NCSBN LESSON 2 SAFETY & INFECTION CONTROL
The nurse attends an interdisciplinary meeting on the Identify vulnerable clients, Use a "two to transfer" policy, Install and use bed
topic of fall prevention. What specific tactics can be used alarms , Use "low beds" for at-risk clients RATIONALE- Fall prevention involves
to reduce falls in health care settings? (Select all that managing a client's underlying fall risk factors and then implementing strategies
apply.) to reduce falls. Using restraints, including side rails, can actually increase the risk
of fall-related injuries and deaths. Clients with neurocognitive disorders cannot
process the information we provide when we attempt to reorient them to our
reality. The other techniques listed are used (in combination) to help prevent falls
in health care facilities.
A nurse is stuck in the hand by an exposed needle left in Immediately wash hands with vigor RATIONALE- The immediate action of
a client's bed linens. What immediate action should the vigorously washing the hands will help remove any possible contamination. If the
nurse take? site bleeds it will help remove the contaminate. Then, the sequence of actions
would be options "notify," "look up" and "contact."
At 3 months, the infant has cleft lip and soft palate repair. Remove soft elbow/arm restraints every 2 hours under supervision RATIONALE-
In the immediate postoperative period for a cleft lip The goal after surgery is to protect the new repair and stitches, which requires
repair, which action is the priority? some temporary changes in feeding, positioning and activity for the infant. The
priority is to wear arm restraints (for the first 10 days after surgery) to keep him
from putting his hands in his mouth; the restraints can be removed only for
bathing or for exercising the arms. When the infant acts hungry, he will be given
a clear liquid feeding using either a syringe fitted with a special soft tubing or a
special cleft lip feeder. The infant can be positioned on his side or back to keep
him from rubbing his face in the bed. The RN will provide instructions about care
of the incision line prior to discharge.
The nurse is reinforcing information about accidental Empty the child's mouth in any case of suspected poisoning RATIONALE-
poisoning in the home to a group of parents. What Emptying the mouth of the poison prevents any further ingestion. It should be
information should the nurse be sure to include? done first to minimize further contact with the substance. Vomiting should never
be induced unless told to do so by the Poison Control Center or a health care
professional. First aid for inhaling toxic substances is to move the child to fresh
air.
The nurse is in a crowded shopping area in an urban Keep the nose and mouth covered RATIONALE- An RRD, or "dirty bomb,"
setting when a radiologic dispersal device (RDD) generates radioactive dust and smoke, which can be dangerous if inhaled. The
explodes scattering radioactive dust and material into the nurse should initiate measures to limit contamination, instructing victims to cover
environment. What should the nurse instruct the victims their noses and mouths. Neither lying down or covering the head does anything
in proximity to the explosion to do first? to limit exposure. Victims should move into a building where the walls and
windows have not been broken and then remove their outer layer of clothing
(sealing them in a plastic bag, if available) to help minimize exposure.
A severely injured client is moved into an examination "I know you are upset. But please control yourself and sit down. Otherwise I will
area of the emergency department. The family member have to call security." RATIONALE- Most violent behavior is preceded by warning
who accompanied the client to the ED is screaming at signs, such as yelling or swearing. The challenge for nurses is to apply
the nurse, saying that someone better start doing interventions that de-escalate a person's response to stressful or traumatic
something right away. What is the best response by the events. The keys to effective limit setting are using commands to express the
nurse? desired behavior and providing logical and enforceable consequences for
noncompliance. Nurses should acknowledge the agitated person's feelings and
be empathetic, reminding him or her that they are there to help.
The nurse is collecting data about the home care for a The presence of environmental hazards RATIONALE- A safe environment for the
client with Alzheimer's disease. Which piece of client with increasing memory loss is a priority focus of home care. Note that the
information should be the priority for the nurse to other options would be included in the documentation - with importance being in
document? this order: "environmental hazards,""over-the-counter medications," "intake
changes" and then "respite care." The question is asking the reader to prioritize,
which usually means that all the responses are correct but one is more important
than the rest.
The client is diagnosed with active tuberculosis (TB) and Contacts need to be traced and screened
the case has been reported to the health department.
What is the most important reason for notifying the public
health department?
The adult client is alert and cooperative. The client has a One caregiver applies a transfer belt and uses the stand-and-pivot technique
short leg cast and can only partially bear weight on the
casted leg. Which technique can be safely used to
transfer the client from the bed into a chair?
An outpatient client is scheduled to receive an oral Urine and saliva will be radioactive for 24 hours after ingestion
solution of radioactive iodine. In order to reduce hazards,
the practical nurse should reinforce which information?
, NCSBN LESSON 2 SAFETY & INFECTION CONTROL
The child is newly diagnosed with hepatitis A. Which Wash hands thoroughly with soap and warm water after contact with the child
teaching instructions would the nurse reinforce with the
child's parents?
A client reports feeling dizzy when getting up from a lying Support the client in a sitting position until the dizziness subsides
position. Which is the correct action for the nurse to take
before assisting the client to ambulate?
Central Nervous System Infections meningitis, encephalitis
Childhood & Vaccine-preventable Infections Varicella (chicken pox), diphtheria, tetanus, mumps (infectious parotitis),
pertussis (whooping cough), poliomyelitis, rubella (German measles), rubeola
(measles)
Gastrointestinal Infections staphylococcal food poisoning, botulism
Acute Bacterial or Viral Gastroenteritis salmonella, gastroenteritis, viral hepatitis, Clostridium difficile
Hemolymphatic Infections mononucleosis, cytomegalovirus, toxoplasmosis
Respiratory Infections influenza, tuberculosis, histoplasmosis, pharyngitis, scarlet fever, rheumatic
fever, pneumonia
Sexually Transmitted Infections gonorrhea, chlamydia, syphilis, genital herpes, chancroid, AIDS, genital warts
Urinary Tract Infections cystitis, pyelonephritis
transmission by direct contact microorganisms are transferred from one infected person to another person
transmission by indirect contact transfer of an infectious agent through a contaminated intermediate surface,
object or vector (mosquitoes, flies, mites, fleas, ricks, rodents, etc.)
epidemiologically important organisms for contact VRE (vancomycin resistant enterococcus) & Clostridium Difficile (C. Diff.)
transmission
droplet precautions transmission involves contact of the conjunctivae or the mucous membranes of
the nose or mouth of a susceptible person with large particle droplets containing
microorganisms generated from someone who either exhibits a disease or who is
a carrier of the microorganism
respiratory droplets are generated when an infected person coughs, sneezes, or talks, or during
procedures such as suctioning, endotracheal intubation, cough induction by
chest physiotherapy and cardiopulmonary resuscitation
close contact (typically within 3 feet or less) between the source client and a susceptible
person is required, the use of a standard surgical mask is required
The nurse attends an interdisciplinary meeting on the Identify vulnerable clients, Use a "two to transfer" policy, Install and use bed
topic of fall prevention. What specific tactics can be used alarms , Use "low beds" for at-risk clients RATIONALE- Fall prevention involves
to reduce falls in health care settings? (Select all that managing a client's underlying fall risk factors and then implementing strategies
apply.) to reduce falls. Using restraints, including side rails, can actually increase the risk
of fall-related injuries and deaths. Clients with neurocognitive disorders cannot
process the information we provide when we attempt to reorient them to our
reality. The other techniques listed are used (in combination) to help prevent falls
in health care facilities.
A nurse is stuck in the hand by an exposed needle left in Immediately wash hands with vigor RATIONALE- The immediate action of
a client's bed linens. What immediate action should the vigorously washing the hands will help remove any possible contamination. If the
nurse take? site bleeds it will help remove the contaminate. Then, the sequence of actions
would be options "notify," "look up" and "contact."
At 3 months, the infant has cleft lip and soft palate repair. Remove soft elbow/arm restraints every 2 hours under supervision RATIONALE-
In the immediate postoperative period for a cleft lip The goal after surgery is to protect the new repair and stitches, which requires
repair, which action is the priority? some temporary changes in feeding, positioning and activity for the infant. The
priority is to wear arm restraints (for the first 10 days after surgery) to keep him
from putting his hands in his mouth; the restraints can be removed only for
bathing or for exercising the arms. When the infant acts hungry, he will be given
a clear liquid feeding using either a syringe fitted with a special soft tubing or a
special cleft lip feeder. The infant can be positioned on his side or back to keep
him from rubbing his face in the bed. The RN will provide instructions about care
of the incision line prior to discharge.
The nurse is reinforcing information about accidental Empty the child's mouth in any case of suspected poisoning RATIONALE-
poisoning in the home to a group of parents. What Emptying the mouth of the poison prevents any further ingestion. It should be
information should the nurse be sure to include? done first to minimize further contact with the substance. Vomiting should never
be induced unless told to do so by the Poison Control Center or a health care
professional. First aid for inhaling toxic substances is to move the child to fresh
air.
The nurse is in a crowded shopping area in an urban Keep the nose and mouth covered RATIONALE- An RRD, or "dirty bomb,"
setting when a radiologic dispersal device (RDD) generates radioactive dust and smoke, which can be dangerous if inhaled. The
explodes scattering radioactive dust and material into the nurse should initiate measures to limit contamination, instructing victims to cover
environment. What should the nurse instruct the victims their noses and mouths. Neither lying down or covering the head does anything
in proximity to the explosion to do first? to limit exposure. Victims should move into a building where the walls and
windows have not been broken and then remove their outer layer of clothing
(sealing them in a plastic bag, if available) to help minimize exposure.
A severely injured client is moved into an examination "I know you are upset. But please control yourself and sit down. Otherwise I will
area of the emergency department. The family member have to call security." RATIONALE- Most violent behavior is preceded by warning
who accompanied the client to the ED is screaming at signs, such as yelling or swearing. The challenge for nurses is to apply
the nurse, saying that someone better start doing interventions that de-escalate a person's response to stressful or traumatic
something right away. What is the best response by the events. The keys to effective limit setting are using commands to express the
nurse? desired behavior and providing logical and enforceable consequences for
noncompliance. Nurses should acknowledge the agitated person's feelings and
be empathetic, reminding him or her that they are there to help.
The nurse is collecting data about the home care for a The presence of environmental hazards RATIONALE- A safe environment for the
client with Alzheimer's disease. Which piece of client with increasing memory loss is a priority focus of home care. Note that the
information should be the priority for the nurse to other options would be included in the documentation - with importance being in
document? this order: "environmental hazards,""over-the-counter medications," "intake
changes" and then "respite care." The question is asking the reader to prioritize,
which usually means that all the responses are correct but one is more important
than the rest.
The client is diagnosed with active tuberculosis (TB) and Contacts need to be traced and screened
the case has been reported to the health department.
What is the most important reason for notifying the public
health department?
The adult client is alert and cooperative. The client has a One caregiver applies a transfer belt and uses the stand-and-pivot technique
short leg cast and can only partially bear weight on the
casted leg. Which technique can be safely used to
transfer the client from the bed into a chair?
An outpatient client is scheduled to receive an oral Urine and saliva will be radioactive for 24 hours after ingestion
solution of radioactive iodine. In order to reduce hazards,
the practical nurse should reinforce which information?
, NCSBN LESSON 2 SAFETY & INFECTION CONTROL
The child is newly diagnosed with hepatitis A. Which Wash hands thoroughly with soap and warm water after contact with the child
teaching instructions would the nurse reinforce with the
child's parents?
A client reports feeling dizzy when getting up from a lying Support the client in a sitting position until the dizziness subsides
position. Which is the correct action for the nurse to take
before assisting the client to ambulate?
Central Nervous System Infections meningitis, encephalitis
Childhood & Vaccine-preventable Infections Varicella (chicken pox), diphtheria, tetanus, mumps (infectious parotitis),
pertussis (whooping cough), poliomyelitis, rubella (German measles), rubeola
(measles)
Gastrointestinal Infections staphylococcal food poisoning, botulism
Acute Bacterial or Viral Gastroenteritis salmonella, gastroenteritis, viral hepatitis, Clostridium difficile
Hemolymphatic Infections mononucleosis, cytomegalovirus, toxoplasmosis
Respiratory Infections influenza, tuberculosis, histoplasmosis, pharyngitis, scarlet fever, rheumatic
fever, pneumonia
Sexually Transmitted Infections gonorrhea, chlamydia, syphilis, genital herpes, chancroid, AIDS, genital warts
Urinary Tract Infections cystitis, pyelonephritis
transmission by direct contact microorganisms are transferred from one infected person to another person
transmission by indirect contact transfer of an infectious agent through a contaminated intermediate surface,
object or vector (mosquitoes, flies, mites, fleas, ricks, rodents, etc.)
epidemiologically important organisms for contact VRE (vancomycin resistant enterococcus) & Clostridium Difficile (C. Diff.)
transmission
droplet precautions transmission involves contact of the conjunctivae or the mucous membranes of
the nose or mouth of a susceptible person with large particle droplets containing
microorganisms generated from someone who either exhibits a disease or who is
a carrier of the microorganism
respiratory droplets are generated when an infected person coughs, sneezes, or talks, or during
procedures such as suctioning, endotracheal intubation, cough induction by
chest physiotherapy and cardiopulmonary resuscitation
close contact (typically within 3 feet or less) between the source client and a susceptible
person is required, the use of a standard surgical mask is required
