NCLEX Fundamentals: Safety and Infection Control
The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers?
- First and last name - DOB - Medical record number do NOT use room number
The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure.
1) Perform hand hygiene 2) Place specimen in a biohazard bag 3) Scrub cath hub with antiseptic before use Do NOT: - Discard first 10 mL of blood - Flush the line with sterile normal saline
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?
Disposable gown Face shield Gloves Surgical mask
Which diseases are on droplet precautions?
Flu and pertussis
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?
Frequent hand hygiene
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.
Hand hygiene Gown Mask or respirator Goggles or face shield Gloves
What are interventions in care for a patient with cellulitis of the leg?
Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated to reduce edema. - Additional nursing interventions include applying warm compresses, monitoring the size of the cellulitis, and using personal protective equipment to prevent infection transmission.
A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia?
Partially or fully deflate the cuff - The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs.
A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action?
Pours sterile NS into a sterile basin from a bottle opened 30 hours ago - must be unopened for <24 hours
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?
Put a gauze wrap and stockinette over the IV site
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?
Reinforcing a torn PICC catheter dressing with tape Scrubbing the port with alcohol for 5 secs - scrubbing should be done for 10 - 15 seconds
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
Remove IV catheter - more important than AMA form
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?
Step slightly behind the client with feet apart, extend one leg, and let client slide against it to the floor
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?
Transport the client 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
The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection?
Use prepackaged, premoistened cloths containing chlorhexidine to bathe the patient
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?
Verify the patients activity perscription
A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?
Wear clean gloves to remove the old dressing, and wear sterile ones to apply the new dressing
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?
Wear gown, gloves, and N95 respirator Ensure that pregnant staff do not care for patient Place single use thermometer and stethoscope in room Place patient in a private room with negative air pressure Request discontinuation of isolation once patients lesions have crusted over
A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.... I can get out of anything. There could be trouble now." Which of the following is the best response to this client?
What kind of trouble are you thinking about? - assess the patient before acting
The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first?
gloves - see in google docs
At what platelet level are bleeding precautions implemented?
level below 50,000
The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection?
A femoral line inserted in the ER post cardiac arrest 48 hours ago - Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter. - The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture sites, it is not located at the insertion site. The femoral line is still at higher risk for infection.
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?
1 person safety standby with walker
Which of the following drug administrations should be reported as a practice error?
1) Cephalexin administered, patient is allergic to penicillin 2) Immunization for 3 month old given in the ventrogluteal site 3) Warfarin administered, patient is 12 weeks pregnant - Intramuscular injections are given in the vastus lateralis to children age <7 months. - Penicillins and cephalosporins can have a cross-sensitivity response.
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?
Assess abdominal distension every 4 hours Keep HOB >30 degrees Maintain endotracheal cuff pressure Use caution when administering sedatives
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. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery?
Clopidogrel is an anitplatelet and should be discontinued 5 - 7 days before surgery (same for NSAIDS, other anticoagulants)
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?
Dorsal surface of the hand - Peripheral IV sites should be selected in the hand or forearm to reduce the risk of catheter-related bloodstream infections. - Sites on the upper extremities located at flexion sites (eg, wrist, bend of arm) and the lower extremities should be avoided.
The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client?
Gown, gloves, N95 respirator, and eye protection - it is a viral respiratory illness
The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care?
Hand washing and N95 respirator
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?
One on one supervision from a sitter
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?
Provide a private room for neutropenic precautions - The client's platelet count of 78,000/mm3 (78 ×109/L) is decreased but not dangerously low; therefore, it is not the highest priority intervention. 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.
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?
Release restraints at regular intervals to assess behavior Use gauze pads on bony prominences under restraints Use a quick release knot Position in semi fowlers
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?
Report the injury
Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)?
The 80 year old with COPD who is on a ventilator - Clients at highest risk for developing hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, invasive tubes or lines, or in the ICU.
