Module 6: Safety and Infection Control
Mary is reviewing the medication prescriptions for her clients. Libby asks Mary about medication safety: "Tell me how to prevent medication errors." Which of Mary's responses, below, indicate that Mary understands measures for ensuring medication safety? Select all that apply. "I should assess the client for allergies after giving the medications." "I should use two client identifiers before giving medications." "I should keep verbal and telephone prescriptions to a minimum." "I won't give a medication that another nurse has drawn up in a syringe." "I should use trade names instead of generic names for drugs to avoid confusion."
"I should use two client identifiers before giving medications." "I should keep verbal and telephone prescriptions to a minimum." "I won't give a medication that another nurse has drawn up in a syringe." RATIONALE: Measures to prevent medication errors include using two client identifiers, avoiding the use of verbal and telephone prescriptions, and giving only medications that the nurse has drawn up or prepared him- or herself. Assessment for allergies should be done before medications are given. Generic names should be used to avoid the many sound-alike trade names of medications.
After a few days, Joseph becomes calmer and seems less confused. He is able to leave his IV and oxygen tubing alone, and the restraints are removed. Today, the hospital's nurse educator presents an educational session on the use of safety devices (restraints). Which statements by the nurses indicate a need for further instruction? Select all that apply. "Restraints should be tied in a secure knot." "Medications are also known as chemical restraints." "When a client is agitated, it's best to give a sedative before the behavior gets worse." "Physical restraints, such as vests, have caused injury and even death in restrained clients." "Family members may agitate the client further if they stay with the client overnight.
"Restraints should be tied in a secure knot." "When a client is agitated, it's best to give a sedative before the behavior gets worse." "Family members may agitate the client further if they stay with the client overnight. RATIONALE: It is true that physical restraints have caused client injury and death, and medications used for noisy or agitated clients are known as chemical restraints. However, alternatives such as asking family members to stay with the client should be tried before any restraints, including medications, are implemented. It is important to tie restraints in a quick-release tie so that they may be removed quickly in an emergency. A restraint should not be secured with a knot.
A nurse employed in an emergency department (ED) on the evening shift is assigned to triage arriving clients. Which client should the nurse designate as the highest priority? A client who twisted her ankle in a fall while inline skating A client with asthma who is not experiencing respiratory distress A client with chest pain who says that he just ate pizza made with a very spicy sauce A client with a minor laceration of the index finger, sustained while the client was cutting an eggplant
A client with chest pain who says that he just ate pizza made with a very spicy sauce RATIONALE: In an ED, triage is used to classify clients on the basis of their need for care and establish priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Trauma, limb amputation, chemical splashes in the eyes, chest pain, severe respiratory distress, cardiac arrest, and acute neurological deficit are all classified as emergencies and are the highest priority. Simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, and renal stones represent urgent needs, and clients with these conditions are given number-two priority. Conditions such as minor lacerations, sprains, or cold symptoms are classified as non-urgent, and clients with these conditions are the number-three priority. TEST-TAKING STRATEGY: Note the strategic words "highest priority." This indicates those clients who must be cared for first. Use the ABCs; airway, breathing, and circulation to direct you to the correct option. A client experiencing chest pain is always classified as a number-one priority until myocardial infarction has been ruled out.
On arriving at the scene of the train accident, Julianne is directed to triage and assist as many victims as possible. Which victim should Julianne care for first as the highest priority? A victim who is huddled and screaming, "I can't find my daughter!" A victim with a laceration of the right calf that is bleeding profusely A victim who is in pain with an obvious fracture of the right humerus A dead victim who obviously sustained severe head trauma and hemorrhage resulting from amputation of the left arm
A victim with a laceration of the right calf that is bleeding profusely RATIONALE: In a disaster situation, the nurse must triage victims according to severity of injury and potential for recovery. Victims with life-threatening injuries that are readily corrected are classified as emergent and are the first or highest priority (in this case, the victim with a laceration of the right calf that is bleeding profusely). Victims with injuries that do not require immediate treatment but that will need to be treated within 1 to 2 hours are classified as urgent and are the second priority (here, the victim who is in pain and has an obvious fracture of the right humerus). Victims with no injuries, those whose condition are noncritical, and victims who are ambulatory are classified as delayed (non-urgent) and are the third priority (in this case, the victim who is huddled and crying). Helping the victim who is dead, in this situation, is not the priority.
Julianne goes on to the hospital's emergency department to prepare for the arrival of victims. An outside area is set up to receive clients. As clients arrive, they are grouped with the use of a color-coded system of triage tags. Which clients would be placed in the yellow-tag category? A teenager with a sprained ankle An older woman with a fractured arm A child who is unconscious with a head injury A young woman with a large bleeding laceration on her lower leg A young man who has a fractured leg and reports a history of asthma A middle-aged man who has a severe crushing head injury and is unresponsive
An older woman with a fractured arm A young man who has a fractured leg and reports a history of asthma RATIONALE: The emergent (red) classification, the highest priority, is given to clients who have life-threatening injuries and need immediate attention and continuous evaluation but have a high probability of survival once they have been stabilized. Such clients include those with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, or acute neurological deficits and those who have sustained chemical splashes to the eyes. The urgent (yellow) classification, the second priority, is given to clients who require treatment and whose injuries have complications that are not life-threatening, provided that they are treated within 1 to 2 hours; these clients require evaluation every 30 to 60 minutes thereafter. Such clients include those with simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, and renal stones. The non-urgent (green) category, the third priority, is for clients with local injuries who do not have immediate complications and who can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. TEST-TAKING STRATEGY: Focus on the subject, the yellow tag category. Recalling that this category is the second priority, given to clients who require treatment and whose injuries have complications that are not life threatening, provided that they are treated within 1 to 2 hours, will direct you to the correct options.
A month later, the community's disaster preparedness council holds a meeting to review the response to the train wreck and discuss other disaster situations that require planning. Julianne presents a summary on "Anthrax Exposure" for the group. Julianne should include which points about anthrax in the presentation? Select all that apply. There is no vaccine against anthrax. Anthrax infection is treatable with antibiotics such as ciprofloxacin, doxycycline, or penicillin. Anthrax occurs in inhalation, cutaneous, and gastrointestinal form. The inhalation form of anthrax is the most severe and can lead to potentially fatal bacteremia. Victims who may have been exposed to anthrax will be taken to a decontamination area first. Victims who may have been exposed to anthrax will be admitted to the emergency department and then taken to the decontamination area.
Anthrax infection is treatable with antibiotics such as ciprofloxacin, doxycycline, or penicillin. Anthrax occurs in inhalation, cutaneous, and gastrointestinal form. The inhalation form of anthrax is the most severe and can lead to potentially fatal bacteremia. Victims who may have been exposed to anthrax will be taken to a decontamination area first. RATIONALE: An anthrax vaccine is available to those who will be in situations where exposure is possible, such as military service; exposure and infections are treated with specific antibiotics. There are three forms of anthrax: inhalation, cutaneous, and gastrointestinal. The inhalation form of anthrax is deadlier than the cutaneous and gastrointestinal forms. Anthrax infection may be treatable with antibiotics such as ciprofloxacin. Victims of anthrax exposure will not be taken directly into the emergency department, because this could result in the exposure of other personnel and clients to the disease. Instead, they will be taken directly to a decontamination area. TEST-TAKING STRATEGY: Focus on the subject, the characteristics of anthrax. Specific knowledge regarding anthrax infection is needed to answer this question. Read each option carefully as you recall the aspects of anthrax infection and exposure.
Seeing that Joseph is restless, the nurse determines that he needs to be monitored closely. His daughter tells the nurse that she is unable to stay with her father because she needs to pick up her teenage children from school. Which action on the part of the nurse is appropriate? Asking Joseph's daughter for permission to apply a safety device (restraint) if necessary Telling Joseph's daughter that his primary health care provider will be called to obtain a prescription for sedation Telling Joseph's daughter that she will need to contact another family member to come to the hospital and sit with Joseph Asking Joseph's daughter to return to the hospital with one of her teenage children so that someone familiar to Joseph will be present
Asking Joseph's daughter for permission to apply a safety device (restraint) if necessary RATIONALE: The nurse should follow agency policies and procedures regarding the use of restraints; however, informed consent must be obtained from Joseph's daughter to apply a restraint to Joseph if necessary. The nurse must also obtain a primary health care provider's prescription for the application of a restraint. Chemical restraint (medication) should be avoided because it will further affect Joseph's ability to interact with his environment. Asking Joseph's daughter to contact another family member and having one of her children care for Joseph are not appropriate. Although it is helpful to provide the client with familiar persons and objects in the environment, these actions place the responsibility of care on Joseph's family
At 3 a.m., a nurse is making her/his rounds. He/She finds a client with Alzheimer's disease climbing over the side rails of his bed. The nurse rushes to the client and assists him back into bed. Which action should the nurse take first to ensure client safety? Asking an assistive personnel (AP) to stay with the client Calling the client's primary health care provider for a prescription for a safety device Checking for a prescription for a sedative and administering the sedative Asking another nurse to obtain a safety device from the supply closet so that the client may be restrained
Asking an assistive personnel (AP) to stay with the client RATIONALE: Safety devices (restraints) are used when other measures have failed to keep the client from engaging in behavior that might cause injury. The least restrictive method of ensuring client safety should be employed before safety devices (restraints) are applied to a client. Therefore, the nurse would first ask the AP to stay with the client. Restraining a client or obtaining a prescription for a safety device (restraint) is not the best first action. Administering a sedative is not a method of use of safety devices (restraints) and would not be the best action to take.
A nurse is irrigating a client's abdominal wound when the client becomes agitated, grabs the bottle of saline solution that the nurse is using to perform the irrigation, and throws the bottle at the nurse. The nurse immediately calls for assistance. What action should the nurse take after an assistive personnel (AP) arrives? Asking the AP to check for a prescription for a sedative Leaving the room and calling the primary health care provider for a prescription for a safety device Stopping the wound irrigation and telling the client that she will complete the procedure when he calms down Asking the AP to apply a safety device to the client
Asking the AP to apply a safety device to the client RATIONALE: A primary health care provider's prescription is necessary for the application of restraints to a client; however, in an emergency situation, if the client presents a risk for injury to self or others, a restraint may be applied. When the nurse must restrain a client in an emergency situation, a primary health care provider's prescription must be obtained as soon as possible thereafter. The nurse should restrain the client and complete the procedure, because leaving an abdominal wound unprotected presents a risk for infection. It is also inappropriate for the nurse to ask the AP to check for a prescription for a sedative; this is the nurse's responsibility. Asking the AP to leave the client's room places the nurse at risk for further injury by the client. Stopping the wound irrigation and telling the client that she will complete the procedure when he calms down is a nontherapeutic action and increases the client's risk for infection.
A nurse receives a telephone call from her next-door neighbor, who is frantically seeking help because her 3-year-old son has swallowed pills from a bottle of ibuprofen. The neighbor tells the nurse that her teenage daughter takes the pills for menstrual cramps and apparently forgot to put the bottle away before leaving for school this morning. After the nurse rushes to the neighbor's house, which action should she take first? Calling the poison center Asking the mother to call an ambulance Assessing the child for airway patency and removing any visible material from the child's mouth Asking the neighbor to call the school and ask her daughter how many pills remained in the bottle
Assessing the child for airway patency and removing any visible material from the child's mouth RATIONALE: In the event of an accidental poisoning, the nurse would first assess airway patency, breathing, and circulation. The nurse would remove any visible material from the child's mouth and then try to identify the type and amount of substance ingested, because this may help determine the correct antidote. The Poison Control Center is also called, but airway is the priority. If the Poison Control Center says that the child should be taken to an emergency department, an ambulance is called. It may be necessary to contact the daughter at school, but this would not be the first action.
TESTLET Mary Houder, a new nursing graduate, has been hired to work as a staff nurse on a medical nursing unit in a large hospital. Mary is required to complete the hospital's orientation program, which includes a fire safety program. During the program, each new employee is given a scenario and expected to demonstrate how he or she would respond to the situation set forth in the scenario. Mary's case scenario reads: You are working on a medical nursing unit and are delivering medications to a client who is ambulatory, is under respiratory precautions, and is receiving oxygen by nasal cannula. When you enter the client's room, you discover a fire blazing in the laundry basket, caused when the client used a match to light a candle. The case scenario asks Mary to respond to the questions that follow. When the fire is discovered, what will you do first? Activate the fire alarm Assist the client in leaving the room Get the fire extinguisher located outside the client's room Assist the client into a corner of the room, as far away from the fire as possible, and shut the oxygen off
Assist the client in leaving the room RATIONALE: In the event of a fire, the nurse would use the mnemonic RACE to set priorities. The nurse's first action would be to rescue and remove all clients in immediate danger away from the fire. The nurse would next activate the fire alarm, confine the fire by closing doors and windows and turning off oxygen and electrical equipment, and then extinguish the fire, using a fire extinguisher.
A hospital nurse transcribing a primary health care provider's prescriptions for a client is unable to read a prescribed dosage because the primary health care provider's handwriting is unclear. Which action should the nurse take? Call the primary health care provider Ask the client about the usual dosage of the medication Call the pharmacy to ask about the usual dosage of the prescribed medication Contact the nursing supervisor for clarification of the primary health care provider's prescriptions
Call the primary health care provider RATIONALE: It is the nurse's responsibility to follow the primary health care provider's prescriptions unless the nurse believes that a prescription is in error or would cause harm to the client. If the nurse implements a prescription that is inaccurate and causes harm to the client, the nurse is responsible. If a primary health care provider's prescription is illegible, it is the nurse's responsibility to clarify the prescription with the primary health care provider. The nurse would contact the nursing supervisor if he or she were unable to make contact with the primary health care provider for any reason, but, because of the unclear handwriting, asking the nursing supervisor for clarification of the primary health care provider's prescription is not the best action; the primary health care provider must make the prescription clear. Calling the pharmacy to ask about the usual dosage is incorrect, for the same reason; the primary health care provider must make the prescription clear. Asking the client about the usual dosage is incorrect, in part because the primary health care provider may have changed the dosage.
A nurse is setting up an intravenous pump that will be used for a client who will be receiving a continuous intravenous infusion of normal saline solution containing heparin. As the nurse prepares to plug the pump's electrical cord into the wall socket, she notes that no socket is available because of other medical equipment being used in the room. Which action by the nurse is most appropriate? Allowing the pump to run in battery mode Obtaining an extension cord from the nurses' lounge Moving the client into the hallway, near a wall socket Calling the hospital's electrical department for assistance
Calling the hospital's electrical department for assistance RATIONALE: The nurse would most appropriately contact the hospital's electrical department for assistance in safely setting up electrical equipment. Safety-type extension cords are used only if necessary, and although this may be an option, it is not the most appropriate one. Electrical outlets should not be overloaded, because this presents an electrical hazard. The nurse would not allow the pump to run on its battery for an extended period. It is inappropriate to place a client in a hallway. This would constitute an invasion of the client's privacy.
A nurse has been asked to become a member of a community group that will help ensure the community's disaster preparedness. At the first meeting, the group reviews FEMA's four disaster management phases. The group decides to focus on the mitigation phase. What action should the group take? Determine the community's hazards and risks for a disaster Identify plans for rescue, evacuation, and care of disaster victims Identify concerns such as safety and the physical and mental health of both the victims and the members of the disaster response team Determine actions that will prevent debilitating effects and those that will restore personal, economic, and environmental health and stability to the community
Determine the community's hazards and risks for a disaster RATIONALE: FEMA, the Federal Emergency Management Agency, classifies disaster management into four phases: mitigation, preparedness, response, and recovery. Mitigation involves actions or measures that can prevent the occurrence of a disaster or reduce a disaster's damaging effects. In this phase, the group determines hazards and risks for a disaster in the community. This phase also involves identifying the resources available for the care of infants, older clients, the disabled, and those with chronic health problems. The preparedness phase involves the development of plans for the rescue, evacuation, and care of disaster victims. In the response phase, disaster planning services, including actions taken to save lives and prevent further damage, are put into action. Primary concerns in this phase include the safety and physical and mental health of both the victims and the members of the disaster response team. The recovery phase involves work to prevent debilitating effects and restore personal, economic, and environmental health and stability to the community.
A nurse is watching an assistive personnel (AP) wash his/her hands. The nurse should intervene if the AP performs which action? Dries from the forearms down to the fingertips Uses a clean, dry paper towel to turn off the water faucet Uses plenty of lather and friction and scrubbing for 15 seconds Keeps the hands and forearms lower than the elbows while washing
Dries from the forearms down to the fingertips RATIONALE: The hands are dried from the cleanest area (fingertips) to the least clean (forearms). When washing the hands, the nurse must avoid splashing water on his/her uniform. The hands and forearms are kept lower than the elbows. Abundant lather and plenty of friction are applied for at least 10 to 15 seconds, after which the fingers are interlaced and the palms and back of the hands rubbed in a circular motion at least five times each. A clean, dry paper towel is used to turn off the faucet, and the nurse avoids touching the faucet handles with the hands.
The nurse checks Joseph every 30 minutes to assess skin integrity under the restraint and the circulatory status of Joseph's hands. The nurse should instruct the assistive personnel (AP) assigned to Joseph to remove the restraints at which time? When Joseph falls asleep If Joseph asks that they be removed Every 2 hours for range-of-motion exercises If Joseph stops pulling on the oxygen and IV lines
Every 2 hours for range-of-motion exercises RATIONALE: Restraints should be removed for 30 minutes every 2 hours to provide an opportunity for Joseph to change position and for full range-of-motion exercises to be performed with his hands and arms. The nurse would remain with Joseph while the restraints are removed. The remaining options do not ensure Joseph's safety or ensure that Joseph will not pull on his oxygen and IV lines.
An emergency department (ED) nurse receives a telephone call from the local police department and is told that several victims of an industrial explosion will be brought to the ED. Which action should the nurse take immediately? Calling as many off-duty nurses as possible and having them come to the hospital to care for the victims Following the directions outlined in the hospital's disaster preparedness (emergency response) plan Asking the housekeeping department to deliver an extra cart of linen containing several blankets to the ED Calling the operating room to inform the staff that the hospital may be receiving numerous victims requiring surgery
Following the directions outlined in the hospital's disaster preparedness (emergency response) plan RATIONALE: The ED nurse has an important role in emergency and disaster planning. Knowledge of the agency's emergency response plan, including the roles and responsibilities of the members of the response team, is vital. An ED nurse who is notified that several victims of a disaster will be arriving at the department should immediately activate the emergency response plan by notifying his/her supervisor and following the directions in the plan. Although asking for extra supplies, calling employees at home to come in to care for victims, and informing the necessary areas of the hospital to be on alert may be implemented, none is the immediate choice.
The nurse is preparing to assist George with a morning bath and planning to change the linens on George's bed. Which protective equipment should the nurse wear to perform these procedures? Gloves and mask Gloves and gown Gloves, eyewear, and mask Gloves, gown, mask, and eyewear
Gloves and gown RATIONALE: Contact precautions require the wearing of gloves when the nurse enters the client's room and whenever he or she is providing direct client care or coming into contact with potentially contaminated surfaces or items in the client's room. A gown is also worn if contact with the client's items is anticipated or if the client has diarrhea. A mask is used if the infection in question is transmitted by way of the airborne or droplet route. Eyewear is worn if it is anticipated that splashing of body fluid will occur. Eyewear and a mask are not necessary for contact precautions.
Mary has completed the orientation program and is now working on the client care unit with a nurse mentor, Libby. Together they review their assigned clients. The client in room 1104 has just been admitted. Which factors in this client's admission assessment and earlier history (refer "Chart" below) indicate that she is at risk for falls? Select all that apply. Admission AssessmentPaula Snow, an 87-year-old white woman, was admitted through the emergency department after being found on the floor of her living room, unable to get up. X-rays revealed no fractures, but she has a large bruise on her left hip and forehead. A CT scan of the head was unremarkable. Her daughter states that Paula has fallen four times in the last year and that she forgets to use her walker. Paula is oriented to person only. Medical HistoryGallbladder removed, age 48Hypothyroidism; takes levothyroxine dailyHypertension; daughter states that Paula takes a "fluid pill" daily. Her age Disorientation History of falls Taking a "fluid pill" daily History of hypothyroidism Use of an assistive device (walker)
Her age Disorientation History of falls Taking a "fluid pill" daily Use of an assistive device (walker) RATIONALE: Several factors can indicate that a person is at risk for falls. Generally, people over age 60, those with an unsteady gait, and those who use assistive ambulatory devices are at risk. In addition, certain medications, such as diuretics, sedatives, and antihypertensives increase the risk for falls because of the possibility of orthostatic hypotension. Thyroid-replacement medication does not put the client at risk for falls. People with confusion or disorientation are also at higher risk. A history of previous falls also increases risk greatly.
You quickly obtain a fire extinguisher to extinguish the fire and pull the pin on the extinguisher. What is your next action? Squeezing the handle to activate the extinguisher Squeezing the handle and aiming at the center of the flames Holding the fire extinguisher at waist level and aiming the nozzle at the top of the flames Holding the hose in one hand and the handle in the other, then aiming the nozzle at the base of the flames
Holding the hose in one hand and the handle in the other, then aiming the nozzle at the base of the flames RATIONALE: The nurse's first action would be to pull the pin on the fire extinguisher. The nozzle of the extinguisher is then aimed at the base of the fire, not at the top of the flames. The handle is squeezed and the nozzle swept from side to side over the fire.
The primary health care provider writes a prescription for George, who is still under contact precautions, to undergo chest radiography. Which action on the part of the nurse is appropriate? Delaying radiography until contact precautions have been discontinued Scheduling the x-ray once culture results from George's stool specimen are negative Reminding the primary health care provider that George is under contact precautions and that he should not leave his room Informing the staff in the radiography department that contact precautions have been instituted for George
Informing the staff in the radiography department that contact precautions have been instituted for George RATIONALE: When contact precautions have been instituted for a client, the nurse plans to limit transport of the client to essential purposes only. If transport is necessary, the nurse ensures that precautions are taken to minimize contamination of environmental surfaces or equipment. Therefore, the nurse would inform the staff in the radiography department that contact precautions have been instituted for George. Delaying scheduling George for his x-ray and tests is inappropriate and unnecessary.
After the victims have been cared for and transported to local emergency departments for further assessment and treatment, to which function of the recovery phase does the emergency response team turn? Providing disaster training programs Checking the function of emergency equipment Initiating actions that will return the community to normal Trying to find facilities that will care for infants, older client, the disabled, and clients with chronic health problems
Initiating actions that will return the community to normal RATIONALE: The recovery phase consists of actions taken to return the community to normal after a disaster. It involves preventing debilitating effects and restoring personal, economic, and environmental health and stability to the community. In the mitigation phase of disaster planning (the first phase), the team determines which resources are available for the care of infants, older clients, the disabled, and clients with chronic health problems. Providing disaster training programs and checking the function of emergency equipment are actions taken in the preparedness phase.
A nursing student arrives at the clinical nursing unit and presents a plan of care for the assigned client to the nursing instructor. The assigned client requires the use of mitten restraints because he has been pulling at his endotracheal tube. Which interventions regarding restraints in the plan of care require revision? Select all that apply. Ensuring that the restraint straps are attached to the bed frame Making sure that one finger can be inserted under the restraint Using a quick-release tie to secure the restraint to the bed frame Checking for a renewal of the primary health care provider's prescription for the restraints Checking skin integrity and neurovascular and cardiovascular status every hour Removing the restraints every 2 hours for 30 minutes to perform range-of-motion exercises
Making sure that one finger can be inserted under the restraint Checking skin integrity and neurovascular and cardiovascular status every hour RATIONALE: A restraint is a physical device used to limit the physical activity of a client or to immobilize a client or an extremity for safety purposes. Specific guidelines must be followed when a client is under restraint. Federal, state, and agency guidelines regarding the use of restraints must be followed. A primary health care provider's prescription is needed, and the prescription must be renewed within a period set forth by federal, state, or agency guidelines. To prevent injury when side rails are raised or lowered, restraint straps should be attached to the bed frame. A quick-release tie is used so that the restraint may be quickly removed if necessary, such as in an emergency. The nurse must ensure that the restraint is not too tight and see that 2 fingers can be inserted under the restraint. The nurse should check skin integrity and neurovascular and cardiovascular status every 30 minutes. Also, the nurse must remove the restraints every 2 hours for 30 minutes to perform range of motion exercises.
A nurse is watching a nursing student implement standard precautions as she delivers care. The nurse should intervene if the nursing student performs which incorrect action? Washing the hands after removing a pair of soiled gloves Putting on a gown and gloves to change the bed linens of an incontinent client Manually placing the cap on a needle after administering an IV push medication Wearing gloves, eyewear, and a face shield when emptying a urine drainage bag
Manually placing the cap on a needle after administering an IV push medication RATIONALE: Needles are not recapped manually because of the risk of a needle-stick; rather, they are discarded in a puncture-resistant container immediately after use (a mechanical device for recapping the needle may be used if one is available). Standard precautions must be practiced with all clients in every setting. These precautions involve handwashing and the use of gloves, masks, eye protection, and gowns, as well as other protective devices, as appropriate for client contact. Standard precautions are used to help prevent contact with blood, body fluids, non-intact skin, and mucous membranes. A mask, eye protection, or face shield is worn if client care activities have the potential to result in splashes or sprays of blood or other body fluids. A gown is worn if soiling of clothing is likely. The hands are always washed when gloves are removed.
A client who has returned from the operating room after repair of a hip fracture is alert but confused, pulling at the IV catheter that has been inserted in her left arm. The nurse should apply which type of safety device to best keep the client from pulling out the IV line? Which type of restraint would be best for keeping the client from pulling out the IV line? Belt Wrist Elbow Mitten
Mitten RATIONALE: A mitten restraint, a thumb less device that covers the client's hand, is used to restrain the hand, preventing the client from dislodging invasive equipment (e.g., an IV line). It allows greater movement than does a wrist restraint. A wrist restraint is used to immobilize an extremity but does not allow movement as a mitten restraint does. A belt restraint is wrapped around the client's waist and used to secure a client to the bed or stretcher. An elbow restraint, consisting of a fabric wrap with slots into which tongue blades are inserted, is wrapped around the elbow area to keep the joint from being flexed.
After immediately instituting contact precautions, which action should the nurse take next? Moving George to a private room Leaving George in the semiprivate room with his roommate Advising George's roommate to wash his hands at least once an hour Informing George's roommate that it is safe for him to use the same bathroom George is using
Moving George to a private room RATIONALE: C. difficile is a bacterial infection that causes acute infectious diarrhea. Clients receiving antibiotics are susceptible to this bacterial infection because the antibiotics alter the normal bowel flora. Signs/symptoms range from mild watery diarrhea to severe abdominal pain, fever, leukocytosis, and leukocytes in the stool. This bacterial infection can be transmitted by way of direct client contact or environmental contact, and the client should be placed in a private room or with a cohort client. Leaving George with his current roommate, advising George to wash his hands at least once an hour, and informing the roommate that it is safe to use the same bathroom are therefore all inappropriate.
The nurse monitors Joseph closely after his daughter leaves and notes that Joseph is pulling his oxygen cannula off and tugging at the IV line. The nurse calls Joseph's primary health care provider and obtains a prescription to apply wrist restraints, then asks the assistive personnel (AP) to apply mitten restraints to Joseph's hands. Shortly thereafter, the nurse checks the restraints. Which finding indicates that the AP has applied the safety devices correctly? The restraint is placed over the IV site. The restraint ties are attached to the side rails. Padding is placed on the wrists, under the restraints. Only one finger can be inserted under each secured restraint.
Padding is placed on the wrists, under the restraints. RATIONALE: The skin and bony prominences are padded before a restraint is applied to reduce friction and pressure to the skin and underlying tissue. A restraint is not placed over the site of an IV line or another therapeutic device, because it could cause an occlusion. The restraint is tied to the bed frame, not the side rail, because the client could be injured if the side rail is lowered. Also, the bed frame moves when the head of the bed is raised or lowered, preventing injury to the client. The nurse should be able to insert two fingers under a secured restraint. A tight restraint may cause constriction and impede circulation.
The next day, George's IV catheter is dislodged and the nurses are unable to start another peripheral line. He still needs the IV antibiotics, so a peripherally inserted central line (PICC) is inserted into his right forearm. A few days later, the dressing over the IV site gets wet and the nurse prepares to assist a new graduate with the sterile dressing change, using a commercial sterile dressing change kit. Which action on the part of the new graduate nurse reflects the use of correct sterile technique for a dressing change? Select all that apply. Holding objects at a level below the waist Reaching over the sterile field to pick up an object on the other side Preventing liquid from spilling onto the sterile field and permeating it Touching only the edges of the sterile drape with ungloved hands When opening the kit, opening the outermost flap away from the body while keeping the arm away from the sterile field
Preventing liquid from spilling onto the sterile field and permeating it Touching only the edges of the sterile drape with ungloved hands When opening the kit, opening the outermost flap away from the body while keeping the arm away from the sterile field RATIONALE: Specific techniques must be used to preserve the sterile field. Objects must be held above the level of the waist; items held below the waist are considered contaminated. The nurse would never reach across a sterile field because of the risk of contaminating the field. When liquids permeate a sterile field, it is considered contaminated and must be replaced. Ungloved hands may touch the 1-inch unsterile border of a drape or sterile field. When opening a sterile kit, the nurse must open the outermost flap away from the body yet keep the arm away from the sterile field to avoid contamination.
A nurse spending the day with friends at an amusement park is sitting on a bench, watching people ride a roller coaster. Suddenly the nurse hears panicked screaming and sees that one car of the coaster has struck another one stopped on the track. What action should the nurse take immediately after rushing to the scene? Calling 911 Providing care to victims with life-threatening problems Triaging the victims and providing directions to laypersons who are willing to help the victims Asking someone to call the nearest hospital to let the staff know that victims of the accident will be arriving there shortly
Providing care to victims with life-threatening problems RATIONALE: The hands are dried from the cleanest area (fingertips) to the least clean (forearms). In the community setting, a nurse who is the first responder to a disaster must immediately attend to the victims with life-threatening problems. Once rescue workers have arrived on the scene, immediate plans for triage should be made. Although 911 must be called, doing so would not be the first action of the nurse: instead, the nurse should continue attending to any life-threatening conditions and ask someone else to call 911. Asking someone to call the nearest hospital to inform the staff about the accident and warn them that victims will be coming is not an immediate priority; the victims will be transported by emergency medical services once those with urgent needs have been attended to.
The nurse is preparing to remove gloves, gown, mask, and eyewear worn during care of a client. Indicate in the order of priority, how the nurse would remove the contaminated items. List them from the first contaminated item to the last item the nurse would remove. Order Sequencing Option Remove gloves Untie upper mask strings Remove mask Remove eyewear Remove gown Untie lower mask strings
Remove gloves Remove eyewear Remove gown Untie lower mask strings Untie upper mask strings Remove mask
During evening rounds, the nurse goes into George's room wearing a gown and gloves and finds George's wife sitting in the chair beside the bed. She is not wearing a gown or gloves. The nurse reminds her that it is necessary to wear the gown and gloves for her protection. Mrs. Mandaris replies, "Honey, I don't need to wear that stuff. Whatever infection he has, I've already got"! Which responses by the nurse are most appropriate? Select all that apply. Saying nothing in reply Replying, Then I will have to notify the nursing supervisor. Replying, Mr. Mandaris has an infection that can be harmful to others. That is why we wear a gown and gloves when we are in the room. Replying, Yes, you're probably right, Mrs. Mandaris. You have been exposed and are not sick. Replying, Mrs. Mandaris, it is important for your protection and for the protection of others that you wear the gown and the gloves. Let me help you with it.
Replying, Mr. Mandaris has an infection that can be harmful to others. That is why we wear a gown and gloves when we are in the room Replying, Mrs. Mandaris, it is important for your protection and for the protection of others that you wear the gown and the gloves. Let me help you with it.
Julianne quickly grabs a bag containing the items she needs when responding to a disaster. She then drives to the scene of the accident. As Julianne plans to respond and help care for victims, what does she recall as the priority task? Determining the community risks Identifying specific responsibilities of various disaster response personnel Initiating actions that will return the community to normal after the disaster The physical health, safety, and mental health of both the victims and the members of the disaster response team
The physical health, safety, and mental health of both the victims and the members of the disaster response team RATIONALE: FEMA identifies four disaster management phases: mitigation, preparedness, response, and recovery. In this situation, the response phase is the priority. This phase includes putting disaster planning services into action, including actions to save lives and prevent further damage. The primary concerns of this phase include safety and physical and mental health of both the victims and the members of the disaster response team.
The next morning, Joseph's primary health care provider examines Joseph and writes a new set of prescriptions (refer to medical chart). Which of these prescriptions needs to be clarified by the nurse? The prescription for blood cultures The prescription to get Joseph out of bed for meals. The prescription to continue the use of wrist restraints as needed. The prescription for the swallowing study by speech therapy
The prescription to continue the use of wrist restraints as needed. RATIONALE: Restraints must be prescribed by the attending primary health care provider, per the hospital's restraint policy. The "as needed" restraint prescription is not appropriate. The other prescriptions are appropriate for Joseph
A client has a prescription for an intravenous (IV) infusion of 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride at a rate of 100 mL/hr. The nurse obtains an infusion control device with which to administer the prescription and hangs the IV solution at 7 a.m. At 10 a.m. the nurse notes that 500 mL of solution has infused. The nurse assesses the client, checks the infusion rate, obtains a new infusion control device, and contacts the primary health care provider. The primary health care provider prescribes a decrease in the rate of infusion to 50 mL/hr and orders a serum potassium level. The potassium level is 3.5 mEq/L (3.5 mmol/L). Which information should be included on the incident report in regard to this event? Select all that apply. The primary health care provider was contacted. The serum potassium level at 10:30 a.m. was 3.5 mEq/L (3.5 mmol/L). A total of 200 mL of IV fluid was accidentally infused into the client. There was 500 mL of solution remaining in the IV bag at 10 a.m. The infusion control device malfunctioned causing an excess amount of IV fluid to infuse into the client.
The primary health care provider was contacted. The serum potassium level at 10:30 a.m. was 3.5 mEq/L (3.5 mmol/L). There was 500 mL of solution remaining in the IV bag at 10 a.m. RATIONALE: The incident report should contain the client's name, age, and diagnosis. The report should also contain a factual description of the incident, any injuries sustained by those involved, and the outcome of the situation. The nurse avoids the use of subjective data and documents objective data. The nurse also avoids any implication that an accident occurred or that an error was made. The statement that 200 mL of IV fluid was accidentally infused into the client implies that an accident resulted from an error. Likewise, the statement that the infusion control device malfunctioned, causing an excess amount of IV fluid to be infused into the client, poses an implication. The remaining statements identify factual and observable data free of unwanted implications.
What type of fire extinguisher will you use to extinguish the fire? Type A Type B Type C Any type is appropriate.
Type A RATIONALE: The most commonly used fire extinguishers are categorized as type A, B, or C. Type A is used for ordinary combustibles (e.g., wood, cloth, paper, and many plastic items). Type B is used for flammable liquids (e.g., gasoline, oil, grease, tar, and oil-based paint). Type C is used for electrical equipment. Because this fire involves cloth and was ignited by a match used by the client, Type A extinguisher would be used.
A nurse receives a telephone call from the admissions office and is told that a child with respiratory syncytial virus (RSV) is being admitted to the hospital. Which type of precautions does the nurse prepares to institute for the child? Enteric Droplet Contact Airborne
contact RATIONALE: Contact precautions are instituted for any client with a known or suspected illness that is easily transmitted by way of direct client contact or through contact with items in the client's environment. RSV, respiratory syncytial virus, is easily communicable, mainly through contact with contaminated surfaces. RSV is not transmitted by way of the enteric or airborne route or in droplets.
