt and walker

1 Option 2: If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance Option 3: This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift Option 4: If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2 person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible

A 2 year old who swallowed an overdose of adult cough syrup is being discharged from the ED. The parent says to the nurse, "from now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? 1. "Can you lock your dresser drawer?" 2. "Make sure all of your medicines have childproof caps." 3. "That sounds like a safe plan." 4. "You need to keep an eye on your child at all times."

1 The best preventative measures include placing all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting them away after each use

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply 1. Don gown, gloves, and N95 respirator when entering the client's room 2. Ensure that pregnant staff members are not assigned to care for this client 3. Place single-use, disposable thermometer and stethoscope in the room 4. Place the client is a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted

1, 2, 3, 4, 5 Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus, which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both AIRBORNE ISOLATION (N95 mask and negative pressure room) and CONTACT ISOLATION (gown, gloves, disposable equipment) Option 5: Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued

The nurse is caring for a client with bacterial meningitis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply 1. Disposable gown 2. Face shield 3. Gloves 4. N95 respirator 5. Surgical mask

1, 2, 3, 5 Bacterial meningitis and many respiratory illnesses (influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet away from the client. Droplet precautions for routine care (med admin) require the use of a SURGICAL MASK, as the highest risk of transmission is through inhalation of droplets Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (suctioning, wound care). Dedicated medical equipment (stethoscope, blood pressure cuff) should remain the room

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The HCP prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply 1. Apply pads to the side rails 2. Have oxygen supplementation available 3. Prepare to insert a urinary catheter 4. Remove all linen from the bed 5. Set up bedside suction equipment

1, 2, 5 During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen are set up at the bedside

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply 1. Keep dedicated equipment for client 2. Perform hand hygiene before exiting the room 3. Place a "No Visitors" sign on the client's door 4. Wear a face mask when in the room 5. Wear an isolation gown when providing direct care

1, 2, 5 In addition to standard precautions, the client infected with multidrug-resistant organisms (vancomycin-resistant enterococci or methicillin-resistant staphylococcus aureus MRSA), C. diff, and scabies will require contact precautions that include: -Place client in a private room (preferred) or semi-private room with another client with the same infection -Dedicate equipment for client -Wear gloves when entering the room -Perform excellent hand hygiene before exiting the room -Wear gown with client contact and remove it before leaving the room -Place door notice for visitors -Ensure client leaves the room only for essential clinical reasons (tests, procedures)

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore NG tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply 1. Assess abdominal distension every 4 hours 2. Check gastric residual every 12 hours 3. Keep head of the bed at >30 degrees 4. Maintain endotracheal cuff pressure 5. Use caution when administering sedatives

1, 3, 4, 5 Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: -Assess for GI intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus -Assess feeding tube placement at regular intervals -Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H2O) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents -Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary -Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex -Avoid bolus tube feedings for clients at high risk for aspiration

Which of the following drug administrations should be reported as a practice error? Select all that apply 1. Cephalexin administered; client has history of anaphylaxis from penicillin 2. Hydromorphone 2 mg administered; client reports pruritus 3. Immunization for 3 month old administered in ventrogluteal site 4. Oral niacin (nicotinic acid) administered; client has facial flushing 5. Warfarin administered; client at 12 weeks gestation

1, 3, 5 Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site

The nurse removes PPE after completing a wound dressing change for a client in airborne precautions. Which PPE should the nurse remove first? 1. Face shield/goggles 2. Gloves 3. Gown 4. Mask/respirator

2 A gown is not normally required in an airborne precaution room; however, if contamination is probable (dressing change, contact with bodily fluids), a gown is necessary. Gloves should be removed first To remove gloves, grasp the first glove by its palmar surface and pull off inside out. Next, slide fingers of the ungloved hand under the second glove at the wrist and peel off over the first glove

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? 1. Antecubital fossa 2. Dorsal surface of the hand 3. Dorsum of foot 4. Lateral surface of wrist

2 Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed

The ED nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? 1. 4-year old diagnosed with scabies who has red burrows and bumps along the neckline and inner elbows 2. 7 year old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash 3. 12 year old with a positive rapid influenza test who has a fever, cough, and runny nose 4. 14 year old with 4 inch would on inner aspect of thigh with a positive culture for MRSA

2 Infectious agents that are spread by air currents are among the most contagious of pathogens. Therefore, clients with AIRBORNE INFECTIONS (measles, TB, varicella, severe acute respiratory syndrome) should be isolated first using airborne precautions. Option 1: Clients with scabies will be placed in contact isolation Option 3: Clients with flu are placed on droplet precautions Option 4: Clients with MRSA are placed on contact precautions

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? 1. A private room with contact and droplet precautions 2. A private room with negative airflow and contact and airborne precautions 3. A private room with positive airflow and airborne precautions 4. A semi-private 2 bedroom with standard precautions

2 Shingles lesions that are open may transmit the infection by BOTH AIR AND CONTACT. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather recirculating to the rest of the hospital. LOCALIZED SHINGLES require only standard precautions for clients with intact immune systems and contained/covered lesions Option 3: Positive airflow would pull fresh air from the outside into the hospital room, and then the air from room would circulate throughout the rest of the hospital.

A female client is admitted to the ED after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply 1. Locate and remove any medication patches 2. Locate possible medical alert band or necklace 3. Remove rings and jewelry and lock in a secure location 4. Remove tampon and replace with menstrual pad 5. Take out contacts if no presence of eye trauma

2, 3, 4, 5 Option 1: Medication patches should not be removed without first consulting the HCP. Clients are often prescribed transdermal patches for chronic conditions (clonidine for HTN, nitroglycerin for angina). Removing and discarding a medication patch without additional info may harm the client

A comatose client in the ICU has an indwelling urinary catheter. Which actions should the nurse implement to reduce the incidence of catheter-associated UTIs? Select all that apply 1. Cleanse periurethral area with antiseptics every shift 2. Ensure each client has a separate container to empty collection bag 3. Keep catheter bag below the level of the bladder 4. Routinely irrigate the catheter with antimicrobial solution 5. Use sterile technique when collecting a urine specimen

2, 3, 5 -Perform routine perineal hygiene with SOAP AND WATER each shift and after bowel movements -Keep drainage system off the floor or contaminated surfaces -Use sterile technique when collecting a urine specimen -Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder -Avoid prolonged kinking, clamping, or obstruction of the catheter tubing -Encourage oral fluid intake in clients who are awake

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? 1. Get the client out of bed and away from the radiation source 2. Manually reinsert the implant and notify the HCP 3. Use long-handled forceps to secure the implant in a lead container 4. Wrap the implant in the linens and place it in a biohazard bag

3 An internal radiation implant (brachytherapy) emits radiation in or near a tumor to treat certain malignancies. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant in case of dislodgment

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC). The nurse should call the primary HCP for clarification prior to implementation when recognizing that which prescription is an error? 1. Administer IV TPN at 50mL/hr 2. Change occlusive central line dressing every 7 days 3. Flush unused lumens of the CVC with 1000 units heparin every 12 hours 4. Use distal port of CVC to monitor central venous pressure (CVP)

3 Most CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct dose. Doses of 2-3 mL containing 10-100 units/mL are the standard of care for flushing a CVC. Doses of 1000-10,000 units are given for cases of venous thromboembolism; therefore, this prescription is an error Option 1: TPN should be administered through a CVC. Because of its viscosity and high glucose, lipids, electrolytes, vitamins and minerals, it is safest when administered through a CVC or peripherally inserted central catheter Option 4: The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. The distal end of the CVC is in reverse as regards the client, therefore the distal end is at the tip of the catheter in the superior vena cava vein, closest to the right atrium of the heart

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? 1. Step behind the client with arms around waist, squat using the quadriceps, and lower client to the floor 2. Step in front of client, brace knees and feet against the client's and assist to the floor gently 3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor 4. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

3 Option 2: These actions are appropriate for helping a client rise from the bed or chair but do not for assisting a falling client to the floor

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? 1. Have the client remove the existing dressing while the nurse prepares sterile supplies 2. Wear clean gloves for removal and application of a new dressing 3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing 4. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

3 The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require STERILE GLOVES AND STERILE DRESSING SUPPLIES.

A 3 month old infant is treated in the ED for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? 1. Document a description of the injury 2. Question the mother about where the infant sleeps 3. Report the injury per facility protocol 4. Separate the mother from the infant

3 The parent's account of this injury is inconsistent with the developmental milestones of a 3 month old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child Fractures in young children, especially nonambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities After reporting suspected maltreatment, the nurse should: -Facilitate a complete physical evaluation -Document facts and observations objectively -Perform a review of child-care practices with the caregiver

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure? Select all that apply 1. Discard the first 6-10mL of blood drawn from the line 2. Flush the line with sterile NS before and after collection 3. Perform hand hygiene 4. Place the specimen in a biohazard bag 5. Scrub the catheter hub with antiseptic prior to use

3, 4, 5 Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards (biohazard bag). This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. Option 1: When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection Option 2: Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? Select all that apply 1. Client is on a calorie-restricted diet for obesity 2. Creatinine is 1.3 mg/dL 3. History of congenital heart disease 4. INR of 2.5 5. Presence of prosthetic valve

3, 4, 5 Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures (dental work). These clients should receive prophylactic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated INR (2.0-3.0) to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply 1. Age of 50 2. Diagnosis of ovarian cancer 3. Lying pulse 80/min, standing pulse 110/min 4. Osteoarthritis of knees 5. Takes carbidopa/levodopa 6. Uses a cane to ambulate

3, 4, 5, 6 Positive orthostatic vital signs (rise in pulse of >20/min) indicate increased risk of syncope

The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply 1. History of angioedema with lisinopril 2. History of epilepsy 3. Known allergy to avocados and bananas 4. Known allergy to shellfish 5. Lip swelling when blowing up balloons

3, 5 Many food allergies (avocado, banana, tomato) increase the risk for latex allergy because the food proteins are similar to those found in latex

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? Select all that apply 1. Attach wrist restraint straps to the upper side rails 2. Position the client supine to keep restraint straps taut 3. Release restraints at regular intervals and assess behavior 4. Use a square knot to tie the restraint straps to the bed 5. Use gauze to pad bony prominences under restraints

3, 5 When caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (every 2 hours): -Provide skin care and range of motion exercises; ensure basic needs are met -Assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints if necessary to protect skin -Determine the need for continued restraint by releasing restraints briefly and assessing the client's reaction; regularly assessing the need for restraints promotes discontinuation as soon as possible Option 2: Supine positioning increases aspiration risk as the client may be unable to self-reposition if vomiting occurs. Side-lying or semi- Fowler position promotes drainage of emesis or oral secretions Option 4: Restraint straps should be tied in a quick-release knot, in case of emergency, and never in a square knot, which is difficult to release quickly

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? 1. 15 year old student athlete in the ED with a fractured femur 2. 46 year old with a large abdominal incision and 2 peripheral IV lines 3. 72 year old who received a permanent pacemaker 24 hours ago 4. 80 year old with COPD who is on a ventilator

4 Clients at highest risk for hospital-acquired MRSA are OLDER ADULTS and those with SUPPRESSED IMMUNITY, LONG HISTORY OF ANTIBIOTIC USE, OR INVASIVE TUBES OR LINES (hemodialysis clients). Clients in the ICU are especially at risk for MRSA. The 80 year old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator Option 1: A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment. MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin integrity Option 2: This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed immunity Option 3: This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery

The nurse caring for a client with TB transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which PPE equipment when out of the negative-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves 2. Isolation gown and surgical mask 3. N95 respirator mask 4. Surgical mask

4 Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne precautions wears a SURGICAL MASK to protect health care workers and other clients from respiratory secretions

The nurse in the ICU is giving the UAP directions for bathing a client who has a surgical incision infected with MRSA. Which instructions would be most effective for reducing infection? 1. Assist the client to the shower and provide directions to use antibacterial soap 2. Delay the bath until the client has received antibiotic therapy for 24 hours 3. Use a bath basin with warm water and a new wash cloth for each body area 4. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client

4 Current evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? 1. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." 2. I should concentrate on alleviating scratching as it can cause further complications." 3. "My other family members and pets are at risk of bed bug bites." 4. "This must have happened because I did not wash the bed sheets this week."

4 It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children Option 1: It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs

A client with acute ST elevation MI intends to leave the hospital now against medical advice regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building? 1. Insist the client sign the AMA form 2. Provide the client with a copy of hospital results 3. Reassure that the client can return later 4. Remove the IV catheter

4 It is most important that the client's IV catheter be removed to prevent complications (infections) and misuse (access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter Option 1: The goal is for the client to always have an informed refusal and to sign the legal form to indicate understanding of that information. However, if the client refuses to sign, the client is still allowed to leave. The nurse should have witnesses to the events and clearly document in the chart what happened and that the client refused to sign

The nurse prepares to care for a client being admitted with a confined diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client? 1. Gloves and gown 2. Gloves and mask 3. Gown and N95 respirator 4. Gown, gloves, N95, and eye protection

4 Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus. Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the CDC recommends the use of STANDARD, CONTACT, AND AIRBORNE PRECAUTIONS WITH EYE PROTECTION

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with UTI. To promote client safety, which intervention is most important for the charge nurse to implement? 1. A bed near the nursing station 2. Four-point leather restraints 3. Minimizing environmental stimuli 4. One on one supervision from a sitter

4 One on one supervision provided by a trained staff member who stays with the client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Option 1: Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self or others

The HCP writes a prescription for hydromorphone 10 mg IV push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1mg every 2-3 hours prn. What action should the nurse initially take? 1. Administer the medication and monitor client frequently 2. Ask a nursing colleague if this drug amount is used 3. Check hydromorphone dose that the client had previously 4. Question the prescription with the prescriber

4 The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a dose that is too high given that the typical maximum dose is 2mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically Option 3: Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned

A student nurse prepares to change a large wet to damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action? 1. Holds the package 6 inches above the sterile field and drops the sterile gauze onto the field 2. Opens the sterile gauze package with ungloved hands 3. Places the sterile gauze dressing within 2 inches from the edge of the sterile drape 4. Pours sterile normal saline solution into a sterile basin from a bottle opened 30 hours ago

4 The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions' policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened >24 hours ago