Quiz # 2
RACE
*R*escue patients sound the *A*larm *C*onfine the fire *E*xtinguish/Evacuate
antiseptic
*may be used on humans* a substance that stops the growth and reproduction of microorgamisms
Health care providers today need to be aware that health care-associated infections are a serious problem. What is the most effective way to prevent health care-associated infections?
Perform proper hand hygiene before and after caring for a patient.
The patient reports fatigue, weight loss, dyspnea, fever, night sweats and *coughing up small flecks of blood* what should the nurse do FIRST
Put a mask on the patient and escort him to an isolation room. (These are symptoms of TB. It is important to isolate this patient to prevent transmission.)
A patient in contact isolation has a minimal amount of visitors, and the health care staff enters only when patient care is being performed. Based on this information, which patient problem is most appropriate for this patient?
Risk for social isolation
a patient isolated for pulmonary tuberculosis (TB) seems to be anger. The nurse recognizes this is a normal response to the isolation. What action by the nurse is most appropriate?
explain isolation procedures and provide meaningful stimulation.
virulent
extremely pathogenic
TB symptoms
fever, cough, bloody sputum, weakness, chest pain, night sweats
The NS has been diagnosed with strep throat. Under what circumstances can the student go to the clinical unit and care for patient's and complete the clinical objectives?
has been taking prescribed antibiotics for at least 24 hrs. (After 24hrs, she is no longer contagious)
A 45 year old man is admitted to the hospital with cellulitis of the right foot. 3 days later, he develops bacterial pneumonia. How is this type of infection classified?
health-care care- associated (He was admitted to the hospital and 48 hrs later, he contracted another infection)
Health care associated infection
hospital acquired infections ranging from mild to fatal. 48 hrs after hospitalization
the nurse has knowledge about infection and the application of
infection prevention and control principles
although surgical asepsis is practiced in the o.r. &in the specialty areas, the nurse at times also uses surgical aseptic technique at the patient's bedside. For which procedure does the Nurse use surgical asepsis?
inserting an iv, inserting catheter (the areas have to remain sterile to prevent infections)
The nurse is supervising a NS who is setting up a sterile tray to suction a patient. The nurse would *intervene* if the student:
puts on sterile gloves, opens the bottle, and sets the cap on the sterile field. (The outside of the bottle is considered to be contaminated, so the student would have contaminated the whole tray as well as the sterile bottle cap)
The nurse is assisting a health care provider by setting up a sterile tray for a procedure at the bedside. When the nurse opens the tray, there is moisture on a piece of equipment. What should the nurse do?
return the entire tray yo the supply area for resterilzation & obtain a new tray. (Moisture seeping through a sterile packages protective covering allows microbes to travel to the sterile objects- contaminated)
A patient who is HIV positive & ready for discharge expresses fears about exposure of other family members, particularly young children, to the disease. What is the best response to help decrease the patient's fears & concerns?
review principles of mode of transmission for HIV. (Explain how it can be transmitted and take the proper precautions)
A patient in isolation is experiencing signs of social deprivation. Which intervention by the nurse is appropriate?
set specific times when the nusre will return to the patient's room.
The nurse is supervising a nursing student. Which action by the students requires correction because it contributes to the potential transmission of pathogens?
shakes linens to remove debris & then places them in laundry bag. (Puts microbes in the air)
The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position. What action would the nurse perform first (don't know)
Assist the patient to sit back down
True or false: Safety reminder devices (SRDs) are primarily used in long term care facilities.
False. SRDs can be used in any health care setting. Many long term care facilities are currently adopting a restraint-free environment
True or false: There is a 5% chance of a health care worker becoming infected with HIV from a sharps injury
False. There is a .03% chance of a health care worker becoming infected with HIV from a sharps injury
Your patient was admitted to the hospital 4 days ago with cardiac problems and now has bacterial pneumonia. This is an example of what type of infection?
Health care-associated
how to transfer respiratory isolation patient
mask
a young adult is admitted to a medical unit with the diagnosis of hep A & placed in contact precautions. What is the primary goal of this action?
to prevent transmission of infectious microorganisms.
During surgery, the health care provider requests more sterile water. What action must the nurse perform before pouring the solution into the sterile container?
"Lipping" of the bottle with its solution. Before pouring the solution into the container, the nurse pours a small amount into a waste receptacle, which cleans the lip of the bottle. This is referred to as "lipping" the bottle. Wiping the rim of the bottle introduces the possibility of contamination from the cloth or towel. Pouring the water straight into the container does not take into account that the edge of the bottle may not be clean. Handing the bottle over without making sure it is clean would introduce the possibility of infection to the sterile nurse.
carrier/vector
*A person or animal* that does not become ill but harbors and spreads an organism, causing disease in others
A long-term care facility is committing to a restraint-free environment. What will the health care workers implement to encourage this environment? (Select all that apply.)
- Frequent orientation to surroundings. - Explain all procedures and treatments. - Maintain toileting routines.
The nurse is supervising a new UAP in performing care for isolation patients. when is the nurse most likely to intervene
- The UAP wears a mask dangling around the neck and reposition it before entering the room. - Removes mask by grasping the front portion that covers the mouth and pulling it off. - Pushes the sleeves of her isolation gown up while bathing a patient.
In the event of a mercury spill, what is the priority nursing action? 1. Evacuate everyone from the room 2. Close the interior doors and open windows. 3. Vacuum the mercury and the glass shards 4. Mop the floor with hot water and soap
1. Evacuate everyone from the room Everyone should leave the room where the thermometer has been broken. Close interior doors and open windows to increase ventilation to the outside. The area should not be vacuumed, but should be moped with a mercury-specific cleansing agent. The home health nurse should refer to agency policy for additional directions that relate to the home environment.
What does universal carry mean? 1. How to remove a patient from the bed to the floor 2. How to carry a patient as if he/she were an infant 3. How to carry two patients at one time 4. How to evacuate several patients in a short amount of time
1. How to remove a patient from the bed to the floor
Chain of Infection
1. agent 2. reservoir 3. portal of exit 4. mode of transportation 5. portal of entry 6. host
A patient with a latex allergy is exposed to latex. Which sign or symptom is cause for the greatest concern? 1. Hives 2. Laryngeal edema 3. Runny eyes and nose 4. Localized swelling
2. Laryngeal edema Laryngeal edema puts the patient at risk for an airway obstruction. The other signs and symptoms could occur during a type IV hypersensitivity allergic reaction which is less serious.
It is suspected that a patient has been exposed to cyanide gas. The nurse is alert for which symptom? 1. Erratic behavior 2. Nausea and vomiting 3. Respiratory distress 4. Vesicle formation
3. Respiratory distress Severe respiratory distress is the most prominent symptom of cyanide gas exposure.
The nurse started a new job in a small LTC facility in a rural area. The back exit hallway is being used as a storage area and "a new storage area is being planned." What should the nurse do first? 1. Report the facility for unsafe conditions 2. Express unwillingness to work in unsafe conditions 3. Review the facility's policies/procedures for emergencies 4. Check the building for other safety issues
3. Review the facility's policies/procedures for emergencies The nurse would first review the facility's emergency/fire policies and procedures to determine if contingency plans have been made for the blocked hallway. Based on the review of the policies/procedures, the nurse may decide to use the other options.
In the event of a bioterrorist attack, what is the first role that the nurse must perform? 1. Isolate suspected cases 2. Advocate for public safety 3. Liaison with the public health department 4. Recognize high-risk syndromes
4. Recognize high-risk syndromes Before any action is taken, someone must recognize that an unusual biologic event is occurring. The nurse is one of the first health care professionals who will assess patients for flulike symptoms or other symptoms that mimic endemic disorders. The nurse would isolate any suspected cases and immediately contact the supervisor, so that emergency/disaster plan can be activated. The plan should include notification of the local public health department and attention to public safety.
The LPN/LVN is reviewing the admission information of a patient. Which information is of most concern to he nurse that this patient is at high risk for falling? 1. The patient has diabetes 2. The patient had a stroke 3 years ago with no complications 3. The patient becomes disoriented in the evening hours (?) 4. The patient wears eyeglasses and a hearing aid
4. The patient wears eyeglasses and a hearing aid
Which patient is the most challenging regarding maintaining sterile technique throughout the procedure?
75 year old woman who is obese & confused needs a catheter inserted. (She is confused and could try to touch the sterile equipment, since she is obese, inserting the catheter can be hard)
Standard Precautions
A combination of Universal Precautions and Body Substance Isolation guidelines; used in hospitals for the care of all patients.
Safety reminder device (SRD)
A device used to immobilize a patient or a part of the patient's body
A nurse notes that in a client's room there is a vase containing dirty standing water and dead flowers. Which link in the chain of infection could this dirty water represent?
A reservoir
The nurse is speaking with a patient about the need to prevent infection. The nurse recognizes that the patient understands proper hand hygiene when she makes what statement?
After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water.
The nursing instructor is discussing the chain of infection to a group of students nurses. What is the most important information about identifying the chain of infection for the health care provider?
Determination of points at which the infection can be stopped or prevented can be made by identifying the chain of infection.
Naturally Occurring Disasters
Earthquakes, Hurricanes, and Floods
True or false: Safety reminder devices (SRDs) are primarily used in long term care facilities
False. They are used in many health care facilities, and most LTCs are eventually adopting a restraint free environment
What should be included in care for a patient with *incontinence and Rotavirus*
Gloves and gown upon entering the room. (Contact precautions)
wear for known TB patients
HEPA respirator
Fomites are
Inanimate objects(nonliving) involved in the indirect contact transmission of pathogens
aseptic technique **
Infection control practice used to prevent the transmission of pathogens
The patient asked the nurse how his skin will be sterilized before his surgery. What is the. est resp by the nurse?
It is not possible to sterilize the skin, but we will use an antimicrobial solution to eliminate most microorganisms
the nurses are assigned a mixture of patients who need isolation or just routine standard precautions. which nurse has exposed her patients to infection via indirect method of transmission
Nurse B uses her personal stethoscope to assess all of her patients. (Every isolation/ Standard precaution patient is supposed to have their own equipment to prevent transmission)
OSHA
Occupational Safety and Health Administration
The nurse is observing the new staff member who is preparing to do a sterile dressing change. The nurse determines that the staff member requires correction & additional instruction when he observes:
Opening the outter flap of the sterile package by moving it towards the body (always move it away from the body)
exogenous
Produced outside the body
A patient begins to have a gal mal seizure. What is the priority action
Protect against falls and other injuries If the patient is having uncontrollable movements during a grand mal seizure, placing soft material against the side rails offers some protection. Checking the airway and suctioning secretions should be performed by the nurse. Inserting an oral airway is not done during the seizure, but may be done after the seizure is over to keep the tongue from falling backward; also there is always a possibility of a repeat seizure until medication or other therapy is given.
P.A.S.S
Pull, Aim, Squeeze, Sweep
Which of the following is a characteristic of some bacteria that can allow them to lie dormant for long periods of time when conditions for growth are not favorable?
Spores
The nurse is caring for a patient with a wound infection of the lower extremity. Which types of precaution would the nurse use when taking care of this patient?
Standard and Contact Precautions
airborne illnesses
TB, measles, chicken pox, disseminated herpes zoster
The nurse is preparing to open the outer sterile wrap of a indwelling catheter tray. Which flap of the wrap in which direction, should be opened first
The flap that opens away from the nurse
True or false: It is acceptable to delegate monitoring patient behavior for risk and injury and promoting a safe environment as a responsibility of the UAP, in addition to the nursing staff
True
True or false: It is acceptable to delegate monitoring patient behavior for risk for injury and promoting a safe environment as a responsibility of the UAP, in addition to the nursing staff.
True
What should a nurse do when encountering a mercury spill?
Use a special kit designed for cleaning mercury and follow the instructions exactly
A client with a respiratory infection asks the nurse why he is not yet on an antibiotic. The nurse explains that the health care provider has diagnosed him with a type of infection that will not be helped by taking antibiotics. What type of infection does this client MOST LIKELY have?
Viral
The nurse suspects that a patient has an infection. What lab value would the nurse assess to help confirm the suspicion?
WBC
Which patient is most likely to be susceptible to infection because of factors affecting immunologic defense mechanism?
a 73 year old man who recently had chemotherapy and radiation treatments. (Age, chemo and radiatin affect immune defenses)
Contamination
a condition of being soiled, stained, touched by, or otherwise exposed to harmful agents
Formite
a vehicle that is an inanimate object that harbors and transmits pathogens
Terrorism
a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda
The nurse is performing a surgery hand scrub. During a surgical hand scrub, how are the hands to be held?
above elbows (water flows from least contaminated to most contaminated. Removing transient microbes)
Asepsis
absence of pathogenic microorganisms
Poison
any substance that is harmful to your body when ingested, inhaled, injected, or absorbed through the skin
The nurse sees the UAP trying to take an overly full laundry bag from the patient's room to the dirty untility room. The UAP is struggling to manage the bag and is partially dragging it in the floor. What should the nurse do?
assist the UAP to carry the bag and then find out how it got so over full. (assist because the floor is dirty)
identify 4 major classifications of pathogens
bacteria, viruses, fungi, protozoa
Factors that influence the safety of the older adult in the home or health care environment
changes in sensory function (vision, hearing, touch), decreased muscle strength, decreased circulation, medications taken, and possible cognitive alterations
The patient has a large midline abdominal incision. With the specific purpose of reducing a possible reservoir of infection, the nurse:
changes the dressing when it becomes soiled. Soiled dressing promote growth and reproduction of microbes
surgical asepsis
consists of techniques designed to destroy microorganisms and spores
Medical (absence of pathogens) asepsis
consists of techniques that inhabit (stops) the growth and transmission of microongranisms
The new nurse observes a health care provider who routinely comes out of a patient's room, rinses, and then shakes water from her hands so that it splashes on the floor, sink, and her uniform. What should the new nurse do?
contact the infection control nurse for advice. (The infection- control nurse can document the incident. Providing education to the staff about the importance of infection control and prevention)
the patient has TB &has been placed in a negative- pressure isolation room with airborne precautions. Despite repeated attempts to educate the patient, he keeps sneaking out of his room & going outside to smoke. What should the nurse do first?
discuss the behavior with the patient. (Educate the patient of the risk of exposing others to TB)
External Disasters
events outside the hospital that produce a large number of victims (e.g. fires plane or train crashes earthquakes or violent civil disturbances)
Portal of exit (chain of infection)
exit route from the reservoir
Convalescence
gradual recovery of health
mode of transportation
method or vehicle of transportation. How it is spread. Airborne, Contact, Droplet
Nonpathogenic
not harmful
monitoring of activities to assess response to the therapies include
objective nursing assessments, vital signs, and labs
host
one of the links in the chain of infection, an uninfected person or animal that is susceptible to the pathogen
spore
specialized protective stuctures some bacteria have; a round body formed by the bacterium when conditions are unfavorible for growth. The spore becomes dormant until environmental conditions become more favorable for growth and reproduction
Hand washing
standard wash for 15-30 seconds, warm water
Disaster manual Define
steps to be taken prior to, during and after the disaster.
which is a principle of surgical asepsis?
sterile fields & sterilized items are no longer sterile if they contact a clean surface.
sterile technique is called
surgical asepsis
To prevent transmission of an infection, what has to happen
the cycle must be broken
Infection prevention and control
the implementation of policies and procedures in hospitals and other health care facilities to minimize the spread of health-care associated or community acquired infections to patients and other staff members.
Vehicle
the means by which organisms are carried about and transported to the next host once they leave the reservior
disinfection
the use of a chemical that can be applied to objects to destroy microorganisms but not spores
Bioterrorism
the use of biological agents to create fear and threat
A nurse is working in a long term care facility caring for older adults. What type of accident is most often experienced by an older adult? 1. Burns 2. Falls 3. Poisoning 4. Asphyxiation
2. Falls Due to physiologic changes that older adults experience, they are at risk for falls. Most falls occus when transferring to a bedside commode or wheelchair. The most common accident experience by an older adult is related to the physiologic changes of aging, such as loss of vision and balance
examples of mode of transmission
Airbone, Contact, comtaminated food or needles
Health care-associated infections (HAIs)
An infection that is acquired in a hospital setting, formerly known as a nosocomial infection
A disaster situation occurs and involves an explosion in a hospital laundry room. What type of disaster would this be classified as?
An internal disaster
A circulating nurse opens sterile packages while in the operating room. What is the most appropriate way to create a sterile field when opening the sterile package's top triangle?
Away from the nurse
Disasters carried out by people
Bombings, arson, riots, shootings and hostage taking
Center for Disease Control and Prevention (CDC)
Part of the U.S. Department of Health and Human Services, provides facilities and services for investigation, prevention, and control of disease.
The 1st year nursing students are going to the hospital for their first clinical. What is the most important thing that the students should do to prevent exposing patients to HAIs
Perform hand hygiene using recommendations from the CDC. (Hand Hygiene is the most importent in preventing transmission of pathogens)
prodromal period
Short period after incubation; early, mild symptoms
Disaster manual (2)
Specifies departmental responsibilities; chain of command; callback procedures; assignment procedure; patient evacuation procedure and routes; procedures for the receipt and management of casualties; and policies related to the overall management of supplies and equipment
Which patient is showing signs of an inflammatory response in the absence pf infection
The patient's ankle is swollen, red and tender; symptoms started after falling. (These are signs of localized inflammation. It resulted after a fall which is the cause of the infammation)
the nurse performs hand hygiene before donning gloves, completes the procedure, and then doffs the gloves. What is the best rational for performing hand hygiene after doffing the gloves and before leaving the patient's room
There is a risk of perforating the gloves during use and the perforation may not be obvious. (Helps prevent cross contamination)
The patient has been received antibiotic therapy. Which lab result indicates a need to contact the health care provider for a reevaluation of prescribed therapy?
WBC is elevated. (The antibiotics arent working becayse WBCs should be down if the infection is resolving)
The student is reviewing sterile technique. When using the technique, the sn is reminded to hold sterile objects in which location?
above waist level (anything below the waist is considered to be contaminated)
To practice strict surgical asepsis, the nurse:
adheres to principles of sterile technique
The nurse is assigned to represent the unit in the infection prevention & control committee. The community is discussing the CDC's hand hygiene recommendation for implementation in the hospital. Which statement demonstrates an understanding of the CDC's recommendation?
alcohol-based Hand cleaner is effective on hands that are not visibly soiled with blood & body fluids
The nurse is aware that the body has normal defenses against infection. Which medication can affect the acidic environment, which is one defense mechanism?
aluminum/ magnesium antacid. (GI tract- chemically destroys microorganisms incapable of surviving low pH)
sentinel event
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
systemic infection symptoms
fever, feeling I'll or unwell, pain in joints, swelling in the joints, pain in tendons, skin rash with pink or red spots that become pus filled
The nurse caring for the patient in isolation wears latex gloves. Which is an important consideration?
first assess the patient for potential latex allergy. (Latex allergies can be life threatening)
Endogenous
growing within the body
The nurse is working in a clinical medical area with a census of 15. Each patient has a different illness. When planning care, the nurse recognized which of the following as the most important action to provide protection to each patient from health cate- associated infections?
hand hygiene. (Hand hygiene is important in preventing the transmission of infection)
Which patient needs to be placed into contact precautions?
has a draining wound colonized with multiple resistant bacteria. (contagious via direct contact. Multiple resistant bacteria- hard to treat. Draining wound should be covered)
A patient with rubella needs to be transported to the X-ray department. What should the nurse do to prepare the patient for transport?
instruct the patient to wear a mask & follow cough etiquette. (Droplet Precaution. Cough Etiquette: covering mouth when coughing, etc)
Incubation period
interval between *initial infection and first signs and symptoms*
Acute stage
interval when patient's sign and symptoms manifest, *time when individuals most contagious*
a patient comes into the clinic and tells the nurse that he has a sore throat and would like to see a do. For which task(s) does the nurse need to wear gloves?
measuring an oral temp, taking a throat swab and when using a tongue blade to look at the throat. (Wear gloves when the potiental for touching blood, body fluids- mouth-, secretions and excretions)
The nurse is assigned to care for the patients who are in isolation and patients who are not in isolation. What should the nurse do to try to meet the needs of all the patient's?
organize and cluster care of isolation patient's to minimize gowning and ungowning. (Typically, very sick patients are in isolation are the priority. Cluster care: bringing all the supplies you need- meds, care items, etc)
Localized infection symptoms
pain and tenderness, redness and adema
Infectious agent is
pathogen
systemic
pertaining to the body as a whole
The nurse is assisting the physician with an irrigation of a draining abdominal wound. y preparing the sterile tray. Sterility of the tray must be maintained at all times. During the process, which action by the nurse is most correct?
put on sterile gloves to handle the contents of the tray.
When caring for a patient with tuberculosis who is on airborne precautions, the nusre should routinely use:
respirator mask N-95
The Student nurse is preparing to Don sterile gloves. What action indicates understanding of the need procedure?
touch only the inside surface of the first glove while pulling it on to the hand (touching the outside of the glove will cause contamination. touching the inside of the glove I allowed because it lays on the skin)
Sterilization
a method used to kill all microorganisms *including those that form spores*
There are many methods of transmission of infection. Which is the best example of a vehicle of transmission?
A health care worker's hands, hospital equipment, or instruments
disaster situation
An uncontrollable, unexpected, psychologically shocking event that is unique and likely to have a significant impact on a variety of health care facilities.
The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim?
Poison control center
Codes
a system of notification that allows information to be transmitted rapidly
True or False: There is a 5% chance of a health care worker becoming infected with HIV from a sharps injury.
False. There is a 0.03% chance of a health care worker becoming infected with HIV from a sharps injury
microorganism
tiny, usually microscopic entities capable of varrying on living processess
The nurse is considering the use of an SRD to prevent a patient from self injury. When using an SRD, the nurse should: (select all that apply.) 1. obtain a health care provider's order for the SRD 2. explain the purpose of the SRD to the patient 3. explain the purpose of the SRD to the family 4. obtain consensus of nursing staff for type of SRD 5. exhaust all alternatives before using an SRD
1, 2, 3, 5, 1. obtain a health care provider's order for the SRD 2. explain the purpose of the SRD to the patient 3. explain the purpose of the SRD to the family 5. exhaust all alternatives before using an SRD The use of SRDs requires an order, explanation to the patient and family, and is only used as a last resort after other methods have been tried or considered. The entire nursing staff does not have to be consulted about the type of SRD. Type of SRD depends on provider's orders, clinical judgment, and ongoing assessment.
A patient has a care plan with a nursing diagnosis of Risk for Injury. Which interventions would be the most appropriate? (Select all that apply.) 1. Keep bed in low position except when care is given 2. Instruct the use of a call bell and keep in reach at all times 3. Orient patient to the room and environment to provide familiarity 4. Allow patient to have reading materials and clothing lying about the room 5. Assist the patient to the bathroom frequently
1, 2, 3, 5. Each of these interventions is necessary and appropriate to reduce the risk of injury. Allowing the patient to have reading materials and clothing lying about the room is innappropriate because the environment needs to be free of litter to reduce the risk of tripping and falling.
The nurse is planning to teach a community group about fire safety in the home. What information should be included in the presentation? (select all that apply) 1. No smoking by the patient, family, or visitors in area where oxygen is used 2. Use safety matches to light candles or fire places 3. Install fire alarms, smoke detectors, and carbon monoxide detectors 4. Practice fire escape routes from each room and practice exit drills 5. Use one electrical circuit to facilitate monitoring of cords and appliances 6. Cover electrical cords with a secure carpet to prevent falls
1, 3, 4 1. No smoking by the patient, family, or visitors in area where oxygen is used 3. Install fire alarms, smoke detectors, and carbon monoxide detectors 4. Practice fire escape routes from each room and practice exit drills No one should smoke around oxygen. Fire alarms and other detectors should be properly installed and routinely checked. Family should have escape routes planned and practiced. Use of candles should not be encouraged. Using one electrical circuit creates a potential for overload. Covering electrical cords may decrease falls, but the carpet will mask frayed cords and offer a fuel source for fires.
During the 7am to 3pm shift on the adult surgical unit, the code is announced for an external disaster emergency. Which event best represents this type of situation? 1. A school bus accident 2. A bomb threat in the mail room 3. A hostage event in the emergency department 4. An electrical fire in the maintenance department
1. A school bus accident
The home health nurse is visiting an older adult patient and her husband. What safety concern is of the highest priority when the nurse is assessing this patient's home environment? 1. Accidental poisoning 2. Electric shock 3. Accidental falls (?) 4. Thermal burns
1. Accidental poisoning
The nurse has completed a sterile procedure and is preparing to remove the soiled gloves. To remove the glove, what actions are required of the nurse?
1. Grasp the outer surface of the glove 2. Place the glove in the hand that is still gloved 3. Take fingers of bare hand and tuck inside remaining glove cuff 4. Peel the second glove off, turn inside out, and discard
When caring for the patient who required the use of a SRD, what should be included in the patient's plan of care? (select all that apply) 1. Monitor the skin for signs of impairment 2. Remove the SRD once every 2 hours 3. Secure the ends of the ties to the side rails 4. Ensure that the SRD is in place at all times 5. Reevaluate the need for the SRD frequency
1. Monitor the skin for signs of impairment 2. Remove the SRD once every 2 hours 5. Reevaluate the need for SRD frequency
The LPN is reviewing the care plan of the patient who has an SRD applied for personal safety. Which is the best goal for this patient? 1. Patient will remain free of injury 2. Patient will allow SRDs to be used 3. Nurse will check SRD every 30 minutes 4. Use least restrictive form of SRD possible
1. Patient will remain free of injury
The nurse is observing the UAP who is assisting a resident in a long-term care facility ambulate with a gait belt. Which action by the UAP indicated to the nurse that further instruction is necessary? 1. The UAP loosely fastens the gait belt around the patient's waist 2. The UAP places the gait belt on the resident before assisting the resident to a standing position 3. The UAP grasps the gait belt while assisting the resident out of bed 4, The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair 5. The UAP explains to the resident that the gait belt is used to prevent injury to the resident and the UAP when assisting with ambulation
1. The UAP loosely fastens the gait belt around the patient's waist 4. The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair
An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours. The patient has a history of falls. The nurse intervenes by: 1. obtaining an order for a bed and chair alarm 2. keeping the light on and the television playing all night 3. putting up the side rails and frequently checking on the patient 4. having the family come to check on the patient at night
1. obtaining an order for a bed and chair alarm A bed and chair alarm alert the nursing staff that the patient is getting up, so someone knows to go assist the patient. Keeping the light and television on would add to confusion and disorientation. Side rails are considered a form of restraint and confused patients often attempt to crawl over the rails. Frequently checking on the patient is always a good idea, but the patient can still wander off between times. Having family come in every night is unpractical and unrealistic in an extended care situation.
Why should a hospital have a disaster plan? 1. to be prepared in times of emergent community situations with the possibility of a large number of casualties 2. To be familiar with possible emergent situations that could affect a community 3. To eliminate factors that could cause a community disaster 4. To fulfill federal guidelines that pertain to hospitals
1. to be prepared in times of emergent community situations with the possibility of a large number of casualties
Which occurrence is most likely to be investigated as a "sentinel event"? 1. Patient leaves the hospital against medical advice because she gets angry with the nurse. 2. An older patient sustains a broken arm related to the use of an SRD (*)3. A nurse is 2 hours late administering routine scheduled medications 4. During a follow-up phone call, a patient reports that care in the hospital was poor.
2. An older patient sustains a broken arm related to the use of an SRD A sentinel event is an occurrence that causes death or serious injury. A broken arm suggests that there may have been improper assessment, application, monitoring, or choice of SRD. The other events may be subject to an internal review by risk management, hospital administration, or the nurse manager.
The patient reports dizziness when standing up too fast. Which over-the-counter medications is most likely to be contributing to the patient's orthostatic hypotension? 1. Nonaspirin pain reliever 2. Antihistamine 3. Vitamin supplement 4. Medicated cough drp[
2. Antihistamine Antihistamines cause drowsiness and have mild sedative properties, so patients should be cautioned about side effects.
A 63 year old man is brought to the emergency department for treatment of unintentional poisoning. What is the nurse's first action in caring for this patient? 1. Induce vomiting 2. Assess the patient 3. Place the patient in an upright position 4. Notify the poison control center
2. Assess the patient
Before the nurse can intervene, a UAP pushes contaminated material into an overfilled sharps container and sustains a puncture wound. What should the nurse do first? 1. Tell the UAP to immediately report to the infection-control nurse 2. Assist the UAP to scrub the wound with copious amounts of soap and water 3. Report the UAP for improper handling of hazardous material 4. Dispose of the sharps container to prevent any additional injuries to others.
2. Assist the UAP to scrub the wound with copious amounts of soap and water. Scrubbing and flushing the wound with soap and water is the best first measure to decrease risk of infection. The UAP should contact the infection-control nurse. Sharps boxes should never be overfilled, but are disposed of before they are full and immediately replaced. The nurse and the UAP should both write an incident report which would include the facts.
The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation? 1. The nurse's feelings about having used the SRD 2. The specific type of SRD used 3. Confirmation of a prn order for use of SRD 4. Evidence that the patient was assessed every 8 hours
2. The specific type of SRD used
Which new equipment creates the greatest risk for falls for an older adult? 1. Wheelchair 2. Prescription lenses 3. safety bar in shower 4. walker
2. prescription lenses Any new device or equipment has some risks because of the learning curve; however, new prescription lenses frequently cause some distortion in depth perception and they are less likely to be perceived by the patient or the staff as "new" or directly related to safe ambulation. A wheelchair, safety bar, and walker are designed to increase stability. In addition, the elderly adult is likely to approach these new items with caution.
The nurse notices smoke coming from the wastebasket in a patient's room. Upon entering the room, the nurse sees a fire that is starting to flare up. What should the nurse do first? 1. Extinguish the fire 2. remove the patient from the room 3. close the door to the room 4. turn of all electrical equipment
2. remove the patient from the room The nurse remembers RACE and first removes the patient from the room. As they exit the room, the nurse closes the door to confine the fire to that room and then sounds the alarm. The nurse is not likely to turn off all electrical equipment in this case.
A mother brings her alert and playful child to the clinic because she "found him playing with an empty bottle of baby aspirin". Which question is most important to ask the mother? 1."Has he ever done anything like this before?" 2."How many times has he vomited since the ingestion?" 3."How many pills do you think were in the container?" 4."Did you contact poison control before you drove to the clinic?"
3. "How many pills do you think were in the container" In cases of overdose, it is essential to determine the quantity. The mother may need help to remember that the bottle was half full, or only had 2 or 3 pills. In the case of aspirin, the number of times of vomiting is less relevant, because aspirin is readily dissolved and absorbed in the stomach. The health care team will contact Poison Control regardless of the mother's first report or the first aid given at home. In addition, Poison control is likely to have the mother's call on file. Asking about previous episodes of poisoning would be relevant after current emergency care is given, if the health care team has reason to suspect child neglect/abuse.
When assessing the staff's knowledge of the fire safety precautions, which action indicated the need for further fire safety instruction? 1. fire exits and corridors are kept clear 2. A no smoking sign is posted when oxygen is in use 3. A heating pad cord is taped when a frayed area is noted 4. Facility smoking policies are a part of the admission procedure 5. An UAP evacuated critically ill patients on the elevator during a fire drill
3. A heating pad cord is taped when a frayed area is noted 5. An UAP evacuated critically ill patients on the elevator during a fire drill
For the care of a patient who has an SRD in place, which task can be delegated to a UAP? 1. Observe for circulation distal to the SRD 2. Check for respiratory effort and breathing 3. Change position every 2 hours 4. Determine when the SRD can be removed
3. Change position every 2 hours The UAP can be instructed to assist the patient to change position every 2 hours. Assessment of circulation and respiratory effort should be performed by the nurse. The RN and health care provider should be consulted to determine the time for removal of SRDs.
The nurse is giving instructions to the UAP about patient safety and fall prevention. What should the nurse tell the UAP about helping the patient go to the bathroom? 1. Help the patient whenever she needs help 2. Ask her if she wants to walk or use the bedpan 3. Have her sit up slowly and dangle her legs before standing 4, Help her to the commode chair if she seems weak
3. Have her sit up slowly and dangle her legs before standing. The nurse gives specific measures to prevent orthostatic hypotension (ex. sit slowly and dangle the legs before standing). "Whenever she needs help" is a vague direction that requires the patient to ask for help and then the UAP must decide if help is appropriate, but there is no guidance about circumstance or execution. The nurse should assess whether the use of the bedpan is appropriate for the patient. If the patient is able to get up, walking decreases the complications of immobility. The UAP should not be expected to make a decision about "if she seems weak." This decision should be based on nursing assessment.
The nurse is talking to a young mother who has an infant who has just started to crawl. Based on knowledge of growth and development, which safety issue is currently the most important to discuss with the mother? 1. What to do when using pots and pans on the stove 2. How to ensure backyard pool safety measures 3. How to manage electrical sockets and cords 4. where to obtain safety labels for cleaning products
3. How to manage electrical sockets and cords For infants who are just learning to crawl, the mother should look at what's on the floor and within arm's reach from a crawling position. This would include electrical sockets and cords. Pots and pan handles should be turned away from the child's reach. This becomes relevant when the child begins to stand and walk. Pool safety is more related to toddlers and children. Children can be taught to recognize dangerous products, but this is for preschoolers who have developed language skills.
What type of sensitivity is often seen in the health care environment? 1. Allergic reactions to disinfecting chemicals 2. Reactions to airborne diseases 3. Latex allergies 4. Vinyl allergies
3. Latex allergies
A male patient of average build requires assistance to ambulate down the hall. He has some weakness on the left side. The nurse assists this patient to ambulate by applying a gait belt and standing at his: 1. left side and holding the weak left arm 2. right side and holding the front of the gait belt 3. left side and holding the back of the gait belt 4. right side and holding one arm around his waist
3. left side and holding the back of the gait belt The nurse stands on the WEAKER side and grasps the gait belt at the back. This position allows the nurse to provide support and ease the patient to the floor if he begins to fall.
The nurse is providing home poison control instruction to the parent of a 2-year-old boy. Which statement by the parent indicated the need for further teaching? 1. "I will call the national poison control center if my child ingests a poisonous substance." 2. "I will call 911 immediately if my child ingests medication that is not intended for him." 3. "Child safety caps on household cleaner can still be opened by some children." 4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."
4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."
The nurse is caring for a patient who relies on mechanical ventilation. The nurse hears a fire alarm and flames are visible in a back corridor. What should the nurse do first? 1. Seek assistance to move the patient and the ventilator to safety 2. Turn off oxygen supply and provide manual respiratory support 3. Close the patient's door, call 911, and fight the fire in the corridor 4. Delegate the UAP to move ambulatory patients toward the exit
4. Delegate the UAP to move ambulatory patients towards the exit. By delegating the UAP to move the ambulatory patients, the nurse is rescuing the greatest number. Next, the nurse would call 911. Closing the door is appropriate because the door will block the smoke and the fire. The nurse must then attend to the helpless ventilator patient. Oxygen creates a good environment for a hotter and faster fire, so oxygen is turned off. The nurse now has to manually support respiration by delivering breaths with a bag-valve-mask or a pocket mask. Both methods will be delivering room air. The nurse is aware that moving the patient and equipment would take a minimum of 2 people and this action would also partially block the hallways; thus the nurse would use critical thinking to determine when (or if) to move the patient.
OSHA (Occupational Safety and Health Administration)
A federal organization that provides guidelines to help reduce safety hazards in the workplace
The home health nurse is assessing a child for the risk of injury. Which factor places a child at greatest risk for specific types of injuries? 1. Gender of the child 2. Overall health 3. Education level 4. Developmental level
4. Developmental level
What national organization provides guidelines to protect health care workers in their environment? 1. National Institutes of Health 2. National Alliance for Health Care Providers 3. National League of Nurses 4. Occupational Safety and Health Administration
4. Occupational Safety and Health Administration
An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select? 1. Mummy wrap 2. Wrap jacket 3. Bilateral wrist SRDs 4. Right elbow SRD
4. Right elbow SRD The infant is using his right hand to grab the dressing on the left arm. If the right elbow is secured in a straight position, he shouldn't be able to reach the dressing. (Note - sometimes it may be necessary to pin or secure the SRD to the linen/mattress if the child is very determined.) Mummy wrap is more restrictive and usually used as a temporary restraint during procedures. Bilateral wrist SRDs are also more restrictive and the infant is likely to have skin damage because he will continuously pull to get free. The wrap jacket allows free arm movement.
The occupational health nurse learns of a mercury spill that occurred in the factory in which she is employed. Which action by the nurse is correct? 1. The nurse cleans the mercury spill with alcohol and ordinary cleaning cloths 2. The nurse closes all windows and doors to prevent the mercury spill from spreading out of the area 3. The nurse instructs housekeeping staff to vacuum up the spill 4. The nurse evacuates the area and contacts trained personnel to clean up the spill.
4. The nurse evacuated the area and contacts trained personnel to clean up the spill.
Which instructions should be given to the UAP who is assigned to assist in the care of a patient who is being treated with internal radiation? 1. Do not go into the room unless the patient uses the call bell 2. Help children to don a lead shield apron before entering the room 3. Wear a mask, eye shield, and isolation gown when entering the room 4. Wear your dosimeter during patient care or when handling patient items
4. Wear your dosimeter during patient care of when handling patient items. Anyone involved in the care of a patient who is receiving internal radiation should wear their own dosimeter. This includes handling items such as linen and trash. Routine care must continue (ex vital signs and hygiene); thus staff will enter the room whenever necessary, but care should be well-organized so that minimal exposure occurs. Children under the age of 18 should not visit the patient while there is danger of radiation exposure. Wearing a mask, eye shield, and isolation gown do not offer sufficient protection against radiation exposure
Which health care worker is most likely to be a vector of infection
A nursing student has mild Flu symptoms but feels okay to go to the clinical site. (Harbors the flu before symptoms appear and spreads it)
CDC
Center for Disease Control and Prevention
Airborne precautions
PPE- n95 mask
Hazard Communication Act of the OSHA
Requires health care facilities to inform employees about the presence of or potential for harmful exposure and how to reduce the risk of exposure
Which of the following nursing actions would be considered to be an example of using surgical aseptic technique as opposed to using medical aseptic technique?
The nurse wears sterile gloves and uses sterile gauze to change a surgical wound dressing
True or false: Electrical accidents are often prevented by reporting frayed or broken electrical cords or any shocks felt when using equipment
True
True or false: Growth and the acquisition of new motor skills place children at an increased risk for injury
True
change masks
at least every 20-30 min
examples of pathogens
bacteria, viruses, fungi, and parasites
spores remain dormant until...
conditions become favorable for growth
Portal of entry
entrance through skin, mucous lining, or mouth
Internal disasters
events that occur within a health care agency ex: Pipes burst, fires
clean techniques is called
medical asepsis
To remove the glove, what actions are required of the nurse?
remove 1 glove then use the bare fingers to push the remaining glove off from inside the cuff.
Viruses are
smallest know agents to cause diseases
Reservoir
where the pathogens can grow
The nurse is conducting a fall risk assessment on an elderly patient who is moving into an assisted-living center. Which question(s) would the nurse ask? (select all that apply) 1. Have you had any falls in the past year? 2. Are you able to independently get up after a fall? 3. Do you feel unsteady when you stand up? 4. Are you able to independently walk from room to room? 5. Have you ever lost consciousness after a fall? 6. Do you use a cane or other assistive device?
1, 3, 4, 6 1. Have you had any falls in the past year? 3. Do you feel unsteady when you stand up? 4. Are you able to independently walk from room to room? 6. Do you use a cane or other assistive device? Previous history of falls and unsteadiness increase the risk for falls. If assistance is required to walk from room to room, the nurse must plan to assist the patient to the bathroom and meals. The nurse ensures that all assistive devices are close to the bed or chair. Asking the patient if he can independently get up after a fall is an assessment of strength and independence, but this also suggests that the patient should independently attempt to get up after a fall. (Patient should be assessed for injury after a fall and encouraged to regain balance and strength before attempting to get up.) Assessing for loss of consciousness is usually performed when trying to determine the etiology of the fall (ex. head injury, neurologic event, cardiac event.)
The nurse is reviewing the disaster preparedness plan for a small nursing home. What should be included in the plan? (select all that apply) 1. Emergency treatment for the most critically injured 2. Possible admission to a hospital or transfer to a temporary shelter 3. Log to document residents names and locations 4. system to notify families and health care providers 5. Designation of an area for decontamination 6. Method of patient identification, such as patient bracelet or picture ID
2, 3, 4, 6 2. Possible admission to a hospital or transfer to a temporary shelter 3. Log to document residents names and locations 4. system to notify families and health care providers 6. Method of patient identification, such as patient bracelet or picture ID For nursing hoes or long term care facilities, the plan must include ways to keep track of residents and notification of families and health care providers. The goal would be to provide a safe environment, which may include moving residents to another location. Providing emergency treatment for critically injured patients or initiating decontamination would be included in hospital disaster plans.
The nurse is caring for a patient on a ventilator and reads the order "restraint prn." The nurse considers which factor when caring for this patient? 1. SRDs often decrease anxiety because the patient feels safer 2. All older adult patients need some type of SRD at night 3. Allow as much freedom of movement as possible when applying SRDs 4. When using soft SRDs to prevent pulling of the ventilator tubing, tie them to the side rail
3. Allow as much freedom of movement as possible when applying SRDs
Immediately after donning a pair of gloves, a family member develops red, watery eyes, and contact dermititis with itching on the hands. What should the nurse do first?
Instruct the person to remove the gloves and wash thoroughly with soap and water. (These are symptoms of a laxtex allergy and could be life threatening. Washing hands gets the latex proteins off the skin)
What is the best rationale for the consistent is of Standard Precautions?
It is difficult to accurately identify all patient's infected with blood- borne pathogens. (Treat all contact as if the patient has a BBP- hand hygiene, gloves, gown, masks, and eye protection when appropriate for patient contact)
Localized infection
Microbe enters the body and remains confined to a specific tissue
Today the nurse is assigned to care for a patient who has tuberculosis. What equipment should the nurse routinely use when caring for this patient?
N-95 respirator
Which patient has a condition that will be most challenging for the health care team to manage?
The patient is immunocompromised and has a wound infected with methicillin resistant Staph. aureus (patients with immunocompromised conditions who are admitted to a health care facility have an increased risk of exposure to MRSA- Very difficult to treat)
For what circumstance would it be appropriate to contact the infection control nusre for assistance?
an unusual cluster of infection is seen in the emergency department. (The infection- control nurse will have to notify the local health department about the cluster of infection and implement the correct precautions)