Safety and Infection Control NCLEX Review

Safety and Infection Control NCLEX Review Leave the first rating Students also studied Terms in this set (20) Save NCLEX Review - Management of Ca...26 terms ish_jayme_penafiel Preview NCLEX Safety & Infection Control 29 terms laurahomansxo Preview nclex pn safe, effective care environ...290 terms andria_montgomery Preview Health 106 term bre The paramedics are transporting a poisoning victim to the local hospital. In which of these cases does the nurse anticipate that hyperbaric oxygen therapy will be used?A 2 year-old who ate an undetermined amount of crystal drain cleaner A 21 year-old with suspected ethanol intoxication A 35 year-old found unconscious with suspected carbon monoxide poisoning A 6 year-old found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) A 35 year-old found unconscious with suspected carbon monoxide poisoning The medication benztropine mesylate (Cogentin) is ordered, but the nurse incorrectly administers carvedilol (Coreg). What are the most important actions the nurse should take after making this medication error? (Select all that apply.) Monitor and document the client's blood pressure Document the administration of carvedilol (Coreg) Notify the client Notify the nurse manager Notify the health care provider Monitor and document the client's blood pressure Document the administration of carvedilol (Coreg) Notify the nurse manager Notify the health care provider The charge nurse is making client room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3 year-old child diagnosed with minimal change disease?

• year-old diagnosed with a respiratory infection
• year-old with bilateral inguinal hernia repair
• year-old with a fracture whose sibling has Fifth disease
• year-old with sickle cell disease experiencing a vaso-

occlusive crisis

• year-old with bilateral inguinal hernia repair

The charge nurse on the evening shift is asked to determine which client is a candidate for discharge.Which of these clients should the nurse select as a potential candidate for discharge?An older adult female who is actively dying and has a "do not resuscitate" order A middle-aged adult with a history of type 1 diabetes and one day post diabetic ketoacidosis A young adult, admitted at the beginning of the shift, with an exacerbation of asthma An adolescent, admitted on the day shift to rule out acute pancreatitis, who reports a history of alcohol abuse, with a current blood sugar of 90 A middle-aged adult with a history of type 1 diabetes and one day post diabetic ketoacidosis The client selected to be discharged should be one whose condition is more stable than the others and where there's less of a risk for complications or instability after discharge. Although the client with asthma has a chronic condition, s/he was just admitted and is experiencing an acute exacerbation of the condition. The adolescent is experiencing an acute condition, probably brought on by his/her alcohol abuse. Neither of these clients are stable enough for discharge. It is a humane choice to allow the client who is in the process of dying to stay in the hospital.A nurse is conducting a community-wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?A 15 year-old who likes to repair bicycles A 20 month-old who has just learned to climb stairs A 9 month-old who stays with a sitter five days a week A 10 year-old who occasionally stays at home unattended A 20 month-old who has just learned to climb stairs A client is diagnosed with gastroenteritis, caused by a salmonella infection. Which of these actions is the primary nursing intervention designed to limit the transmission of salmonella?Wash hands thoroughly with soap and water before and after client contact Decontaminate hands with alcohol-based skin disinfectant after client contact Isolate the client in a single room without a roommate Wear two pairs of gloves when changing contaminated linens Wash hands thoroughly with soap and water before and after client contact The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in an automobile.What is the nurse's best response to the parents?"The child must be five years of age to use a regular seat belt." "The child can use a regular seat belt when he can sit still." "Your child must use a car seat until he weighs at least 40 pounds." "Your child must reach a height of 50 inches to sit in a seat belt." "Your child must use a car seat until he weighs at least 40 pounds."

The nurse is to administer a new medication to a client.Which of the following actions best demonstrates an awareness of safe and proficient nursing practice?Prior to administration of the medication, the nurse

should ask: "What is your name? What allergies do you

have?" and then check the client's name band and allergy band.Prior to administration of the medication the nurse should

ask: "What is your name?" then check the client's name

band.Verify the order for the medication. Prior to giving the medication the nurse should say, "Please state your name." Verify the client's allergies on the admission sheet and order. Verify the client's name on the name plate outside the room. Prior to the administration of the medication, ask the client, "What is your date of birth?" Prior to administration of the medication, the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band.A dual check is always done for a client's name. This would involve verbal and visual checks. Because this is a new medication an allergy check is appropriate.The other options have parts that might be correct actions. However, to be the correct answer all of the parts of an option need to be correct.The school nurse is providing information for teachers at a school where a 10 year-old child with epilepsy attends.What is the most important action a teacher can take when the child experiences a tonic-clonic seizure in the classroom?Note the sequence of movements with the time lapse of the event Provide privacy and reassure the other children Clear the immediate area of anything that could harm the child Place something soft and flat under the child's head Place something soft and flat under the child's head During seizure activity, the priority would be to protect the child from physical injury. The teacher could place something soft and flat, like a folded jacket under the child's head to help prevent head trauma. After protecting the head, the prioritized sequence of the actions would be to move furniture away from the child, note movements and time, and then provide privacy, if possible, while reassuring the other students.After an explosion at a factory, one of the employees approaches the nurse and says, "I am a certified nursing assistant (CNA) at the local hospital." Which of these tasks would be appropriate for the nurse to assign to this worker who is assisting in the care of the injured?Take temperatures Check alertness Palpate pulses Measure blood pressure Palpate pulses The heart rate and regularity would indicate if the client is in shock or has potential for shock. If the pulses could not be easily palpated or are irregular, those clients would need to be seen first and further assessment by the nurse could be done (including measuring blood pressure). Taking temperatures is not a priority in this situation.The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated?Complete an incident report Call the health care provider Quickly leave the room and ask the UAP to assist the client Ignore the behavior Complete an incident report

The nurse observes a nursing assistant using antiseptic hand sanitizer and rubbing their hands vigorously after leaving the room of a client diagnosed with Clostridium difficile (C-Diff). Which action by the nurse is appropriate?Praise the nursing assistant for proper use of antiseptic hand sanitizer.Instruct the nursing assistant to use bleach wipes to wipe off their hands.Instruct the nursing assistant to wash their hands again with soap and water.Report the nursing assistant to the infection control practitioner.Instruct the nursing assistant to wash their hands again with soap and water.A nurse is performing well-child assessments at a day care center when a staff member interrupts the examinations for assistance with another child. The nurse finds a crying 3 year-old child on the floor with bleeding gums and two unlabeled open bottles nearby. What should be the nurse's first action?Ask the staff member about the contents of the bottles Call the poison control center and then 911 Administer syrup of Ipecac to induce vomiting Give the child milk to coat the stomach Ask the staff member about the contents of the bottles The nurse needs to assess the situation and determine what the child ingested.Once the substance is identified, the poison control center and emergency medical services should be called.The nurse is caring for a client who is not oriented to time, place or person and has repeatedly attempted to pull out intravenous lines and a feeding tube. The nurse receives an order from the health care provider to apply a vest and soft wrist restraints. Which of the following actions by the nurse are appropriate? (Select all that apply.) Call the health care provider every 48 hours for a new order Document which alternative interventions were used or attempted Release the restraints and provide care every four hours Tie the restraints using quick-release knots Conduct a thorough assessment of the client Explain the rationale for restraints to the client Document which alternative interventions were used or attempted Tie the restraints using quick-release knots Conduct a thorough assessment of the client Explain the rationale for restraints to the client Prior to applying restraints, the nurse must first conduct a thorough assessment of the client and document the behavior and/or events leading to the use of the restraint. The nurse should also document which alternatives to restraints were tried and the client's response to those measures. Even though the client may be confused, the nurse must still explain the reason for applying restraints. A physician's order is required and the order must be renewed each calendar day of use. Many policies state that clients in restraints must be assessed every hour; care is given and documented at least every 2 hours.The nurse understands that which situations require hand hygiene such as handwashing or hand sanitation? (Select all that apply.) After making an entry in the medical record Prior to and after eating After contact with objects in the immediate vicinity of the client After cleaning a wound Before having direct contact with a client Prior to and after eating After contact with objects in the immediate vicinity of the client After cleaning a wound Before having direct contact with a client