UWorld Safety and Infection Control

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate order. All options must be used.

1. Assess for presence of adequate pulse 2. Inspect the client for injuries 3. Get help and move the client to the bed 4. Notify the client's health care provider (HCP) 5. Complete an incident report

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 this client 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.

1. 1-person stand and pivot with gait belt and walker Partial 1-person assist stand & pivot transfer with gait belt or motorized assist device if cooperative 2-person assist with full-body sling if client is uncooperative

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used.

1 Hand hygiene 2. Gown 3.Mask or respirator 4. Goggles or face shield 5. Gloves The CDC suggests the following sequence for donning PPE: hand hygiene, gown, mask or respirator, goggles or face shield, and gloves.

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. 72-year-old with vancomycin-resistant Enterococcus Contact precautions include: Placing client in private room (preferred) or cohorting clients with the same infection Using dedicated equipment (must be disinfected when removing from room) Wearing gloves when entering room Perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) Wearing gown with client contact and removing before leaving room Place door notice for visitors Having client leave room only for essential clinical reasons (ie, tests, procedures). If an x-ray is needed, try to arrange for a portable one.

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply.

1. Apply color-coded, nonslip socks to the client's feet 2. Move the client to a room closer to the nurses' station 3. Place a bedside commode to the right of the client 5. Use a bed alarm to alert staff when the client gets up Many falls are associated with bathroom urgency/frequency. Fall risk precautions include placing the client in a room near the nurses' station, placing a bedside commode by the client's stronger side, applying nonslip socks, and using a bed alarm.

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 health care provider prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply. (Option 3) Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a urinary tract infection. (Option 4) It is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions.

1. Apply pads to the side rails 2.Have oxygen supplementation available 5. Set up bedside suction equipment Seizure precautions are safety measures that typically include raising the upper side rails, placing padding on the side rails, and preparing bedside suction and oxygen equipment.

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. (Option 2) Gastric residual should be checked no less than every 4 hours in intubated clients. Assess feeding tube placement at regular intervals

1. Assess abdominal distension every 4 hours 3. Keep head of the bed at ≥30 degrees 4. Maintain endotracheal cuff pressure - Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 4) 5. Use caution when administering sedatives - Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option 5) - Avoid bolus tube feedings for clients at high risk for aspiration

A client who has been prescribed several medications asks, "Can I take over-the-counter (OTC) medications with my prescriptions?" Which of the following statements by the nurse is appropriate? Select all that apply.

1. "Always ask the health care provider or pharmacist before taking OTC medications." 2."Ingredients in some OTC medications may interact with prescription medications." 4."Remember to discuss all medications, herbs, and supplements you take with your health care providers." 5. "Taking OTC medications can sometimes hide symptoms of a serious disease or illness." Nurses should instruct clients to talk with a health care provider (HCP) or pharmacist before taking over-the-counter medications as they may interact with prescription medications or hide symptoms of a serious condition. All medications, herbal products, and supplements taken should be discussed with HCPs.

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. 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? Advising a parent/caregiver to ensure that medicine containers have childproof caps is an appropriate instruction; however, it is not the priority response in this situation.

1. "Can you lock your dresser drawer?" Medications are the leading cause of child poisoning. The best preventive 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 (Option 1).

The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?

1. "Hold a crutch in each hand on both sides when standing up from a chair." When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side (Option 1). The client then uses the crutches, armrest, and unaffected leg for support when rising. To sit, the client backs up to the chair and moves both crutches into the hand on the affected side. The client holds the armrest with the other hand and lowers the body.

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 (removal of gallbladdeR). Which statement made by the client is critical to report to the health care provider (HCP) before the surgery? Medications (eg, anticoagulants, antiplatelets, NSAIDS, herbal drugs) that increase the risk for excessive bleeding should be discontinued at least 5-7 days before surgery.

1. "I didn't take the clopidogrel pill for my heart yesterday or today." 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. The surgery may be postponed due to the increased risk for intra- and post-operative bleeding (Option 1). Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery.

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? A 4-person sling lift transfer is appropriate for the bariatric client who cannot bear weight or cooperate with the transfer.

1. 1-person safety standby with walker ENCOURAGE INDEPENDENCE This client is able to bear full weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety.

Erythema, induration, and warmth are present at the incision with 1-inch margins. Client reports incisional pain rated as 7 on a scale of 0-10. Decreased sensation is noted at wound edges. Purulent discharge and dusky subcutaneous tissue are present. Temperature is 101 F (38.3 C). Serum blood glucose level is 321 mg/dL (17.8 mmol/L). Which 3 interventions should the nurse anticipate next? An abdominal binder reduces the risk of wound dehiscence by providing support and reducing mechanical stress during movement (eg, coughing). This is appropriate after abdominal surgery but does not take priority over infection. Negative-pressure wound therapy (NPWT) (ie, vacuum-assisted wound closure) is a wound-dressing system that uses negative pressure to remove drainage and accelerate the healing process. NPWT is typically reserved for wounds with healthy granulation tissue and is not initially used when the wound is infected or necrotic. Surgical debridement of necrotic tissue should be performed prior to initiating NPWT.

1. Administer broad-spectrum IV antibiotics to treat the source of infection and reduce the risk of sepsis (Option 1) 2 Obtain a prescription for additional insulin to achieve glycemic control because hyperglycemia delays wound healing and can facilitate bacterial growth (Option 4). 3. Prepare the client for urgent surgical debridement to remove the necrotic tissue and promote wound healing (Option 5) Clinical manifestations of a necrotizing surgical site infection include paresthesia at the wound edges, dusky subcutaneous tissue, and intense pain in the wound. Treatment involves prompt administration of broad-spectrum IV antibiotics, glycemic management, and urgent surgical debridement to prevent progressive tissue death and sepsis.

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply. 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. Excessive hair may be clipped but never shaved as shaving may cause microabrasions and potential portals of entry for microorganisms.

1. After insertion, secure the catheter with a sterile, semipermeable dressing 2. Clean ports with an alcohol swab prior to accessing the catheter system 3. Prior to insertion, apply chlorhexidine, using friction, to the venipuncture site To reduce catheter-related infections from peripheral IV catheters, the nurse should clean the site with chlorhexidine in a back-and-forth motion using friction and allow it to dry completely. The catheter hub is secured with a sterile, semipermeable dressing, and access ports are cleaned with alcohol swabs prior to use.

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? Select all that apply. PASS is a mnemonic to help people remember the steps used in operating a fire extinguisher: P - Pull the pin; A - Aim the spray at the base of the fire; S - Squeeze the handle; and S - Sweep the spray.

1. Aim the nozzle at the base of the fire 2.Pull out the pin on the handle 4.Squeeze the handle to spray 5.Sweep the spray from side to side The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher: P - Pull the pin on the handle to release the extinguisher's locking mechanism A - Aim the spray at the base of the fire S - Squeeze the handle to release the contents/extinguishing agent S - Sweep the spray from side to side until the fire is extinguished

A client with suspected foot osteomyelitis is scheduled for an MRI. Which findings should the nurse notify the health care provider about before the test? Select all that apply.

1. Aneurysm clip 2. Cardiac pacemaker 4. Retained metal foreign body in eye Usual contraindications for MRI include implanted devices (eg, pacemaker, implantable cardioverter defibrillator, medication ports), certain metal implants (eg, plates, pins, brain aneurysm clips, joint prostheses), and presence of a retained metal foreign body. However, some of these devices are now manufactured with MRI-safe materials that should be verified.

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? Educational objective: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 (Applying a hand mitt, soft wrist restraint, or arm board)

1. Apply a gauze wrap and elastic stockinette around the IV site A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line.

The nurse is observing client care situations. Which of the following situations would require an order for physical restraints from the health care provider? Select all that apply. An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint. A mummy restraint involves swaddling an infant for temporary immobilization to perform a routine procedure and is not considered a physical restraint. Orthopedic immobilizers and protective devices used temporarily during routine procedures are not considered physical restraints.

1. Belt restraint used for a client with confusion who is on bed rest but continually attempts to get out of the bed - Belt restraints are applied at the waist and tied using a quick-release knot. They are used to protect a confused client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts mobility (Option 1). 5. Soft ankle restraint used to prevent bleeding at the femoral site for a client who had a cardiac catheterization and is drowsy -Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities. 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 (Option 5).

Which of the following drug administrations should be reported as a practice error? Select all that apply What about other types of antibiotics? Tetracyclines (e.g. doxycycline), quinolones (e.g. ciprofloxacin), macrolides (e.g. clarithromycin), aminoglycosides (e.g. gentamicin) and glycopeptides (e.g. vancomycin) are all unrelated to penicillins and are safe to use in the penicillin allergic patient. Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues. Educational objective:

1. Cephalexin administered; client has history of anaphylaxis from penicillin -History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option 1). 2. Immunization for 3-month-old administered in ventrogluteal site - For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option 3). 3. Warfarin administered; client at 12 weeks gestation - 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 (Option 5).

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions. The registered nurse intervenes when the student performs which action? Hand hygiene with an alcohol-based hand rub is recommended, unless there is visible soiling of the hands with body fluids, or after contact with Clostridium difficile. In both situations, hand hygiene must be performed with soap and water to thoroughly remove contaminants left behind by alcohol-based rubs.

1. Cleans the disposable stethoscope with chlorhexidine solution before reuse with a different client Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas. Dedicated equipment should be kept in the room for client care, and then disinfected or discarded when no longer needed (Option 1).

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.

1. Date of birth 2.First and last name 4.Medical record number During medication administration, the nurse identifies "the right client" using information that is permanent and unique to the client. Acceptable identifiers are first and last name, date of birth, and medical record number.

The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound care)..

1. Disinfect surfaces using a diluted bleach solution 4. Wear a protective gown 5.Wear nonsterile gloves Contact precautions for clients with active C difficile infection include: Placing the client in a private room. Disinfecting contaminated surfaces using a sporicidal solution (eg, diluted bleach/hydrogen peroxide) (Option 1). - Wearing a protective gown and gloves when entering the client's room (Options 4 and 5). - Placing signage on the outside of the client's door to indicate that personal protective equipment is required for client care.

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis 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 5.Surgical mask Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option 5). 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 (eg, suctioning, wound care) (Options 1, 2, and 3). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection.

The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used.

1. Place the call light within the client's reach 2. Remove the gown and gloves without contaminating hands 3. Discard the gown and gloves and perform hand hygiene 4. Exit the negative-pressure room and close the door 5. Remove the N95 respirator mask and perform hand hygiene Personal protective equipment should be removed in order from most to least contaminated. The gown and gloves may be removed together. For clients on airborne precautions, the nurse should exit the negative pressure room and close the door before removing the N95 respirator mask. Removing the mask in the room risks exposure to infectious airborne microorganisms.

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. Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities (Option 2).

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 in a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted -Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued (Option 5). Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

A nurse prepares a client for knee arthroscopy requiring general anesthesia. Which actions should the nurse complete? Select all that apply. If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary.

1. Encourage the client to void prior to surgery 2. Ensure that the client has been on NPO status 3. Place signed informed consents in the client's chart 5. Witness that the correct surgery site is marked by the surgeon

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply. Raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails.

1. Ensuring bed alarm remains activated 2.Initiating an hourly rounding schedule 4. Moving client to a room close to the nurses' station - Asking family members or visitors to stay at the bedside with the client 3) Lines, tubes, and drains (eg, indwelling urinary catheter, IV tubing) tether (ie, tie) the client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated (eg, strict hourly output, critical illness), not for the nurse's convenience (eg, clients requiring frequent toileting or incontinence care). The nurse can reduce urinary urgency and incontinence episodes by offering clients toileting with hourly roundin

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.

1. Exercise programs - Falls are a leading predictor of mortality and morbidity in older adults. General exercise programs, especially those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries from falls (Option 1). 2. Good room lighting 3. Handrails in stairwell 5. Staff hourly rounds Non-slip rubber-soled shoes are recommended to prevent falls.

A nurse is caring for a client who is intubated and has a subclavian central venous catheter. Which nursing intervention is most important to prevent the spread of infection to this client?

1. Frequent hand hygiene Hand hygiene is the most important factor in preventing infection transmission. The nurse should perform hand hygiene before and after client contact, before donning and after removing gloves, and after contact with bodily fluids (Option 1). Principles for proper hand hygiene include: ) Personal protective equipment (eg, gloves) is appropriate but is not as important as (and does not replace) hand hygiene to prevent the spread of infection.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.

1. Guide the client to the floor and gently cradle the head 3.Move objects that may cause injury away from the client4 5.Place the client in left lateral position 6.Remain with the client, observe, and record the seizure activity Safety measures implemented during a seizure include positioning the client to protect from injury, maintaining a patent airway, and observing the seizure activity. During the seizure, the nurse does not restrain the client or place objects in the client's mouth.

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control agitation in the client in alcohol withdrawal. (Option 3) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to control violent behavior in the client with schizophrenia. (Option 4) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort.

1. Haloperidol for a client with a fall history who keeps getting out of bed without assistance Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol (Haldol) in this client (Option 1).

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter?

1. Have the client wear a mask Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room.

Needlestick injuries should be reported immediately. If a health care worker is exposed to HIV via blood (eg, needlestick injury), they should

1. Immediately wash the site with soap and water. 2. Screening the client for additional bloodborne pathogens (eg, hepatitis B virus, hepatitis C virus) that could have been transmitted to the health care worker 3. Anticipating initiation of postexposure prophylaxis with antiretroviral therapy as soon as possible. Oral antibiotics are not indicated because HIV is a viral infection. Squeezing the wound tissue is not indicated. Instead, the nurse should allow blood to drain freely from the needlestick injury site. Replacing the cap on used needles is not indicated because this increases the risk of needlestick injuries. The nurse should engage the needle safety device (eg, retract stylet after IV catheter insertion) if present and use a biohazard sharps container to safely dispose of the needle.

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 5. Wear an isolation gown when providing direct care -Wear gown with client contact and remove it before leaving the room (Option 5) ,,

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.

1. Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 2.Pull glove off over the soiled dressing to encase it before disposal 4. 4. Wash hands prior to putting on gloves and after removing them Educational objective:In the home care setting, infection control procedures for changing a dressing include washing the hands before and after gloving, opening sterile supplies carefully to avoid contamination, and placing old dressings inside a glove or plastic bag before disposal in the household trash.

The nurse is providing teaching regarding home oxygen use for a client with emphysema who is using a nasal cannula and portable oxygen tank. Which of the following statements by the client would require follow-up? Select all that apply. Safety precautions for home oxygen use include keeping oxygen at least 5-10 ft (1.5-3.0 m) away from open flames, maintaining the prescribed liter flow, and avoiding flammable/combustible products (eg, wool).

1."I can continue to cook on my gas stove." 2."I can increase the liter flow whenever I feel short of breath." - Maintaining the prescribed liter flow of oxygen. The client should notify the health care provider about increased shortness of breath because additional treatment may be indicated (Option 2). 5. "I should use a wool blanket on my bed instead of cotton." -Avoiding wool fabrics because they can cause static electricity, which may ignite a fire in the presence of oxygen. Clients should use cotton blankets and wear cotton fabrics (Option 5).

PRIORITY - PRECAUTIONS

1st: Airborne 2nd: Droplet 3rd: Contact

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? 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. Sites on the upper extremities located at flexion sites (eg, wrist, bend of arm) and the lower extremities should be avoided

2. Dorsal surface of hand 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 nurse is educating a client recently diagnosed with an anaphylactic allergic reaction to latex. Which statement by the client indicates that the client understood the condition correctly?

2. "I should keep my epinephrine auto-injector pen with me at all times. Clients with an anaphylactic allergic reaction should keep an epinephrine auto-injector pen (eg, EpiPen) with them at all times (Option 2). An intramuscular epinephrine injection into the thigh rapidly counteracts the life-threatening swelling, hypotension, and vasodilation that characterize anaphylaxis. Diphenhydramine (eg, Benadryl) is also given to treat the rash or itching (eg, hives, wheals, urticaria).

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider? Medications that cause increased risk for bleeding include anticoagulants (eg, warfarin, heparin) and antiplatelets (eg, aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole).

2. "I took my prasugrel yesterday morning." Antiplatelet medication (eg, prasugrel, clopidogrel, ticagrelor, dipyridamole) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the health care provider (HCP) that the client is still taking prasugrel and took it the day before surgery (Option 2).

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate? Amitriptyline is a tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as atrioventricular block, hypotension, cardiac arrest, and seizure. An outpatient clinic is not sufficiently staffed or equipped for acute management of amitriptyline toxicity. The nurse should refer the client to the nearest emergency department, which is the safest environment for monitoring and treatment.

2. "Please go directly to the nearest emergency department for evaluation. TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting, are recommended (Option 2).

The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? Clients with methicillin-resistant Staphylococcus aureus infection are placed on contact precautions. The 14-year-old is contagious, but only if direct contact is made. The client requires isolation but is not a priority over the client whose pathogens are airborne. Clients with scabies will be placed in contact isolation. The 4-year-old is contagious, but only if direct contact is made. Therefore, isolating the client with airborne precautions is the priority. Clients with influenza are placed on droplet precautions. The 12-year-old can spread pathogens via large droplets released into the air when coughing, sneezing, or talking. The client would be the second priority for isolation.

2. 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash Infectious agents that are spread via the AIRBORNE ROUTE are among the MOST CONTAGIOUS. Therefore: *Measles, Tuberculosis, Varicella, Herpes zoster/shingles SARS (severe acute respiratory syndrome) should be isolated first among airborne precautions. These clients are placed into a NEGATIVE PRESSURE ROOM with high rates of air exchange or negative particulate filtration systems.

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 clien

2. A private room with negative airflow and contact and airborne precautions 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.

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?

2. Assess the client's general hygiene and nutritional status 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.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance? Select all that apply. The Institute of Medicine (2000) recognizes 4 types of errors. They are: - 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) report? (Option 1) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option 3) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship.

2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine - Option 2 is a treatment error. 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse - Option 4 is a communication error as well as inadequate follow-up. 5.Provider was not notified of client's positive blood culture results -Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client? hemicolectomy is a surgery to remove the part of your large intestine called your colon.

2. Complications, including death, could result Just as there is informed consent, there is informed refusal. The client should be made aware of all the possible complications (including the possible worst-case scenario, which is usually death) when making a decision, and this should be documented. The nurse should try to work with the client to get at least partial compliance when it is in the client's best interest (eg, wear the SCDs for a limited time).

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply ) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria. Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention.

2. Ensure each client has a separate container to empty collection bag 3.Keep catheter bag below the level of the bladder 5. Use sterile technique when collecting a urine specimen 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, and using sterile technique when collecting urine specimens.

A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next? IV infusion pumps display an occlusion alarm when IV solution cannot be infused due to pressure in the line. Common causes of occlusion include clamped or kinked IV tubing, clotting in the IV catheter, and kinking in the IV catheter with extremity movement (eg, elbow, wrist). The nurse should assess the tubing and IV site and flush the IV catheter to check patency.

2. Exchange the IV pump with a different one - In the absence of identifiable occlusion, an alarming IV pump should be exchanged for a different one (Option 2). Malfunctioning equipment may harm the client and should be removed from the care area. The malfunctioning equipment is labeled as out of service and is sent for maintenance. An IV catheter that has no symptoms of occlusion (ie, resistance to flushing) or infiltration (eg, swelling, coolness, pain) does not need to be replaced.

The home health nurse is teaching fall prevention strategies to the family of a client who experienced a stroke. Which of the following would be the most effective method for preventing falls in the home?

2. Install grab bars and glare-free lighting in the bathroom of the home The greatest impact on fall prevention in the home can be made by installing grab bars in the bathroom and adequate glare-free lighting throughout the home, including the bathrooms (Option 2). Many falls occur in bathrooms while clients are toileting or bathing, making grab bars highly beneficial. In addition, poor lighting contributes to falls; adequate glare-free lighting and night lights help compensate for vision changes that may lead to falls.

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. In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). The PPE removal process after caring for a client with Ebola 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.

2. Keeping the door of the client's room closed at all times - Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (Option 2). 3.Maintaining a log of everyone in and out of the client's room - For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (Option 3). 5.Restricting visitors from entering the client's room - -Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option 5).

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply (Option 1) Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client.

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 - Contact lenses: Remove to prevent corneal injury (Option 5)

The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention?

2. Provide for client assistance with ambulation A client with a positive Romberg test has a loss of sense of self in space and needs assistance with ambulation to prevent injury and provide safety.

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider? No povidone-iodine (Betadine) is used during an MRI; gadolinium contrast is used.

2. The client has an implantable cardioverter defibrillator (ICD) MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function.

The nurse is caring for a pregnant client who is impaired and has a positive urine drug screen. When questioned about substance abuse, the client begins to throw objects at the nurse and yells, "I'm leaving this hospital right now before you call the police on me!" What is the best response by the nurse? The client with impaired thinking from substance abuse is legally incompetent to leave the hospital against medical advice. During periods of extreme anxiety and stress, clients are prone to irrational thinking. The nurse should avoid reasoning (eg, explaining the dangers of refusing treatment) until the situation has been de-escalated and the client is no longer in crisis.

3. "Please stay. You and I both have the same goal: to keep you and your baby safe. To de-escalate a violent situation involving a client with irrational thinking (eg, from substance use), the nurse should ensure the safety of the client and others and use calm, clear, nonthreatening communication focusing on mutual goals. The nurse should avoid attempting to reason with the client or providing false reassurance.

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? An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside. 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.

3 .Use long-handled forceps to secure the implant in a lead container 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. If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure (Option 3). The nurse should also notify the health care provider (radiation oncologist).

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission.

3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections.

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double-sided tape) (Options 1 and 4).

3. "I walk in my stockings at home because it helps to relieve my bunion pain." - Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home Many falls in the home can be prevented by exercising regularly, getting regular vision exams, maintaining a well-lit, clutter-free environment, using grab bars in the bathroom, periodically reviewing medications and side effects with a pharmacist and/or HCP, and wearing an electronic fall alert device.

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered.

3. Donning personal protective equipment 1. Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant 2. Donning personal protective equipment to protect the nurse when providing care (Option 3) 3. Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (Option 2). 4. Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options 1 and 4).

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care?

3. Explore the client's abilities and motivation to perform care at home The nurse must assess a client's knowledge, skills, and motivation to identify barriers to self care. Through this identification, the nurse can help develop an individualized plan to meet health care needs.

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 health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error? Most CVCs 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 thromboembolis

3. Flush unused lumens of the CVC with 1000 units heparin every 12 hours 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 units/mL-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 and should be clarified by the nurse. The Centers for Disease Control and Prevention (CDC) recommend that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is a high-alert medication (at high risk for causing significant harm to the client if given in error). 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. According to the CDC, an occlusive dressing should be changed every 7 days. The nurse should check the institution's protocol for frequency of dressing changes. The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. T

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client on airborne transmission-based precautions. Which PPE should the nurse remove first?

3. Gloves The proper removal of personal protective equipment limits self-contamination. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials.

The nurse is caring for a client diagnosed with active pulmonary tuberculosis. Which elements of transmission-based precautions are required for the nurse when providing routine care? Select all that apply. Surgical masks are rated for protection against larger respiratory droplets (eg, influenza).

3. Hand hygiene 4.N95 particulate respirator MTV Suspected or confirmed pulmonary tuberculosis requires airborne transmission-based precautions. Clients are placed in negative pressure airborne infection isolation rooms, and health care staff must wear a fit-tested N95 or higher level respirator during care. Hand hygiene upon entry and exit of the client's room is always required.

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? (Option 3) Sending letters home to parents is premature at this point. After professional pest control personnel evaluate the classroom/school, letters can be sent to inform parents of the findings and any precautions that should be taken.

3. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags Laundering clothing in hot water and using the highest temperature setting on a dryer will kill any bed bugs attached to clothes. The clothing should then be stored in tightly sealed plastic bags to prevent additional infestation (Option 1).

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.

3. Known allergy to avocados and bananas 5. Lip swelling when blowing up balloons Latex allergy is an exaggerated immune reaction to exposure to latex-containing products (eg, gloves, catheters, tape). 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).

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. Carbidopa and levodopa combination is used to treat Parkinson's disease, sometimes called shaking palsy or paralysis agitans. Fall risk does not increase until age >65-75. Fall risks include using assistive ambulatory devices, orthostasis, taking sedatives or antiparkinson medications, or being age >65-70.

3. Lying pulse 80/min, standing pulse 110/min - Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls (Option 3). 4.Osteoarthritis of knees 5.Takes carbidopa/levodopa - Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls (Option 5). 6.Uses a cane to ambulate

The nurse is caring for a client with HIV. The nurse understands that which of the following are true regarding transmission-based precautions? Select all that apply. HIV standard precautions: hand hygiene, gloves HIV cannot be transmitted through urine, saliva, sweat, or emesis. Gown, gloves, and face shield are necessary if the procedure has a risk of contact with infected bodily fluids (eg, peripheral IV insertion, vaginal delivery). It is not necessary for every client encounter.

3. Neutropenic precautions are implemented based on laboratory results - A client with HIV can become immunodeficient due to a high viral load and a low CD4+ and neutrophil count (ie, neutropenia). This increases the risk for opportunistic viral, fungal, and bacterial infections. Neutropenia is detected via complete blood count blood with differential. For clients with a low absolute neutrophil count detected via laboratory result, neutropenic precautions (eg, donning a mask, avoiding raw foods) are implemented to help protect the client from opportunistic infections (Option 3). 5. The nurse should perform hand hygiene before and after providing client care - HIV is a virus that attacks a type of WBC known as CD4+ cells. The virus is transmitted through contact with bodily fluids including semen, vaginal secretions, blood, and breast milk. The nurse should use standard precautions (ie, hand hygiene, gloves) when performing routine care (eg, assessment, oral medication administration) when risk of contact with infected bodily fluids is low (Option 5).

e 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. 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.

3. Perform hand hygiene 4.Place the specimen in a biohazard bag 5.Scrub the catheter hub with antiseptic prior to use 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 and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene? Ménière disease (ie, endolymphatic hydrops) results from excess fluid accumulation in the inner ear. As a result, the semicircular canals cannot function effectively, leading to acute episodes of vertigo, tinnitus, hearing loss, and aural fullness. Vertigo can be incapacitating and is generally accompanied by nausea and vomiting.

3. Places the bed in the lowest position with all side rails raised Clients experiencing an acute episode of Ménière disease may report a sensation of being pulled to the ground (ie, drop attack) and are at high risk for falls. The bed should be placed in the lowest position with two of the side rails raised for safety. Raising all side rails is considered a restraint and requires intervention by the nurse (Option 3). ) Vertigo may be minimized by providing the client with a quiet, dark room free from stimulation (eg, television, flickering lights). The client should also avoid sudden head movements.

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error? ) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result.

3. Potassium of 7.0 mEq/L (7.0 mmol/L) With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. High serum potassium levels could be due to hemolysis or clotting during the blood draw. If a clinical assessment does not correlate with the laboratory values, repeat testing is needed.

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. Peripherally inserted central catheter lines provide central venous access for clients who require long-term medication administration or infusion of noxious substances. Maintaining the line integrity with aseptic technique and routine care (sterile dressing changes, flushing the line, blood pressures/venipunctures on unaffected arm) is important for continued use and prevention of central line-associated bloodstream infections.

3. Reinforcing a torn peripherally inserted central catheter line dressing with tape - Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape. 4.Scrubbing the port with alcohol for 5 seconds before use -he nurse should "scrub the hub" with alcohol or chlorhexidine/alcohol for 10-15 seconds. This should be done before flushing, drawing blood, or administering medication.

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. Restraint straps should be attached to areas that move with the bed frame (ie, elevates with the frame and head of the bed). Areas that do not move with (eg, base) or move independently of (eg, side rails) the frame should never be used, as injury may occur when they are raised or lowered (eg, pulling, entrapment).

3. Release restraints at regular intervals and assess behavior 5. Use gauze to pad bony prominences under restraints Nurses caring for restrained clients must ensure that basic needs are met, assess skin integrity and neurovascular status of restrained extremities, and determine the need for continued use. Supine position is avoided to decrease aspiration risk. Side-lying or semi-Fowler position promotes drainage of emesis or oral secretions.Quick-release knots are used to attach restraints to parts of the bed frame that move with bed position changes.

The nurse sustains a needlestick injury while administering insulin to a client who is HIV positive. Place in order the steps the nurse should take. All options must be used.

3. Remove the gloves 5. Wash the area with soap and water 2. Notify the nurse supervisor 1. Seek evaluation and treatment from going to to the employee health clinic 4. Take postexposure prophylaxis. If postexposure prophylaxis (PEP) for HIV exposure is warranted, the antiretroviral therapy should be given as soon as possible; PEP is most effective when given within 2 hours of an exposure incident.

A 3-month-old infant is treated in the emergency department 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, because the muscles required for rolling over do not develop until age 6 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. ) The nurse should document facts and observations objectively. The history provided by the parent or caregiver and the time from injury occurrence to evaluation should be included.

3. Report the injury per facility protocol Fractures in young children, especially nonambulatory, are always concerning and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada (Option 3). However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, congenital dermal melanocytosis) mimicking maltreatment.

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply. Clostridium difficile is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client with C difficile, it is critical that the nurse implement contact isolation precautions to prevent transmission of microorganisms between clients, including: ption 2) Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound care).

3. Requests that the client be assigned to a single-client room - Placing the client in a single-client room, if possible, or in a cohort with other clients infected with C difficile (Option 3) 5. Wears a single-use, disposable gown during client care -Wearing a single-use, disposable gown and clean gloves during all client care and discarding the equipment before leaving the room (Option 5) Performing hand hygiene before and immediately after client care with soap and water Using dedicated medical equipment (eg, stethoscope, blood pressure cuff) that is not shared between clients and always remains in the client's room

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?

3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor These nursing actions can help prevent injury if a client is falling while the nurse is assisting with 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, and let the client slide down the extended leg to the floor.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?

3. UAP has lowered the bed and raised all 4 side rails (82%) Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate.

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing 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. The nurse should carefully remove the soiled dressing to avoid shedding any microorganisms into the air and expose the wound for minimal time to avoid additional contamination.

The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Click on the exhibit button for additional information. Avoiding intramuscular injections and minimizing venipunctures is most important when the platelet count is below 50,000/mm3 (50 ×109/L), as these can cause prolonged bleeding.

4. Provide a private room and neutropenic precautions The client's laboratory results show severe neutropenia, with a reduced white blood cell count (normal 4,000-11,000/mm3 [4.0-11.0×109/L]) and reduced absolute neutrophil count (normal 2200-7700/mm3 [2.2-7.7 ×109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: - A private room - Strict handwashing - Avoiding exposure to people who are sick - Avoiding all fresh fruits, vegetables, and flowers - Ensuring that all equipment used with the client has been disinfectant

The nurse should consider which of the following client reports as an indication of an allergic reaction? Nitroglycerine is a vasodilator and a headache from dilating cerebral vessels is an expected finding. The side effect is treated with acetaminophen (Tylenol). Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. This is an expected, frequent side effect and is not an allergic reaction. Clients are advised to elevate the legs when lying down and to use stockings.

4. "My lips swell when I eat bananas or avocados." Latex allergy is suspected when there is a food allergy to banana, kiwis, or avocados. Peripheral edema is an expected side effect of peripherally acting calcium channel blockers. Headache is an expected side effect of nitroglycerine. Clients taking warfarin (Coumadin) should consume the same amounts of food high in vitamin K.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?

4. "This must have happened because I did not wash the bed sheets this week." 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. Client treatment aims to minimize itching until the rash is gone.

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the nurse's priority response? ) It is the nurse's professional responsibility to provide instruction and guidance to the parent. Although caregivers should have the number of the poison control center readily available, referral might delay care and place the child at further risk of a negative outcome if the child is already deteriorating. If the child's condition is stable, the nurse should instruct the parents to contact the center for further evaluation and instructions.

4. "What is your child doing right now?" (62%) The exact amount of alcohol that this child presumably ingested is unknown. It is most important to assess the child's condition (eg, behavior, mental status, physical signs and symptoms) to determine if immediate emergency measures (eg, calling 911, cardiorespiratory support) are necessary or if the parent should be instructed to contact the poison control center (Option 4). When a child accidentally ingests a poisonous substance, it is most important to assess the child's condition, including physical signs and symptoms, mental status, and behavior. Based on the condition of the child, the nurse can provide guidance and instructions to contact the appropriate agency (eg, emergency services, poison control center).

Which client is most at risk for methicillin-resistant Staphylococcus aureus infection?

4. 80-year-old client with a hemodialysis catheter who lives in a long-term care facility Methicillin-resistant Staphylococcus aureus (MRSA) is an antibiotic-resistant strain of bacteria commonly colonized on the skin or in the nares. Risk factors for MRSA infection include recent hospitalization, advanced age, residence at a long-term care facility, immunosuppression, antibiotic use, and invasive lines (eg, hemodialysis catheter).

The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room? ) Impetigo is no longer contagious after 24 hours of antibiotics. This client would not require isolation. Poison ivy rash is not considered contagious. A person develops the rash only on contact with the urushiol oil itself. The pustule

4. Child with suspected pertussis who has paroxysms of coughing Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation immediately to prevent the spread of disease.

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? A client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required. ) The CDC recommends standard precautions for clients with hepatitis C and those who are HIV positive. A private room is not necessary for a client who has osteomyelitis or diabetic ketoacidosis. A client with a latent tuberculosis infection (LTBI) has a positive tuberculin skin test, has no symptoms of infection, and is not contagious. Immunosuppressant drugs, chemotherapy, and debilitating disease can convert a LTBI to active disease. At this time, the client requires only standard precautions.

4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture The Centers for Disease Control and Prevention (CDC) recommends placing a colonized client on contact precautions and in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. Therefore, the client with pneumonia should be placed in the private room. The Centers for Disease Control and Prevention recommends contact precautions and private room placement for a client who is colonized with methicillin-resistant Staphylococcus aureus, especially if the client can transmit the bacteria through body secretions or excretions.

The nurse responds to a client room where a resuscitation effort is in progress. The client's immediate family member does not want to leave the room. How should the nurse handle this situation?

4. Let the family member stay and assign a staff member to explain the situation If family members do not disrupt client care, they should be allowed to stay in the room with an assigned staff member who will explain the interventions being implemented (Option 4). The nurse should always be an advocate for the client and the family. Witnessing the efforts of the resuscitation team can be reassuring even if the outcome is negative. The nurse should be prepared to escort family members from the room if they become disruptive.

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement?

4. One-on-one supervision from a sitter Client and staff safety is an ongoing concern when working with clients who are confused and agitated. The least restrictive restraint should be used. 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. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client's situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client's visibility would also help.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it.

4. Perform the morning assessment The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. The preoperative checklist can be completed after consent is obtained.

The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up ) Outside edges of the sterile field (ie, 1 inch [2.5 cm]) are used to position the field. These edges are considered contaminated, and sterile items should not be placed within this space.

4. Pours sterile saline solution from a recapped bottle opened 30 hours ago Items opened within 24 hours that were properly sealed and stored may be reused for sterile procedures if facility policy permits. Items open for more than 24 hours are no longer considered sterile (Option 4).

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take?

4. Question the prescription with the prescriber When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) 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? 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 form.

4. Remove the intravenous catheter It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter. 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 (failure to do so constitutes false imprisonment). The nurse should have witnesses to the events and clearly document in the chart what happened and that the client refused to sign.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery?

4. Temperature 100.4 F (38 C) with cough Low-grade temperature and cough could indicate the presence of an infection, and the nurse should report these findings to the HCP as soon as possible before surgery. The administration of anesthesia in a client with a fever and cough can exacerbate an unknown viral or bacterial condition, increase the risk for postoperative pneumonia, and interfere with the postoperative healing process. The HCP may prescribe further testing, consult the anesthesia professional, postpone the elective surgery, or proceed with the surgery depending on the individual situation and type of surgery scheduled.

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next?

4. Transport the client to the operating room under implied consent Implied consent in emergency situations includes the following criteria: - There is an emergency - Treatment is required to protect the client's health - It is impractical to obtain consent - It is believed that the client would want treatment if able to consent In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?

4. Verify the client's activity prescription A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall.

The nurse is preparing to transfer a client from the bed to the chair for the first time. The client has generalized weakness and is unable to follow instructions. Which would be the most appropriate method for the nurse to use to transfer this client safely?

THE BIG ASS MACHINE using two people Given this client's weakness and inability to cooperate with instructions during the transfer, a pivot transfer would be unsafe. A standing-assist lift may also be unsafe as it also requires the client to follow directions. Therefore, a full-body sling with mechanical lift should be used to safely transfer this client (Option 4). This prevents musculoskeletal injuries to the health care worker and provides the safest method of transfer for this client.