HESI - Safety and Infection Control
A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage?
A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.
Which conditions are given a green tag according to triage disaster tag system? Select all that apply.
A green tag is issued for clients who are nonurgent or classified under class III. Strains and abrasions are considered minor injuries and nonurgent. Walking wounded clients with minor injuries are triaged under this category. Clients with open fractures and who can wait some time for care are issued yellow tags and triaged under class II. Clients with airway obstruction are issued red tags and triaged under class I. Clients with high cervical spinal cord injury are issued black tagsas they are expected to die and are categorized under class IV.
A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in what?
A plastic liquid detergent bottle with a screw-top lid. Most states (provinces) allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.
An isolation room
An isolation room is a private room fitted with special air handling and ventilation to prevent the transmission of airborne droplet nuclei 5 micrometers or smaller. It has monitored negative pressure to prevent air from moving from the room into the corridor of the facility. Room air is exchanged 6 to 12 times an hour to the outdoors or through a monitored high-efficiency filtration system. Mycobacterium tuberculosis remains suspended in the air for prolonged periods and is transmitted in air currents. A private room does not have the technical equipment to manage airborne droplet nuclei of 5 micrometers or smaller. Other children and people on the unit will be exposed to the infected individual's pathogens that travel through air currents. A four-bed room or semiprivate room will expose the children and other people on the unit to the infected individual's pathogens.
What does the nurse understand to be the role of emergency medical technicians (EMTs) in emergency nursing after a disaster?
EMTs offer basic life support interventions that include monitoring vital signs. Paramedics are advanced life support care providers that perform advanced techniques such as providing intubation, establishing IV access, and performing advanced airway management.
What is a manifestation of tertiary syphilis?
Gummas which are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.
Which is the first antibody formed after exposure to an antigen?
IgM (immunoglobulin M) is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.
A nurse is preparing a 5-year-old girl who has undergone a myringotomy for discharge. What should the parents be taught about their child's care at home?
Insert earplugs whenever a bath is given. Water in the ears after myringotomy supports the growth of pathogens and should be avoided. The ears should be kept open to the air and allowed to drain naturally. There is no reason to keep the child isolated. Cleaning the ears with cotton swabs is contraindicated because it may result in trauma.
A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory tract infections. After the surgery, what should the nurse teach the parents to do?
Offer crushed ice chips. Ice chips are soothing and promote vasoconstriction. Cool water, flavored ice pop, or diluted fruit juice may be given but fluids with a red or brown color should be avoided to distinguish fresh or old blood in emesis from the ingested liquid. Milk and milk products coat the mouth, causing the child to clear the throat, which may precipitate bleeding. The supine position promotes edema and does not allow oral secretions to drain from the mouth. The head of the bed should be elevated and the child should be positioned on the side. Mouthwash solution is too caustic; a warm, saltwater solution is preferred.
Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse implements safety precautions. Which information should the nurse consider when planning care for this client?
Oxygen is necessary for the production of fire. Oxygen does not burn; it supports combustion.
What is the purpose of critical incident stress debriefing (CISD) after a disaster?
Prevent post-traumatic stress disorder (PTSD) Critical incident stress debriefing (CISD) addresses pre-crisis through post-crisis interventions. After working through the turmoil and the emotional impact of the incident as well as the aftermath, the staff may find it difficult to "get back to normal." Without intervention during and after the emergency, they may develop post-traumatic stress disorder (PTSD)
Disaster Mortuary Operational Response Teams (DMORT)
The National Disaster Medical System (NDMS) is responsible for managing the Federal Government's medical response to medical emergencies and disasters. One of their additional services is the Disaster Mortuary Operational Response Team (DMORT). DMORTs manage mass fatalities.
Radium inserted in the vagina of a client now is being removed. Which safety precaution should the nurse employ when assisting with the radium removal?
Radium must be handled with long forceps because distance helps limit exposure. A nurse does not clean radium implants. Foil-lined rubber gloves do not provide adequate shielding from the gamma rays emitted by radium. The amount and duration of exposure are important in assessing the effect on the client; however, documentation will not affect safety during removal.
A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take?
Remove anyone who is in immediate danger. The nurse is following the standard fire safety procedure RACE: "R" represents removing any clients from immediate danger. In RACE, "A" represents alarming or activating the fire alarm, "C" represents containing the fire source by closing all windows and fire doors, and "E" represents extinguishing the fire and/or evacuating.
Which school-age children require close supervision when using a skateboard? Select all that apply.
School-age children who are 6 years, 7 years, 8 years, or 9 years all require close supervision when using a skateboard. The 5-year-old school-age client should not be allowed to ride a skateboard due to the high risk for injury.
A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions?
Sputum is free of acid-fast bacteria. The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.
Medical Reserves Corps - MRC
The MRC offers its services to health care facilities or the community in a supportive to supplemental capacity during times of need, such as a disaster or pandemic disease outbreak.
A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?
Wear a particulate respirator mask. Tubercle bacilli are transmitted through air currents; therefore personal protective equipment, such as a particulate respirator that filters out organisms as small as 1 µm, is necessary. Gowns and gloves are not necessary. Tuberculosis is spread by airborne microorganisms; gloves are necessary only when touching articles contaminated with respiratory secretions. It is only necessary to avoid contact with objects in the client's room that are contaminated with respiratory secretions. Limiting contact with the client's nonexposed family members is unnecessary.
Which is the minimum number of disaster drills the committee must plan and implement each year?
While it is appropriate to have more than the minimum number of disaster drill each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year.
