FUNDAMENTAL SKILLS: Safety and Infection

How to lubrate the insertion end of NG tube

Water soluble lubricant is used to lubricate 3 inches of the tube at the insertion end.

Cutaneous Kaposis Sarcoma: Lesion are open and draining a scant amount of serious fluid

Wear Gown and gloves....Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage on bed linens.

Throat Culture

When collecting a throat culture, the client is told that the test is performed to help identify microorganisms causing the symptoms. The client is instructed to tilt the head back, and both the tonsillar pillars and the posterior pharynx wall are swabbed. A tongue depressor is used in the collection so that the swab is less likely to contact the normal flora of the mouth. The swab is immediately placed in a labeled culture tube and transported to the laboratory.Th

When is it safe to place the car safety seat in a face forward position?

When the toddler weight 20 lb and is 1 year old

How how should you place a client when a tube feeding is administered?

With the head elevated 45 degrees the client is placed in a high Fowler's position for a bolus feeding and in a semi-Fowler's position (30 to 45 degrees) for a continuous feeding to allow gravity to help the flow of formula and to prevent reflux and aspiration.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client?

"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed." to reduce the risk of infecting the neonate.

Sterile Field using principles of aseptic technique

- Open the distal flap of a sterile package first. - Prepare the sterile field just before the planned procedure. - Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

pulmonary angiography pre-procedure

- Shave the anticipated entry site. - Obtain a signed informed consent form. -Inquire whether the client has any allergies to shellfish. -Ask whether client has ever experienced an allergy to any contrast media.

A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care

- Wearing gloves when emptying the client's bedpan - Keeping all linens in the room until the implant is removed - Wearing a film (dosimeter) badge when in the client's room - Wearing a lead apron when providing direct care to the client

Normal Platelet count

150,00 to 450,000

Maximal time limit for exposure to the client with an unsealed internal radiation

30 minutes every 8 hours

A nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The health care provider has prescribed an amount of 100 mL/hr. The nurse plans to fill the feeding bag with:

400 mL of formula Feeding can be hung at room temperature for a period of 4 hours. If 100 mL/hr is prescribed, the nurse would fill the feeding bag with a maximum amount of 400 mL. Feeding hung longer than 4 hours at room temperature creates the risk of bacterial invasion in the formula.

Normal White blood cell count

4500 to 11000

Miller Abott Tube

A Miller-Abbott tube is an intestinal tube that has a double lumen, one for a tungsten balloon and the other for suction or drainage. After insertion of the tube, the nurse should assist the client on the right side

Which specific instruction should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV)-positive?

Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool. Meticulous skin care helps protect the HIV-infected newborn from developing secondary infections. Feeding the newborn in an upright position, using a special nipple, and bulging fontanels are unrelated to the pathology associated with HIV.

When a patient has a Sengstake Blakemore tube inserted which priority item is at the bedside??

A pair of scissors When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the registered nurse is notified immediately and the balloon lumens will be cut.

Rubeola

Airborne or direct contact with infectious droplet

A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate?

Isolation precautions for at least 24 hours after the initiation of antibiotics

Oxygen at home

Keep the oxygen concentrator slightly away from the walls and corners to permit adequate airflow

Use mask for

Droplet and airborne

Meningitis

Droplet precautions

Aseptic technique

Aseptic technique is important to reduce the risk of infection.

What does it mean when a platelet count is low?

Bleeding precaution need to be initiated when the platelet count decreases

What kind of precaution for CLOSTRIDIUM DIFFICILE?

Contact Precautions

A nurse is assigned to assist in caring for a client who has had an autograft placed on the lower extremity. The nurse plans to:

Elevate and immobilize the surgical extremity. Autografts placed over joints or on lower extremities are often elevated and immobilized after surgery for 3 to 7 days.

Meningococcal Meningitis

DROPLET PRECAUTIONS

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention?

Determining what common food item was ingested by those affected

How should HIV positive client feed there babies?

HIV positive client need to bottle feed their neonates because HIV transmission can occur during breast feeding

A health care provider (HCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas and the client is still passing brown liquid stool. Which action should the nurse take next?

Notify the HCP. Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse notifies the HCP (or act based on agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 2, 3, and 4 are incorrect for these reasons.

A nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which of the following items when performing this care?

Particulate respirator, gown, and gloves The nurse who is in contact with a client with TB should wear an individually fitted particulate respirator. The nurse would also wear gloves as per standard precautions. The nurse wears a gown whenever there is a possibility that the clothing could become contaminated, such as when giving a bed bath.

What to check Before the initiation of Cold Pack therapy on the Right lower extremity

Pedal Pulse Capillary refill Color of extremity Temperature of the skin

Anthrax Transmission

Skin Inhalation Gatrointestinal

suprapubic prostatectomy

Suprapubic prostatectomy is surgery to remove part or all of your prostate gland. Your prostate gland is found below your bladder and surrounds the top of your urethra. Your urethra is a tube that carries urine from your bladder to the outside of your body.

Postanesthesia

The PACU is a critical care unit where the patient's vital signs are closely observed, pain management begins, and fluids are given. The nursing staff is skilled in recognizing and managing problems in patients after receiving anesthesia.

Roseola

Transmitted via saliva

Impetigo

Treated with oral antibiotics

A school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which is included in the list?

Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

How to use the cane

The client should move the cane and the affected side together. The cane helps to support the affected side as it moves forward. It also helps the client to maintain balance. The client holds the cane on the unaffected side to shift the client's weight away from the affected side. The client holds the cane close to the body to prevent the client from leaning.

A nurse is caring for a client who has hand restraints. The nurse assesses the skin integrity of the restrained hands:

Every 30 minutes

Continous Passive Motion

The client should not try to adjust the flexion and extension settings. These are decided on by the orthopedic surgeon and are maintained as prescribed.

What does it mean when a client is immunosupressed.

The client who is immunosuppressed has a decrease in the number of circulating WBCs.

Methicillin resistant Staphylococcus Aureus (MRSA) contact precautions

Gloves, a gown, and goggles Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions