Safety and Infection Control - ML6

The nurse is working with a client assignment on the medical-surgical unit. Which client encounters require client identification with two identifiers? Select all that apply. 1.)Administering a medication. 2.)Beginning an enteral feeding. 3.)Delivering a breakfast tray. 4.)Directing visitors to a client room. 5.)Changing bed linens

Answer: 1.),2.)&3.) Administering a medication, Delivering a breakfast tray and Beginning an enteral feeding. Explanation: The nurse will need to use two identifiers with administering a medication, delivering a breakfast tray, and beginning an enteral feeding. Changing the bed linens and directing visitors are not identification safety issues.

A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?

To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required?

Answer: "I will heat my baby's formula in the microwave" Explanation: Infant formula should NEVER be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care? 1.) Bending and twisting while providing care may cause injury. 2.) The center of gravity is located at the waist. 3.) A client's level of consciousness and ability to cooperate are not important factors during transfer. 4.) Tightening the abdominal muscles and tucking the pelvis may strain the lower back.

Answer: 1.) Bending and twisting while providing care may cause injury. Explanation: Bending and twisting during routine care, such as bathing, should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as possible during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back.

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? 1.) Hold the medication until speaking with the NP. 2.) Call the pharmacist and discuss a substitution for the medication. 3.)Give the medication without hearing back from the NP. 4.)Ask patient if allergy is real/serious.

Answer: 1.) Hold the medication until speaking with the NP. Explanation: The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication.

An infant goes into cardiac arrest. While conducting resuscitation, the team notes critical supplies are missing because the cart was not restocked properly by the nurses after an earlier arrest. The baby sustains brain damage as a result of delays in obtaining needed supplies. How does the nurse manager address this situation? 1.) Hold the nurses responsible because hospital procedure was not followed. 2.) Report that the pharmacy did not restock the medications missing from the cart. 3.) Report the situation to the director of nursing so practice can be changed. 4.) Reassure the nurses that they will not be held liable for the negative outcome.

Answer: 1.) Hold the nurses responsible because hospital procedure was not followed. Explanation: Agency and hospital policies and procedures establish standards of care. If a nurse deviates from the standard, liability could result if an injury is sustained. In this case, the baby sustained brain damage because the nurses failed to follow the procedure for restocking the crash cart immediately after a code. The nurse needs to report to the pharmacy that the medications need to be restocked. The pharmacist cannot be blamed or held liable if they were not notified. The manager should not tell the nurses they will not be held liable. There is not evidence that current practice needs to be changed, just followed consistently.

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? 1.)"A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse." 2.) "If both sexual partners are HIV-positive, unprotected sex is permitted." 3.) "Use of contraceptive halts spread of HIV" 4.) "The only safe sex I can do is hugging, petting, and mutual masturbation."

Answer: 1.)"A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse." Explanation: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. Hormonal contraceptives, implants, and injections offer no protection against HIV transmission. Safe sex practices include hugging, petting, mutual masturbation, and protected sexual intercourse. Abstinence is the most effective way to prevent transmission.

A nurse is caring for a client with diarrhea caused by Clostridium difficile. Which personal protective equipment should the nurse use? Select all that apply. 1.)gloves 2.)gown 3.)mask 4.)eye protection 5.) shoe covers

Answer: 1.)&2.) gloves and gown Explanation: The client should be on contact isolation. Due to expected contact with the client and bedding when doing an assessment, gloves and gowns are needed. Mask and eye protection are only required if splatter is expected. Shoe covers are not required.

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination? 1.)wearing protective coverings 2.)changing gloves immediately after use 3.)Standing 2 feet (61 cm) from the client 4.)speaking minimally

Answer: 2.) changing gloves immediately after use Explanation: Bedside rails, call bells, drug-administration controls operated by the client, and other surface areas are frequently touched by caregivers with used gloves. Changing gloves immediately after use protects the client from contamination by organisms. Cross-contamination is a break in technique of serious consequence to the severely compromised client. Standing 2 feet (61 cm) from the client, speaking minimally, and wearing protective covering shirts are not required in standard interventions for risk of infection.

When caring for the client with hepatitis B, which situation would expose the nurse to the virus? 1.)contact with fecal material 2.)a blood splash into the nurse's eyes 3.)Touching the client without gloves 4.)Forgetting to recap used needle

Answer: 2.)a blood splash into the nurse's eyes Explanation: Hepatitis B virus is spread through contact with blood, body fluids contaminated with blood, and such body fluids as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions. The risk of transmission of hepatitis B through feces is low. Touching the client without gloves is acceptable when there is no danger of contact with blood or body fluids. Recapping a used needle is a common source of needlestick injuries; needles should be properly disposed of uncapped.

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? 1.) Transfer report 2.) Shift report 3.)Telemedicine report. 4.)Incident report.

Answer: 4.)Incident report. Explanation: An incident report, also termed a variance report or occurrence report, is a tool healthcare agencies use to document anything out of the ordinary that results in or has the potential to result in harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns and initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link healthcare professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

The nurse finds a fire in the linen closet. Which action(s) should the nurse take to prevent the spread of fire? Select all that apply. Contain the fire. Rescue clients. Activate the alarm. Evacuate the unit. Complete the incident report. Pour water on fire

Answer: Contain the fire. Rescue clients. Activate the alarm. Evacuate the unit. Complete the incident report. Explanation: RACE is an acronym used to remember these items in the case of a fire. Rescue: assist anyone in immediate danger and help get them to a safe area as fast as possible. Alarm: alert others by activating any available alarm system. Contact 911 to report the location of the fire and alert on-site personnel. Contain: confine the fire as soon as possible by closing windows and doors behind you during evacuation. Extinguish: only attempt to put out the fire if it is small, if you have the proper equipment, and if it is safe to do so yourself. Retrieve the nearest fire extinguisher and follow the "P.A.S.S." procedure: P = Pull the pin breaking the plastic seal; A = Aim at the base of the fire; S = Squeeze the handles together; and S = Sweep from side to side. The nurse will need to complete the incident report. The nurse will not sprinkle water over the fire, but should use the fire extinguisher.

A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection?

Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.

The nurse notices drops of a liquid on the hallway floor of a health care facility. What should the nurse do first?

Liquids found on the floor should be removed immediately. The nurse should first put on gloves and then wipe up the liquid. Following removal, Environmental Services should be contacted to thoroughly cleanse the floor with a disinfectant solution. Placing paper towels over the drops is a safety hazard. "Wet floor" signs will be posted after the floor is cleansed by Environmental Services.

A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate?

Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline because poisoning accidents are common in toddlers owing to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers should not be allowed in the road unsupervised.

Which action is the best precaution against transmission of infection?

Mothers can transmit gonorrhea during the birth process; untreated, it can cause serious eye damage to the neonate so eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection is appropriate. A neonate whose mother has hepatitis B should receive hepatitis B immunoglobulin within 12 hours of birth, not eye prophylaxis. CMV doesn't require strict isolation; however, the neonate may be treated with I.V. antivirals. HIV is transmitted via blood and body fluids. Contact isolation, not strict isolation, is appropriate.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:

Safety needs. The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

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?

The most significant way to prevent a head injury in young children is to have them wear a helmet while riding a bike. Safety gates at staircases are most important for preventing head injuries in INFANTS. Although it is important to supervise preschool children when playing, supervision does not ~prevent~ a head injury. Accompanying children when crossing the street is important, but it would be more important to teach a child to look both ways before crossing. Most head injuries can be prevented through the use of helmets, therefore this is the most important information to teach.

The nurse is ready to administer a partial fill of imipenem-cilastatin in the IV pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. What should the nurse do?

The nurse should first determine whether the client received the last dose of imipenem-cilastatin. If the client did not receive the last dose, the nurse should notify the health care provider (HCP) that the client did not receive the dose, receive prescriptions, document, implement the prescriptions, and complete an incident report. The nurse should not automatically discard the partial fill of imipenem-cilastatin found at the client's bedside until further investigation is done. The nurse should recognize the cost of medications such as imipenem-cilastatin and consult the pharmacist after identifying information on the partial fill bag that was found. After verifying all information, the nurse can administer the new partial fill of imipenem-cilastatin so that the client can receive the antibiotic on time.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route?

When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options (axillary, tympanic, oral) are appropriate routes for measuring the temperature of a client with a cardiac disorder.