Safety and Infection control

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate?

"A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse."

Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?

Rewarm the neonate gradually.

A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. Which of the following approaches should the nurse initially utilize?

Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

A cloth chest restraint has been prescribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols.

A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints?

Fasten the restraint to the bed frame using a quick-release knot.

The licensed practical nurse is collecting a wound culture from a client's gaping surgical incision. Which would the nurse consider to ensure proper culture collection?

Gently roll a sterile swab from the center of the wound outward to collect drainage.

What should a nurse do to ensure a safe hospital environment for a toddler?

Move the equipment out of reach.

An older adult client admitted to the hospital with an exacerbation of heart failure is confused, has inadvertently pulled out the IV catheter, and is attempting to get out of bed. The health care provider orders the use of physical restraints. Which nursing action reflects safe nursing care?

Tie the restraints to the bed frame using a quick-release knot.

A client is being returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set

The nurse should determine a child's body surface area by using:

a nomogram.

The nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. To prevent contamination of the specimen, the nurse should:

aspirate urine from the tubing port, using a sterile syringe.

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves:

performing a preoperative surgical scrub for at least 3 to 5 minutes.

A student nurse is performing wound care while the instructor observes. Which observation by the instruction requires immediate intervention of the student nurse's action?

pouring solution directly onto a sterile field barrier

The parents of a 3-year-old with a congenital heart disease report during a checkup that they are concerned about giving a flu vaccine to their child. Which statement is appropriate for inclusion in the nurse's response?

"The flu vaccine is both safe and recommended to children who have chronic illness such as heart disease."

A client with an indwelling catheter asked the nurse to remove the catheter. Which first intervention is best when removing an indwelling catheter?

Deflate the balloon before removing the catheter.

A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?

Risk for injury

The nurse is caring for a client with a fractured hip. The client becomes combative, confused, and tries to get out of bed. His vital signs and pulse oximetry results are unchanged. The nurse should:

notify the nursing supervisor to see if a staff member can sit with the client.

A client has a surgical wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?

In a circle, from the center outward

A neonate born at 32 weeks' gestation is taken to the neonatal intensive care unit (NICU). When caring for this neonate, what are the most important nursing actions to prevent and control infection?

Practice meticulous hand washing.

After surgery to repair a cleft lip, an infant has a Logan bar in place. Which postoperative nursing action is appropriate?

Holding the infant semi-upright during feedings

A client who underwent abdominal surgery returns from the postanesthesia care unit with a nasogastric (NG) tube in place. The client complains of nausea. While preparing to attach the client's NG tube to intermittent suction, the nurse notices that the ground on the suction machine's plug is broken. What priority action should the nurse perform first?

Obtain another machine from central supply.

The nurse is performing wound care on a client. Which task indicates surgical asepsis?

Preparing sterile surgical instruments for the physician to debride the wound

A nurse is caring for a school-age child who is at risk for harming himself or herself when left alone. What is the nurse's most appropriate intervention?

Provide one-on-one observation.

A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?

"For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe."

An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff?

"The client needs to be placed in a private, negative air pressure room."

A nurse finds a client at high risk for falls laying on the floor unresponsive with a large hematoma noted on the client's head. After caring for the client, it is determined the client sustained a subdural hematoma and remains unresponsive. The nurse determines that the primary nurse forgot to put the client's bed in the lowest position and place the call light within reach. The primary nurse asks, "What happens next? Will I be fired?" What is the best statement by the nurse?

Because this client sustained severe harm not expected in their course of illness, I must follow our facility's policy and complete a sentinel event form."

How should a nurse position an infant when administering an oral medication?

Held in the bottle- or breast-feeding position

A school nurse is conducting a seminar for parents of preschool children on the prevention of head injuries. What is the most appropriate information for the nurse to give the parents?

Children should always wear helmets when riding bicycles.

A 16-year-old client comes to the physician's office for a physical examination that's required to play sports. The mother reports that her son is unusually tired during the day. She explains that he works at a part-time job, is socially active, and gets about 7 hours of sleep each night. Physical examination reveals that the client grew 3" during the past year. Which intervention by the nurse is most appropriate?

Explaining that his sleep requirements have increased related to the increased metabolic demands of growth

While assessing a home care client, the nurse notices a family member smoking near the client's oxygen. Which action by the nurse is best?

Explaining to the family member that oxygen is flammable and smoking must be avoided

A white male, age 43, is admitted to an acute care facility with a tentative diagnosis of infective endocarditis. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis?

History of aortic valve replacement

A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which action by the nurse is the best solution?

Hold the medication until speaking with the NP.

A 3-month-old admitted to the pediatric unit with meningococcal meningitis has just been assessed by the registered nurse. Which nursing intervention has the highest priority at this time?

Instituting droplet precautions

At 8 a.m., a licensed practical nurse (LPN) collects data on a client who is scheduled for surgery at 10 a.m. During the data collection, the nurse detects dyspnea, a nonproductive cough, and back pain. What is the nurse's priority action?

Make sure that the health care provider is immediately notified of these findings.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours?

Remove restraints and assess skin and circulation.

The nurse is caring for a client on an oncology unit who is refusing further chemotherapy treatment after the rationale for the treatment has been clearly explained. What is the nurse's best action?

Support the client's decision and hold all treatments.

During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing.Which intervention best addresses this nursing diagnosis?

Support the neonate's head and back with the forearm.

A health care provider and nurse are discussing treatment options with a client diagnosed with severe ulcerative colitis symptoms. Which potential complication requires frequent assessment?

bowel perforation

A client reports slipping on a throw rug while going to the bathroom at night. Which data should be gathered for prevention of further falls?

home safety

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury?

leaning forward toward the object

A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:

maintain the client on complete bed rest with bathroom privileges only.

The nurse is reviewing the plan of care for a client diagnosed with schizophrenia who has just been admitted to the psychiatric unit. Which intervention would the nurse identify as the priorityfor this client?

providing a consistent, predictable environment

A nurse is caring for a client who threatens suicide and is placed on constant observation. The nurse follows the client into the bathroom. The client says, "You don't need to follow me into the bathroom. Give me some space." Which response by the nurse is most appropriate?

"I must stay with you until we are sure you will not hurt yourself."

A nurse needs assistance in getting an older adult client with confusion back into bed from the chair. The nurse leaves the client sitting alone in the room while going to find someone to assist with the transfer. While the nurse is gone, the client gets out of the chair, falls, and sustains an injury. What did the nurse fail to do?

Arrange for continual care of the client.

An 8-year-old child is brought to the clinic with watery eyes and clear nasal drainage that has lasted more than 10 days, without fever. The nurse observes that the child has dark circles under the eyes and a crease above the tip of the nose. Which intervention should be the nurse's priority?

Collect data about potential environmental allergy triggers.

A client comes to the clinic reporting a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. To best obtain the specimen, which action does the nurse take next?

Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth.

The nurse is reinforcing anticipatory guidance on safety topics to a group of parents who have preschool-age children. When reinforcing education, what is appropriate to cover for the preschool level? Select all that apply.

bike helmet use water safety bathtub safety

A nurse has just been trained in how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor?

calibrating the machine after installing a new battery

An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions?

negligence

A client is admitted with hemophilia. Which sports should the nurse recommend for this client? Select all that apply.

swimming golf

Which precaution should a nurse caring for a 2-month-old infant with respiratory syncytial virus (RSV) take to prevent the spread of infection?

wear gown, gloves, and mask

A client recovering from a stroke has slid down in bed and needs to be repositioned. Which action should the nurse take to ensure safety for both the client and the nurse?

Ask for assistance from the lift team.

To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this?

By swabbing the labia minora from front to back

A client who was voluntarily admitted to an inpatient psychiatric unit suddenly begins yelling, throws a chair, and exhibits extreme agitation. Which consideration would be most important for the nurse to keep in mind when addressing the client's current behavior?

Restraints should be used only as a last resort.

When planning care for a child with rheumatic fever, which is the greatest area of concern?

prevention of falls

During a well-baby visit, a toddler's parent states that the parent keeps all medications out of the toddler's reach in the kitchen cabinet. Which is an appropriate response by the nurse?

"Medications should be kept in a locked location."

The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report.

A female client has a fractured left hip. Her left leg is in Buck's traction while the client is being prepared for a hip pinning. What should the nurse plan to do when inserting an indwelling catheter?

Instruct the client to deep breathe during catheterization.

The nurse is caring for an infant who has undergone a surgical repair of a cleft lip. The health care provider prescribes elbow restraints. What nursing action should be included in the infant's plan of care?

Remove the restraints every 2 hours.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical- surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters

A nurse is preparing a client for magnetic resonance imaging (MRI) scan to confirm or rule out a spinal cord lesion. Which action would pose a threat to the client during the procedure?

The client wears a watch and wedding band.

The nurse is caring for a client with dementia that has a tendency to wander into other client areas, posing a safety risk for the client and others. Which method would be most beneficial for this client to promote safety that is the least restrictive?

Use an electronic monitoring system.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply?

decreasing environmental stimulation

The nurse administers an I.M. injection. Afterward, the nurse should:

discard the uncapped needle in a puncture-proof container.

A client is transferred to the locked psychiatric unit from the emergency department after attempting suicide by taking 200 acetaminophen tablets. Now the client is awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions.

The nurse is caring for a preschooler. Which technique will the nurse apply as most effective in preventing hospital-acquired infections in this population?

hand washing

A nurse is providing care to a client after surgery. The nurse must practice surgical asepsis when performing which procedure?

insertion of an indwelling urinary catheter

The nursing team is caring for clients on a clinical unit when the fire alarm sounds. Which nurse on the team acts most appropriately to contain a fire?

the nurse who closes all the inside doors

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first?

the prescriber

A nurse is reviewing principles of good body mechanics with a student practical nurse. Which technique should be emphasized?

using large muscles in the legs for leverage

A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions?

wearing gloves for providing mouth care

A toddler with bacterial meningitis is being admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?

droplet precautions

Which behaviors from a client with dementia would prompt nursing intervention?

attempting to hit others