UWorld Fundamentals: Safety/Infection Control

Precautions for Middle East Respiratory Syndrome (MERS)?

- Standard, contact, and airborne precautions with eye protection should be used when caring for a client with suspected or diagnosed Middle East respiratory syndrome - Middle East Respiratory Syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms include fever, cough, and SOB that often worsen and cause death.

Nursing actions to assist a falling client during ambulation?

- Step slightly behind the client with feet wide apart and knees bent - Place arms under the axillae or around the client's waist - Place one leg behind the other and extend the front leg - Let the client sit down and extend leg to the floor

PPE for droplet precautions? (Neisseria meningitidis, Haemophilus influenzae type B, Diphtheria, Mumps, Rubella, Pertussis, Group A Streptococcus (strep throat), Viral influenza)

- Surgical mask for routine care, such as assessment or medication administration - If there is risk of contact with bodily fluids during procedures (eg, wound care, suctioning) --> gloves, gown, and face shield

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia? 1. Fully inflate the cuff before feeding 2. Have the client sit in an upright position with the neck hyperextended 3. Partially or fully deflate the cuff 4. Provide a modified diet of pureed foods

- The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs.

Varicella-zoster virus (ie, chickenpox, shingles) precautions:

- Transmitted through airborne particles or contact with open vesicles - Airborne isolation (N95 particulate respirator mask, room with negative air pressure) - Contact Isolation (gown, gloves, disposable equipment) - Pregnant healthcare workers should not be exposed to clients with TORCH (Toxoplasmosis, Other [VZV/Parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus)

Transporting a client with tuberculosis to the radiology department for a chest x-ray, which PPE to use?

- While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect healthcare workers and other clients from respiratory secretions. - The CDC recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious an does not require protection from inhaled air.

Who is at risk for nosocomial infections?

- Young children - Elderly - Immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions

fall prevention for older client in long-term care?

- exercise programs - good lighting - handrails - hourly staff rounds - non-slip rubber-soled shoes

Infection control measures for Clostridium difficile colitis?

- strict contact precautions - gown and gloves at all times - alcohol cannot kill C diff spores, so caregivers must use soap and water in place of alcohol-based hand sanitizers - contaminated surfaces and equipment should be disinfected using a diluted bleach solution - the nurse should NOT wear a mask solely to avoid the unpleasant order as this may be offensive and embarrassing to the client

Which of the following drug administrations should be reported as a practice error? Select all that apply. 1. Cephalexin administered; client has a hx 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: Do not administer warfarin if the client is pregnant. IM injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have cross-sensitivity response. Narcotic-induced pruritus is not a true allergy.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply. 1. 38-year-old with methicillin-resistant Staphylococcus aureus 2. 42-year-old with Clostridium difficile diarrhea 3. 69-year-old with pertussis infection 4. 72-year-old with vancomycin-resistant Enterococcus 5.80-year-old with influenza

1,2,4 - Clients with multidrug-resistant organisms (MRSA, VRE), C difficile diarrhea, and scabies require nursing staff to implement contact precautions.

The nurse on the IV therapy team is making rounds in the intensive care unit 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 lien 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 intensive care unit 72 hours ago

1. Femoral central venous catheters may be placed in emergency situations but should be removed/replaces asap due to the high risk of contamination and infection - central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize the risk of infection - (option 2) preferred site and inserted in OR where surgical asepsis is easily accomplished - (option 3) PICC lines can be left in for weeks or months - (option 4) preferred site; redness at suture site not insertion site

How to don PPE?

1. Hand hygiene 2. Gown 3. Mask or respirator 4. Goggles or face shield 5. Gloves

The nurse is forming a plan of care for an 82-year-old client with a history of anxiety, hypertension, urinary incontinence, and arthritic back pain. Which nursing diagnosis should be addressed first? 1. anxiety 2. chronic pain 3. r/f acute confusion 4. risk for falls

4. Risk for falls is an immediate safety concern - (option 3) a client with advanced age in an unfamiliar environment may develop acute confusion during the hospital course, but a high fall risk is a more immediate concern on admission.

Alcohol poisoning in children?

Because children's bodies absorb alcohol quickly, the symptoms of alcohol poisoning can occur within 30 mins or less after consumption. Clinical indications include confusion, vomiting and seizures, difficulty breathing, flushed or pale skin, and coma secondary to low blood sugar.

Nursing care when caring for an unconscious client during admission?

Check for: - Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status - Contact lenses: Remove to prevent corneal injury - Medication patches: to prevent drug interactions and determine conditions currently being treated (don't remove without consulting HCP first) - Tampons: Remove to prevent toxic shock syndrome - Jewelry: Remove to prevent constrictive injury or vascular damage if edema develops

MRI is contraindicated in?

Clients with: - Aneurysm clips - Metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel - The large magnet of an MRI can damage implantable devices or interfere with function - MRI is a noninvasive test that does not require anesthesia

Reducing infection for MRSA patients?

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. Bathing clients in this way can significantly reduce MRSA infection.

Nursing intervention when an internal radiation implant has been dislodged?

If an internal radiation implant has dislodged, the nurse should use long-handled forceps to place it in a lead-lined container to contain radiation exposure.

How to flush central venous catheter (CVC)?

Most CVC's require intravenous heparin flushes to maintain patency and prevent clotting. Single-dose vials of 2-3 mL of 10 units/mL or 100 units/mL are the standard of care. A dose of 1000-10,000 units is given for cases of thromboembolism.

Intervention for elderly client with delirium and agitation to promote safety?

One-on-one supervision from a sitter

Precautions for active shingles?

The client with open lesions from a herpes virus infection, such as shingles or chicken pox, will require both contact and airborne precautions and a private room with negative airflow.

Nursing care for clients with cellulitis?

- Affected extremity is elevated to reduce edema and promote lymphatic drainage - Applying warm compresses to promote circulation to the area of infection, alleviate discomfort - Monitoring the size of the cellulitis - Using PPE to prevent infection transmission

Nursing care for restraint clients?

- Assess skin integrity and neurovascular status of restrained extremities (gauze to pad bony prominences) - Determine the need for continued use - Supine position is avoided to decrease aspiration risk - Quick-release knots (NOT square nots) are used to attach restraints to parts of the bed frame that move with bed position changes

Precautions to prevent aspiration in the client receiving continuous tube feeding?

- Assessing for gastric intolerance (ie, residual, distention) every 4 hours - Keeping the head of the bed at >30 degrees - Using sedation cautiously - Regular assessment of tube placement - If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and suction appropriately

To reduce catheter-related infections from peripheral IV catheters?

- Clean site with chlorhexidine in a back-and-forth motion using friction and allowing it to dry completely - Catheter hub is secured with a sterile, semipermeable dressing - Access ports are cleaned with alcohol swabs prior to use - Peripheral IV catheters should not be removed or replaced more frequently than every 72-96 hours unless signs of complications (eg, infiltration, infection, phlebitis) occur.

Fall risk precautions?

- Client near nurses' station - Bedside commode by the client's stronger side - Applying nonslip socks - Using a bed alarm

Clostridium difficile precautions?

- Contact isolation precautions - Single-client room assignment if available - Disposable gowns and clean gloves - Hand hygiene with soap and water - Surgical masks are not necessary unless perform client care with the possibility of body fluid splashing

Precautions for MRSA?

- Contact precautions including standard precaution measures in addition to use of a gown and gloves and single-client-use equipment

Nursing actions when preparing a client for surgery?

- Ensure informed consent has taken place and documents are in chart - Witnesses that the correct operative site is marked and verified by the client - Ensure client NPO and voids prior to surgery - If an IV line has not been started, 18-gauge preferred but 20-gauge is acceptable.

Preventing falls at home?

- Exercising regularly - Getting regular vision exams - Maintaining a well-lit, clutter-free environment - Grab bars in the bathroom - Periodically reviewing meds with HCP - Wearing an electronic fall alert device - Wearing shoes or slippers with non-skid soles, both inside and outside the home

Interventions to reduce falls in high-risk clients?

- Hourly rounding - Moving the client to a room close to the nurses' station - Using bed alarms

Interventions to reduce falling when using axillary crutches at home?

- Looking forward when walking - Maintaining a clutter-free environment - Resting crutches upside down on the axilla pads when not in use - Using a small bag to hold personal items - Wearing sturdy rubber-soled shoes - Keeping crutches in good repair

Active pulmonary TB precautions?

- N95 respirator or powered air-purifying respirator - Negative-pressure isolation room with high-efficiency particulate air filter - As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield

Who is at risk for developing hospital-acquired MRSA?

- Older adults - Suppressed immunity - Long history of antibiotic use - Invasive tubes or lines - In the ICU

What is the Romberg test?

- Part of focused neuro exam - Client with positive Romberg test has a loss of sense of self in space and needs assistance with ambulation to prevent injury and provide safety

Suicide precautions?

- Raising upper side rails - Placing padding on the side rails - Preparing bedside suction and oxygen equipment

What is Meniere disease?

- Results from excess fluid accumulation in the inner ear - Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness - Vertigo can be severe and is associated with N/V. Clients report being pulled to the ground

Who is at risk for falls?

- Using assistive ambulatory devices - Orthostasis - Positive orthostatic vital signs (eg, rise in pulse of >20/min) indicate increased risk of syncope and falls - Taking sedatives or antiparkinson medications - Being age >65-70

Infection control procedures for changing a dressing in home care setting?

- Washing the hands before and after gloving - Opening sterile supplies carefully to avoid contamination - Placing old dressings inside a glove or plastic bag before disposal in the household trash

What is an adverse event that requires an incident/event/irregular occurrence/variance report?

-Injury to a client caused by medical management rather than a client's underlying condition - Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) - Treatment (error in performance of procedure, treatment, dose; avoidable delay) - Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) - Other (failure of communication, equipment failure, system failure)

Contraindications for MRI? 1. Aneurysm clip 2. Cardiac pacemaker 3. Colostomy 4. Retained metal foreign bod in eye 5. Transdermal testosterone patch

1, 2, 4 Contraindications include: - Implanted devices (eg, pacemaker, implantable cardioverter defibrillator, medication ports) - Certain metal implants (eg, plates, pins, brain aneurysm clips, joint protheses) - Presence of a retained metal foreign body

Which situations would require the nurse to obtain a prescription for physical restraints? Select all that apply. 1. Belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest 2. Elbow restraints used temporarily for a toddler while drawing blood 3. Full padded side rails in the raised position for a client during a seizure 4. Long leg immobilizer used for a client with a fractured tibia 5. Soft ankle restraint to prevent bleeding at the femoral site following cardiac catherization

1, 5 - (option 1) considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily - (option 2) elbow restraints used as a protective device to temporarily immobilize a child (<30 mins) to perform a medical or surgical procedure are not considered a physical restraint - (option 3) protects client from immediate injury; not considered a restraint - (option 4) prescribed for therapeutic purposes and is not considered a restraint - (option 5) Following a procedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently

Steps for preparing the sterile field for a wet-to-damp dressing change?

1. Perform hand hygiene 2. Open a sterile gauze package with ungloved hands 3. Hold the inverted opened gauze package 6" above the sterile field 4. Place the sterile gauze dressing more than 1" from the edge of the sterile field 5. Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits)

Removal of PPE for client on both contact and airborne precautions?

1. Place the call light within the client's reach and ensure the client's bed is locked and in the lowest position. 2. Remove the gown and gloves (ie, contact isolation PPE) in order of most to least contaminated. The nurse can remove gloves and then gown, or alternately, gown and gloves together. 3. Discard the gown and gloves and then perform hand hygiene. 4. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway. 5. Remove and discard the N95 respirator mask and perform final hand hygiene.

Steps nurse should take in needle stick?

1. Remove gloves 2. Wash the area 3. Report the incident to the facility exposure office 4. Proceed to employee health for baseline blood draw 5. Possible postexposure prophylaxis

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. 1. Ensuring the client wears an N95 respirator at all times 2. Keeping the door of the client's room closed at all times 3. Maintaining a log of everyone in and out of the client's room 4. Removing both pairs of gloves before removing gown and mask 5. Restricting visitors from entering the client's room

2, 3, 5. Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict PPE use, restriction of visitors, and a log of individuals who enter and exit the room. - The PPE removal process requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last.

A comatose client in the ICU has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated UTI's? SATA 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: Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene, cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag, an using sterile technique when collecting urine specimens, ensure each client has a separate, clean container. - (option 1) perineal hygiene using soap and water only every shift and PRN. - (option 2) routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention.

The ED nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? 1. 4-year-old diagnoses 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 wound on inner aspect of thigh with a positive culture for methicillin-resistant Staphylococcus aureus

2. Airborne infections (eg, measles, tuberculosis, varicella) are spread by air currents and are among the most contagious of diseases. - (option 1) clients with scabies = contact isolation - (option 3) clients with influenza = droplet precautions - (option 4) clients with MRSA = contact precautions

A nurse is caring for a homeless client who is 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 hand 3. Dorsum of foot 4. Lateral surface of wrist

2. Peripheral IV sites should be selected in the hand or forearm to reduce the risk of catheter-related bloodstream infections. Sites on the upper extremities located at flexion sites (eg, wrist, bend of arm) and the lower extremities should be avoided. - (option 1) the antecubital fossa (AC) is commonly selected in emergency situations due to its size and ease of cannulation but its problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. - (option 3) the foot is not typically accessed in adults without a specific health care provider prescription. Occasionally used in emergency situations; however, veins in the legs and feet may have decreased venous return, and complications can lead to DVT - (option 4) the radial vein is present on the lateral side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1. Ask the client to explain the bruises on the torso 2. Assess the client's general hygiene and nutritional status 3. Report the bruises to the client's HCP 4. Talk to the client's child about the injuries

2. When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

Impetigo is no longer contagious after how many hrs of antibiotics?

24 hours

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. SATA 1. Discard the first 6-10 mL of blood drawn from the line 2. Flush the line with sterile normal saline 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 - (option 1) when drawing 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 infection - (option 2) flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. but it will not prevent infection transmission.

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply. 1. Flushing the line before and after each medication use 2. Pausing the peripheral nutrition prior to drawing blood from a different port 3. Reinforcing a torn peripherally inserted central catheter line dressing with tape 4. Scrubbing the port with alcohol for 5 seconds before use 5. Taking the client's blood pressure in the left arm

3,4 -(option 1) Line should be flushed before and after med - (option 2) All infusing meds (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels - (option 3) Dressings that no longer occlude the insertion site must be changed immediately - (option 4) scrub for 10-15 seconds - (option 5) BP and venipuncture should not be performed on the affected arm

A client who was placed in restraints appear in the hallway an hour later and states, "I'm Houdini... I can get out of anything. There could be trouble now." Which of the following is the best response to this client? 1. "How are you feeling now?" 2. "How did you manage to get out of restraints?" 3. Say nothing but signal to other staff that assistance is needed 4. "What kind of trouble are you thinking about?"

4. In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. The client statement has multiple possible meanings. Seeking clarification is a therapeutic communication technique that will help the nurse determine the next steps.

Highest priority for a private room assignment? 1. Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C 2. Client with COPD who has a latent TB infection 3. Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis 4. Client with pneumonia who has a positive MRSA culture

4. The CDC recommends contact precautions and private room placement for a client who is colonized with MRSA, esp if the client can transmit the bacteria through body secretions or excretions. - A client with a + nose swab for MRSA is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at inc risk for infection with MRSA; if signs (fever, wound drainage, purulent mucus) are present, treatment is required. - (option 1 and 3) CDC recommends standard precautions for clients with hepatitis C and those who are HIV +. - (option 2) Client with latent TB infection has a + TB skin test, has no symptoms of infection, and is not contagious.

Priority for a nurse to do before client leaves the building AMA? 1. Insist the client to 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. When a client leaves against medical advice (AMA) it should be an informed refusal. The nurse should inform the health care provider immediately. The most important action is for the nurse to remove the IV catheter prior to discharge. A client cannot be held against his/her will if the client refuses to sign an AMA.

Transfer method for pt who has generalized weakness and is unable to follow instructions?

A client who can bear weight partially but is unable to cooperate with instructions requires a full-body sling with mechanical lift and 2 caregivers for safe transfer.

What to tell parent when child accidentally ingests amitriptyline?

Amitriptyline is a tricyclic antidepressant (TCA) that can cause toxic cardiac and neurological effects in children, even in small doses. Children who have accidentally ingested TCAs should be evaluated immediately in an ED.

How to prevent accidental drug overdoses in children?

Keep medicines out of sight, in a locked drawer or cabinet

Client asks if they can take OTC meds with prescriptions?

Nurses should instruct clients to talk with a HCP or pharmacist before taking OTC medications as they may interact with prescription medications of hide symptoms of a serious condition. All medications, herbal products, and supplements taken should be discussed with HCPs.

How to operate fire extinguisher?

P: Pull the pin A: Aim spray at the base of the fire S: Squeeze the level on the handle S: Sweep the spray from side to side

How to reduce falls in the home?

Removing area rugs and installing grab bars in the bathroom

Latex allergy?

Risk factors include swelling, hives, or itching after exposure to common latex-containing products (eg, balloons); certain food allergies (eg, banana, avocado, tomato); and a history of multiple latex exposures (eg, self-catheterization, multiple surgeries).

Nursing precautions for catheter-associated, vancomycin-resistant enterococcal bacteremia?

The client with multidrug-resistant organisms (MRSA or VRE) infections, C difficile diarrhea, or scabies will require institution of contact precautions such as good hand hygiene n entry and exit of the client's room, gloves on entry, and a gown for direct client care. The client's room should have dedicated equipment, and the door should have a sign informing visitors about these precautions.

Confused clients 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?

The least restrictive device or method to keep a client from interfering with medical treatment should always be tried first, before applying a physical restraint. Concealing the IV site and tubing by wrapping the forearm in gauze an elastic stockinette can be effective in keeping a confused client from pulling at the IV line.

How to prevent bed bugs in school?

The most important measures to prevent bed bugs from getting onto apparel is to launder clothes in hot water, dry them using the highest temperature setting on a dryer, and then store them in tightly sealed plastic bags. This will help to prevent additional bed bug infestation and transportation to other locations.

Nursing priorities when implementing a chemical contamination emergency response?

The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. PPE should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered.

Client's family member refuses to leave room while client is being resuscitated?

The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

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?

The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles requires for rolling over do not develop until age 4-5 months. The nurse has a duty to report suspected child maltreatment to the appropriate authorities as required by law.

Accidental ingestion of poisonous substance in children?

When a child accidentally ingests a poisonous substance, it is most important to assess the child's condition, including physical s/s, mental status, and behavior. Based on the condition of the child, the nurse can provide guidance and instructions to contact the appropriate agency (eg, ED, poison control services).

Most appropriate method for transferring 450 lb client 2 days after bariatric surgery (pt is cooperate, pleasant, able to fully bear weight)? 1. 1-person safety standby with walker 2. 2-person full-body sling lift 3. 2-person standing-assist lift 4. 4-person full-body sling lift

When determining most appropriate method, assess 1) whether the client can bear weight 2) whether the client is cooperative - A client who is able to fully bear weight and cooperate can transfer independently with standby assistance for safety.

How to sit and stand using crutches?

When standing or sitting in a chair, clients with crutches should hold both crutches in the hand on the affected side and hold the armrest with the other hand for support. Clients should touch the back of the unaffected leg to the chair before sitting, and should move to the chair edge and rise up with the unaffected leg to stand.