NCLEX-PN Safety and Infection Control

NCLEX-PN Safety and Infection Control (1 review) Students also studied Terms in this set (68) Fayetteville Technical Community College NUR 103 Save Safety and Infection Control NCLEX ...19 terms e_abdullah1Preview Safety 14 terms Taylor_Bourgeois1 Preview MedSurg HURST 137 terms jship_24Preview NCLEX 106 term Lind The home health nurse is caring for a client who is identified as high risk for falls. What observations would indicate a therapeutic response to home fall prevention education?

• Installs a grab bar in the tub
• Turns night lights on at bedtime
• Only use assistive devices when leaving home.
• Goes barefoot while in the home.
• Uses throw rugs in walking areas to prevent slipping.

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• & 2

Placing a grab bar in a slippery tub can assist the client in getting into and out of tub. Turning on night lights at night ensures that the client can navigate safely, this reducing the risk of falls.A nurse is caring for a client diagnosed with the Ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client?

• Single-use impermeable gown
• Powered Air Purifying Respirator (PAPR) or N95

respirator.

• One pair of sterile gloves
• Single-use boot covers
• Single-use apron

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1, 2, 4, 5

The nurse should wear a single-use (disposable) impermeable gown OR a single- use impermeable coverall. Either a PAPR or a disposable. NOSH-certified N95 respirator should be worn to reduce the risk of contamination in the case of an emergency situation where a potentially aerosol-generating procedure would be performed. The PAPR reduces the risk of self-contamination while providing client care, but the N95 respirator is less likely bulky. If the N95 respirator is selected for use, nurses should be extremely careful to make sure that they do not accidentally touch their faces under the face shield during client care. Disposable boot covers should be worn and should extend to at least mid-calf. Some agencies may add the single use shoe covers over the boot covers to reduce the risk of contaminating the underlying shoes.

When disposing of waste in a client's room, the nurse would place which items in a biohazard red bag?

• Chest drainage unit
• Doxorubicin IV bag and tubing
• Staples removed from an abdominal incision
• Tramadol 50 mg tablet prescribed but refused by

client.

• Soiled dressing
• Paper trash with identifying client information

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• & 5

Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood or body fluids should be disposed of in a red biohazard bag.The nurse is assessing the client's blood pressure using an electronic blood pressure machine and notes that the blood pressure reading is much higher than it has been since admission. The client denies history of hypertension.What action should the nurse take?

• Call the primary healthcare provider and report the

elevated blood pressure.

• Check the blood pressure again in 4 hours and

compare to the current blood pressure.

• Re-check the blood pressure using a manual blood

pressure cuff

• Call the nursing supervisor and prepare for a possible

hypertensive emergency.3 Since the client does not have a history of hypertension and has not had elevated blood pressure since admission, the nurse should question the accuracy of the electronic blood pressure machine. Therefore, the nurse should re-check the BP using a manual cuff to determine if the high blood pressure reading was accurate.A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields.What condition does the nurse suspect?

• Pesticide exposure
• Heat stroke
• Anthrax poisoning
• Gastroenteritis

1 These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning.A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest?

• Provide a safe haven for victims of violence
• Provide educational programs about types of violence
• Form a neighborhood watch program
• Develop a media campaign identifying risk factors of

potential abuse.

• Provide for the immediate removal of a victim of

violence from the home.Select all

2, 3, 4

These are all appropriate interventions for the nurse to suggest to the community The key is prevention. The nurse is teaching ways to prevent violence before it occurs. Primary prevention is true prevention.

The nurse is reinforcing information about car accident prevention to a group of high school students. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)?

• Males who have just turned 19 years of age.
• Drivers who have recently acquired a driver's license.
• A group of students that carpool to the senior prom
• Female students who drive to weekly football games

2.According to the Centers for Disease Control and Prevention (CDC), crash risk is particularly high during the first year the teenagers are eligible to drive. Though teenagers who are 19 years old, carpooling to the senior prom, and driving to weekly football games are also at risk for an MVC, they are not the highest-risk n teenage group.A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first?

• Obtain all supplies for the procedures.
• Explain the procedure to the client.
• Check the client's identification band.
• Verify client has signed consent forms.

3.Even in an emergency, the nurse follows the nursing process by initially gathering data, including identifying the client before beginning any ordered interventions.The client's identity must always be verified before any procedure or treatment.While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take?

• Continue to use the infusion pump and request a

replacement pump.

• Stay with the client and monitor the infusion while

another staff member obtains a replacement pump.

• Clamp and disconnect the infusion tubing prior to

obtaining a replacement pump.

• Slow the infusion to keep-open rate and obtain a

replacement pump.

2.The safest action is to stay with the client while a new infusion pump is obtained by another staff member.A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency?

• Have roommate lead client out of the room to safety

area.

• Assign a specific UAP every shift to escort the client to

safety.

• Research established protocols utilized by emergency

groups.

• Discuss best communication methods with client and

family.

• Plan for the supervisor to be responsible for

evacuating the client.Select all

• & 4

When faced with a new or challenging situation involving client safety, the nurse manager should employ the nursing process to assess needs and collect contributing data. Asking for input from emergency preparedness groups, such as the Red Cross or FEMA, could provide ideas about assisting individuals with sensory deficits. Secondly, the nurse should discuss the situation with both client and family to determine appropriate methods of communicating with clients, particularly in an emergency situation.

A child who fractured the ulna and radius following a fall is experiencing itching under the cast. What would be an appropriate nursing intervention to help alleviate itching?

• Apply a small amount of hydrocortisone cream with a

cotton tip applicator,

• Use a soft, sterile, cotton tip applicator to gently rub

area under cast.

• Apply warm, dry heat to the outside of the cast with a

lightweight heating pad.

• Circulate air under the cast utilizing a blow dryer on

the cool setting.

4.Acceptable , safe way to try to alleviate itching is to use a blow dryer on the cool setting to circulate air under the cast. This is the only safe option provided.The nurse is setting up the sterile field for the primary healthcare provider and another nurse to use. As the nurse and primary healthcare provider enter the room they don sterile gowns and gloves. As the procedure begins, the nurse observes that the other nurse in the room has turned her back on the sterile field. What should the observing nurse do first?

• Nothing, as everyone is individually accountable for

their practice.

• Provide the nurse with another gown and sterile

gloves.

• Inform the primary healthcare provider and the nurse

that the sterile field may have been compromised.

• Remind the nurse not to turn back on a sterile field.

3.Anytime a nurse observes that the sterile field is compromised or may have been compromised , it is essential that it is reported to protect client.A client is admitted with irritable bowel syndrome (IBS) and shingles. The nurse is discussing the client assignments with the charge nurse. Which staff member should not be assigned to this client?

• The nurse with a history of roseola.
• The unlicensed assistive personal (UAP) with no history

of roseola.

• The UAP with a history of chicken pox.
• The LPN/VN wit no history of chicken pox.

4.A nurse who has not had chicken pox could contract it and should not be assigned a client with shingles. Those who have not developed antibodies to the varicella zoster virus are susceptible to chicken pox. Chicken pox and shingles are both from the varicella virus.The client has the need for droplet precautions due to a respiratory illness. When providing care for this client, when is it appropriate for the nurse to wear a mask?

• Performing tracheostomy care
• Delivering mail to the client's room.
• Bathing the client.
• Feeding the client
• Making routine room checks.

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1, 3, 4

The nurse will be in close contact with the client and may become contaminated by droplets from the client's respiratory tract. The client may cough while the nurse is feeding or bathing the client.