NCLEX Review Safety and Infection Control

A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The health care provider (HCP) is calling in a telephone prescription for ampicillin. The nurse should take which actions? Select all that apply.

• Repeat the prescription to the HCP. • Ask the HCP to confirm that the prescription is correct as understood by the nurse.

A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first:

prepare to ventilate the child. Explanation: The nurse should recognize these physical findings as signs and symptoms of impending respiratory collapse. Therefore, the nurse's top priority is to assess airway, breathing, and circulation, and prepare to ventilate the child if necessary. The nurse should then notify the emergency medical systems to transport the child to a local hospital. Because the child's condition requires immediate intervention, simply monitoring pulse oximetry would delay treatment. This child shouldn't be returned to class. When the child's condition allows, the nurse can notify the parents or guardian.

A nurse-manager identifies fall prevention as a unit priority. Which of the following actions can the nurses implement to meet these goals? Select all that apply.

• Use bed alarms to remind clients to call for help getting up • Maintain a clear path to client bathrooms • Make hourly rounds to client rooms Explanation: Client falls occur most often when there is need for assistance, but the client has not called for help. Frequent rounding, clear path to all bathrooms, and bed alarms for forgetful clients all have been shown to reduce client falls. Restraints should not be used without an order, or when a less-restrictive approach can be used. Closed doors at night will not reduce the risk for falls, but may increase them if the room is too dark or the nurses do not see the client in an unsafe situation.

A nurse manager overhears a nurse caring for a client with an IV make the following statement: "If you don't stop playing with your IV, I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation?

"I need to inform you that your behavior is within the definition of assault." Explanation: The nurse's response is threatening and could be legally interpreted as assault. The manager must intervene in the best interest of the client and take the opportunity to educate the nurse regarding his or her comments and potential actions. The other options do not represent appropriate interventions for the scenario described.

A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has oxytocin infusing. Which response by the nurse is best?

"You may use the bathroom with my assistance." Explanation: The nurse should tell the client that she may use the bathroom with the nurse's assistance. The nurse should assist the client for the client's first trip to the bathroom after giving birth because it's common for a client to faint after birth. Telling the client she must wait until her vaginal bleeding stops is inappropriate; vaginal bleeding continues for about 6 weeks after childbirth. The nurse shouldn't tell the client she can get up whenever she needs to use the bathroom; doing so places the client at risk for injury.

After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action?

Removing the restraints every 2 hours Explanation: Removing one elbow restraint at a time every 2 hours for about 5 minutes allows exercise of the arms and inspection for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

The client is in the emergency department with her boyfriend. She is just recovering from a "bad trip" from lysergic acid diethylamide (LSD). She is still frightened and a little suspicious. Which nursing action is most appropriate?

having an unlicensed assistive personnel (UAP) stay with the client to decrease her fear Explanation: Having a UAP stay with the client provides for reassurance and safety. Being next to the nursing desk will increase stimuli and confusion. Being alone will increase the client's fears and anxiety. It is inappropriate to ask the boyfriend to provide client supervision for the nurse.

The nurse finds a confused client with soft wrist restraints in place (see figure). The nurse should first first:

untie the restraint and resecure to the bedframe using a quick-release knot. Explanation: To ensure the client's safety when using restraints, the restraint must be secured to the bedframe (not the side rail) using a quick-release slip knot (not a square knot). Assessing and documenting skin should be done regularly when restraints are in use, but safety is first priority. Regularly releasing restraints and performing range of motion is essential but not priority in this case. Providing for the client's basic needs while in restraints (i.e., toileting) is important but not first priority.

In which situation can a client's confidentiality be breached legally?

when a client near discharge is threatening to harm an ex-partner Explanation: Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Student papers should not contain identifying information. Release of information is made directly to the client's insurance company, not to the employer.

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating ordered antibiotic therapy, the nurse should prepare the client for:

delivery. Explanation: After rupture of the membranes in a client who has a fever or other signs or symptoms of infection, the fetus must be delivered promptly. Data obtained by amniocentesis or sonography wouldn't change the decision to deliver the fetus. Tocolytic drugs are used to arrest preterm labor.

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

Airborne and contact precautions Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.

Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility.

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?

Change diapers as soon as they become soiled. Explanation: Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most common complication after inguinal hernia repair in an infant secondary to possible wound contamination with urine and stool. Because the surgical wound is unlikely to separate, an abdominal binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not used, the health care provider (HCP may apply a topical spray to protect the wound. Restraining the infant's hands is unnecessary if the diaper is applied snugly. The infant would be unable to get the hands into the diaper close to the surgical site.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm?

Close all of the doors on the unit. Explanation: The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother?

Complete the hospital identification procedure with mother and infant. Explanation: The hospital identification procedures for mothers and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the mother and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother's ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the mother, but identification verification is a safety measure that must occur first.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

Contact Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule. Explanation: A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 4 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing, despite the amount of helpers.

Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair?

elbow restraints Explanation: Recommended restraints for a child who has had palate surgery are elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed.

A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority?

Ensuring the safety of this client and other clients on the unit Explanation: Ensuring the safety of this client and other clients on the unit is the nurse's immediate priority. Moving the agitated client to a less-stimulating environment, isolating him, or sedating him address the client's needs but don't address those of the other clients. Removing other clients from the area until the agitated client calms down addresses the safety of the other clients without addressing the needs of the agitated client.

After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which of the following actions by the nurse is most appropriate?

Enter the information tomorrow stating it is a late entry. Explanation: The nurse should enter the information on the medical record as a late entry with current date and time. The other options are incorrect because the nurse needs to document the care provided. Blank spaces should not be left in the chart and all care must be documented.

When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information?

Fifth disease is transmitted by respiratory secretions. Explanation: Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasitic conditions, such as giardiasis and pinworm infection, are transmitted by stool.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities. Explanation: The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place her and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?

Perform thorough hand washing before and after touching any child in the day care center. Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection.

The nurse is working in a public health clinic. Four clients present with various skin disorders. Which disorder requires disclosure to public health officials?

Picture 3 is a Rubella (German Measles) rash. Rubella is a contagious viral infection known for its distinctive red rash. Due to vaccines, it is not seen often but is still classified as a communicable disease. Titers are drawn to document immunity. Picture 1 is Poison Ivy characterized by the red raised and sometimes fluid filled vesicles. Picture 2 is a Butterfly rash commonly seen in the autoimmune disease Lupus. Picture 4 is the bull's eye rash commonly seen in Lyme's Disease.

A suicidal client is placed in the seclusion room and given lorazepam because she tried to harm herself by banging her head against the wall. After 10 minutes, the client starts to bang her head against the wall in the seclusion room. What action should the nurse take next?

Place the client in restraints. Explanation: The nurse and staff should place the client in restraints to protect her from further self-harm. The client's behavior is out of control and necessitates external controls for her safety. The healthcare team is trained to deal with this type of behaviors so there is no reason to call hospital security at this time. Calling the HCP for additional medication prescriptions is not appropriate because the lorazepam given by the nurse may take effect if the client remains still. The nurse is responsible for judging whether additional medication is needed later. Instructing a staff member to sit in the room with the client is unsafe for the client and the staff member.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Risk for injury Explanation: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

Which topic would be most important to include when teaching the parents how to promote overall toddler development?

Safety is a priority concern for this age-group. Explanation: Because of toddlers' high energy and poor impulse control, safety is a priority concern for this age-group. Language is important in toddler development, but not the most important at this time. While parents should set clear guidelines for behavior, the priority for toddlers is ensuring safety. Diet habits should be developed at this time, but the most important subject to teach parents of toddlers is safety.

A client with breast cancer received chemotherapy approximately 10 days ago. Her complete blood count today is as follows. Which teaching is appropriate based on these laboratory results? White blood cells 5000/cmm Neurophils 75% Hemoglobin 13 g/dL Hematocrit 40% Platelets 45,000/cmm

Use electric razor to shave legs Explanation: These laboratory values are all within normal limits except the platelet count, so the client is at risk for bleeding. The electric razor will minimize the risk of injury when shaving

A physician orders penicillin G, 300,000 units I.M., for an 18-month-old child. Where should the nurse administer this injection?

Vastus lateralis muscle Explanation: For a child younger than age 3, the thigh (vastus lateralis muscle) is the best site for I.M. injections because it has few major nerves and blood vessels. The deltoid, dorsogluteal, and ventrogluteal sites aren't recommended for a child younger than age 3 because of the lack of muscle development and the risk of nerve injury during injection. Before the dorsogluteal or ventrogluteal sites can be used safely, the child should have been walking for at least 1 year to ensure sufficient muscle development.

A nurse is caring for a client with watery diarrhea and dehydration. Given the client's recent history of heavy antibiotic use, what interventions should the nurse consider?

Wearing gown and gloves when working in the room Explanation: The client presents with the risk factors and symptoms of Clostridium difficile diarrhea which requires contact isolation. Changing diet or giving anti-diarrhea medications will not improve the situation, specific antibiotics are effective in most cases. It is important to encourage fluids but IV would be preferred since oral fluids are expelled in the stool.

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions?

With the heel of one hand Explanation: When performing CPR on a child between ages 1 and 8, the nurse should use the heel of one hand to compress the chest one-third to one-half the depth of the chest. Using only the fingers of one hand isn't appropriate for CPR. The use of two fingertips is appropriate for infant CPR but this method can't compress the chest sufficiently on an older child. The palm is never used for chest compressions in CPR.

A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should:

initiate a time-out. Explanation: The Universal Protocol is used to prevent wrong site, wrong procedure, and wrong person surgery. Actions included in the protocol are as follows: conduct a preprocedure verification process, mark the procedure site, and perform a time out. Exceptions to the Universal Protocol are routine or "minor" procedures, such as venipuncture, peripheral IV line placement, insertion of oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the surgeon or circulating nurse will initiate a time out to verbally confirm a review of informed consent and procedures completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies have been removed. The Chief of Surgery and Medical Director are the ones who will verify the surgeons' levels of expertise.