SAFETY AND INFECTION CONTROL – 100 QUESTIONS AND ANSWERS.

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? battery comparative negligence negligence collective liability negligence Explanation: The position of the client's bed indicates negligence, a general term that denotes conduct lacking in due care. Collective liability stems from cooperation by several manufacturers in a wrongful activity. Comparative negligence holds the injured parties accountable for their fault in the injury. Battery involves harmful or unwarranted contact with the client. A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time? disturbed personal identity risk for injury hopelessness ineffective coping risk for injury Explanation: This client is at increased risk for injury because of severe hyperactivity, disorientation, and agitation. Although ineffective coping, hopelessness, and disturbed personal identity also are appropriate diagnoses, the client's safety takes highest priority. The nurse should take immediate action to protect the client from injury. Brainpower Read More 0:07 / 0:15 A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor? allowing volunteers to return neonates to the nursery affixing a security bracelet that monitors movement to a neonate affixing matching identification bands to the parents and neonate at birth positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway allowing volunteers to return neonates to the nursery Explanation: The new nurse requires additional teaching if allowing volunteers to return neonates to the nursery. Unit staff members won't likely recognize volunteers, whose assignments vary with each shift. Affixing matching identification bands at birth, positioning a rooming-in neonate's bassinet toward the center of the room, and affixing security bracelets are appropriate security measures. A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep their leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take? Ask the staffing coordinator to assign a nursing assistant to sit with the client. Apply wrist restraints. Sedate the client. Continually remind the client not to move their leg and to leave the immobilizer alone. Ask the staffing coordinator to assign a nursing assistant to sit with the client. Explanation: The nurse should ask the staffing coordinator to assign a nursing assistant to sit with the client. This action promotes client safety while avoiding restraint use. Applying wrist restraints doesn't prevent injury to the lower leg. Also, restraints should be applied only after other less restrictive measures have been attempted. A client with stage II Alzheimer's disease has memory impairment that impedes their ability to remember repeated instruction. Sedation isn't indicated for this client A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl? Check the color of the child's urine every day. Sew thick padding into the elbows and knees of the child's clothing. Expect the eruption of the primary teeth to produce moderate to severe bleeding. Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C). Sew thick padding into the elbows and knees of the child's clothing. Explanation: As the hemophilic infant begins to acquire motor skills, falls and bumps increase that risk of bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia. The nurse is caring for a client following a motor vehicle accident resulting in paraplegia. While the client is being prepared for discharge to home, the client's spouse expresses concern about the ability to carry the client, asking "What if I injure my back or drop them?" What discharge teaching should the nurse emphasize related to this concern? the importance of monitoring urinary elimination nutritional changes for the client with paraplegia ergonomic principles and body mechanics signs and symptoms of chronic back pain that should be reported to a health care provider ergonomic principles and body mechanics Explanation: The spouse's question indicates a need for teaching regarding safe client mobility and transfer techniques. Although urinary elimination and nutrition are components of care for clients with paraplegia, education about ergonomic principles and body mechanics is most appropriate at this time based on the spouse's statement. The goal is to provide the spouse with skills to prevent self-injury, not to help identify it. A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: is appropriate is positioned too low. is too large. is too small. is appropriate Explanation: The mask is appropriate because it covers the nose and mouth and fits snugly against the cheeks and chin. The mask is not too low. Masks that are too large may cover the eyes. Masks that are too small obstruct the nose 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. Offer the client sips of clear liquids. Assist the client to the bathroom. Assess cognitive status. Remove restraints and assess skin and circulation. Explanation: Placing a client in any type of restraint is a controversial issue. Strict guidelines exist. The client in restraints must have the skin integrity and circulation assessed every 1-2 hours. It is also appropriate to massage the area and provide range of motion exercises. On a regular basis, the client would be offered to use a bedpan or ambulate to the bathroom and the nurse would assess the cognitive status. A client with a nasogastric tube would not be offered fluids. A client is on isolation precautions for a hospital-acquired infection, and the client's visitors are not following the posted hand hygiene protocol. What is the nurse's best action? Explain to visitors the importance to the client of consistent hand hygiene. Post "do not enter" and "report to the nurse's desk" signs on the hospital door. Document this for the insurance company to bill the client. Report this to the healthcare provider to request an order restricting visitors. Explain to visitors the importance to the client of consistent hand hygiene. Explanation: The nurse should teach the client and visitors of the need to practice consistent hand hygiene. Hand hygiene by visitors reduces the risk of adding a secondary infection being transmitted to the client. Requesting visitor restrictions and contracting the insurance company are inappropriate actions. Posting "do not enter" signs brings attention but is not the most important action. 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? "Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended for me to prevent HIV transmission." "The only safe sex my partner and I can practice is hugging, petting, and mutual masturbation." "A latex condom provides the best protection against HIV transmission during sexual intercourse." "If both sexual partners are HIV-positive, unprotected sex is permitted." A latex condom provides the best protection against HIV transmission during sexual intercourse." Explanation: A latex condom with 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 When developing the plan of care for a client with suicidal ideation, the nurse should address which priority issue? safety self-esteem stress sleep safety Explanation: For the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-harm or self-destruction. Although self-esteem, sleep, and stress are common areas that require intervention for a client with suicidal ideation, ensuring the client's safety is the most immediate and serious concern. A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? Place a cap over the client's head. Immobilize the neck before the client is moved onto a stretcher. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Administer a sedative as ordered. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Explanation: Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse? Complete an incident report. Ask the charge nurse if an incident report is necessary. Discuss the matter with the night nurse the next time she works. Evaluate the client's BP for 4 hours before making decision. Complete an incident report. Explanation: Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority. What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. Maintain a closed drainage system. Recommend the health care provider prescribe antibiotics. Change the catheter daily. Encourage the client to drink 3,000 mL of fluids a day. Provide perineal care at least once a day. Maintain a closed drainage system Encourage the client to drink 3,000 mL of fluids a day. Provide perineal care at least once a day. Explanation: Catheter-associated urinary tract infection is the most frequent type of health care-acquired infection (HAI) and represents as much as 80% of HAIs in hospitals. The nurse should provide meticulous perineal care at least once a day, maintain a closed drainage system, and encourage the client to obtain an adequate fluid intake. It is not necessary to change the catheter daily. It is recommended that long-term use of an indwelling urinary catheter be evaluated carefully and other methods considered if the catheter will be in place longer than 2 weeks. It is not necessary to request a prescription for antibiotics as the client does not currently have an infection. The adult daughters of an older adult client inform the nurse that they fully expect their father to be combative after surgery. Preoperatively, they request that the nurse put all four side rails up and use restraints to keep him safe. What should the nurse tell the daughters? "Certainly; we will want to be sure to keep your father safe, too." "Restraint use is prohibited at our hospital at all times." "We will call the health care provider to get a prescription right away." "We will first try to keep him safe without restraint." We will first try to keep him safe without restraint." Explanation: A least-restraint environment should always be provided as much as possible. Nursing staff are required to attempt lesser restrictive alternatives (e.g., use of family or sitter, reorientation, distraction, or a toileting schedule) prior to notifying the provider of the need for restraints. Nursing staff are also required to document clinical conditions requiring restraint, lesser restrictive alternatives attempted, and client/family education provided regarding restraint use. Provider prescriptions for restraints must be time limited and specific regarding the type of restraint. Additionally, if restraints are implemented, nursing staff must monitor clients for safety (including skin checks and range of motion) and provide frequent food/fluids/toileting. A charge nurse is completing client assignments for the nursing staff on the pediatric unit. Which client would the nurse refrain from assigning to a pregnant staff member? a 2-year-old with Kawasaki's disease an 8-year-old with Rubella a 6-year-old with ringworm a 3-month-old with Roseola an 8-year-old with Rubella Explanation: Rubella (German measles) has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women. Ringworm is caused by a fungal infection on the skin. Standard hand hygiene is necessary. Kawasaki's disease is an autoimmune disease in which blood vessels become inflamed. Roseola is a virus transferred by oral secretions. The nurse is completing a sexual history on a client. The client reports a history of having a sexually transmitted infection (STI) that lies dormant in the body and can reoccur, but does not remember the name. Which STI matches the client's description? syphilis gonorrhea herpes chlamydia herpes Explanation: The nurse is most accurate to identify the herpes infection as the virus can remain dormant in the ganglia of the nerves. Symptoms are usually more severe with the initial outbreak. Subsequent episodes are usually shorter and less intense. The other infections do not have the same characteristics and, if identified, will be documented in the history. The nurse on a gerontology unit will be admitting several new clients to the unit over the next few hours. There are two shared rooms and one single-client room currently vacant on the unit. Which client should be placed in the single-client room? a client who has developed hypokalemia due to Clostridium difficile-related diarrhea a terminally ill client with chronic heart failure who is accompanied by several family members a client who is being readmitted following the dehiscence of an abdominal surgical incision a previously healthy client who has been diagnosed with delirium of unknown etiology and who is agitated a client who has developed hypokalemia due to Clostridium difficile-related diarrhea Explanation: For reasons of infection control, a client with Clostridium difficile-related diarrhea must be housed in a single room. This infection control measure would supersede the need to accommodate visitors. It is ideal for a client who is agitated to be in a single-client room, but the necessity of infection control would override this factor. At the beginning of a shift, the team leader notices that all of the I.V. antibiotics for a client are still in the medication room. What is the team leader's first action? Ask the nurse assigned to this client about the medications. Ask the client if medication was received during the previous shift. Notify the unit's nurse manager. Return the medications to the pharmacy to reduce hospital expenses. Ask the nurse assigned to this client about the medications. Explanation: The team leader should attempt to clarify this matter with the assigned staff first. The client would not be an accurate source of information regarding the I.V. medications. Returning the supplies is secondary to ensuring that the client received the required medications. The nurse is administering medications to a client with advanced Alzheimer's dementia who is confused to person, place, and time. Prior to administering the medication, what action should the nurse perform to verify the client's identity? Ask another staff member the name of the client in the room. Ask the client to state name and birthdate, then compare it to the medication administration record. Check the name listed on the unit board for the room. Compare the name and ID number on the client's wristband to the medication administration record. Compare the name and ID number on the client's wristband to the medication administration record. Explanation: The nurse should compare the name and ID number on the client's wristband to the medication administration record. As the client is not oriented to person, place, or time, it is not appropriate to verify identity by asking the client to state his or her name and birthdate. Checking the name listed on the unit board for the room does not ensure that the client in the room is the correct client. Asking another staff member the name of the client in that room does not ensure adequate verification of identity. A nurse implements a healthcare facility's disaster plan. Which action should be performed first? Identify a command center at which activities are coordinated. Explanation: During a disaster, having a command center to provide direction and coordinate activities is crucial. Cellular phones and pagers may be essential communication tools during a disaster. Essential off-duty personnel should respond to a disaster as quickly as possible. Admitted clients should be triaged and treated in accordance with the facility's triage policy. A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action should the nurse take next? Take the pump out of commission and locate a pump with a valid inspection sticker. Explanation: The nurse shouldn't use any equipment that doesn't have current inspection information. The pump could malfunction, causing harm to the patient. The nurse should remove the pump from service and locate a pump with the proper inspection information. 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." Explanation: In situations in which a client is a threat to self, the nurse can't honor confidentiality. Because this adolescent has a specific plan to commit suicide, the nurse must take immediate action to ensure the adolescent's safety. The physician and mental health professionals should be notified as well as the client's family. The nurse should inform the adolescent that this is necessary, while at the same time conveying a sense of caring and understanding. The local authorities needn't be notified in this situatio Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? talking with the nurse playing a card game with other clients engaging in physical activity keeping track of feelings in a journal talking with the nurse Explanation: Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse. A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client? Prepare for immediate administration of magnesium sulfate. Assess maternal contraction and fetal heart rate pattern. Review history of prior fetal demises with client. Reassure the client that this baby will be healthy. Assess maternal contraction and fetal heart rate pattern. Explanation: The physical aspects of care have a higher priority than the psychosocial aspects. The client report is part of the electronic medical record, but the maternal contraction pattern and the fetal heart rate pattern must be completed immediately upon admission to establish a baseline. The need for a tocolytic agent cannot be determined until the maternal fetal unit has been assessed. Assessment of the circumstances and etiologies of the prior fetal demises are important but are not of the highest importance. The psychosocial aspects are very important in the care of this client and can briefly be discussed as the physical aspects of assessment are being completed, but in-depth psychosocial care will need to wait until the physical aspects have been completed. When caring for the client with hepatitis B, which situation would expose the nurse to the virus? touching the client's arm with ungloved hands while taking a blood pressure contact with fecal material a blood splash into the nurse's eyes disposing of syringes and needles without recapping 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. While hospitalized, a child develops a Clostridium difficile infection. The nurse can anticipate adding which type of precautions for this client? droplet precautions contact precautions airborne precautions standard precautions contact precautions Explanation: Contact precautions are used for serious illnesses that are easily transmitted by direct client contact or by contact with items in the client's environment. Clostridium difficile infection is an example of an infection that is spread in this manner. Droplet precautions are used for serious illnesses transmitted by large particle droplets. Standard precautions are used for all clients. Airborne precautions are used for suspected illnesses transmitted by airborne nuclei. While out of bed walking, a client reports dizziness and requests to go back to the room. The nurse obtains the blood pressure machine and obtains vital signs on the client. The client's pulse is 50 and the blood pressure machine reads 80/40 mmHg. The nurse notes the client is scheduled to receive verapamil and atenolol. Which actions by the nurse are best? Select all that apply. Give the medications and check vital signs later. Call the supervisor and ask what to do. Hold the medications. Call the healthcare provider and provide a report of the events and vital signs. Give the scheduled medications. Hold the medications. Call the healthcare provider and provide a report of the events and vital signs. Explanation: Considering the ordered medications verapamil and atenolol, the pulse rate, and blood pressure, the medications should be held and the healthcare provider should be notified about the events and vital signs of the client. The healthcare provider will decide whether to give the medication or hold at this time. Verapamil and atenolol can cause slow heartbeat, so if the heartbeat is already slow, the medications should be held. The nurse is performing a surgical dressing change and drops a sterile gauze on the bedside table outside the sterile dressing tray's field. What would be the appropriate action by the nurse? Ask an unlicensed assistive personnel to obtain another sterile gauze from the supply room. Leave the room to obtain another sterile gauze dressing. Use sterile gloves to put the gauze back on the dressing tray. Place the noncontaminated side of the gauze next to the wound. Ask an unlicensed assistive personnel to obtain another sterile gauze from the supply room. Explanation: Asking the unlicensed assistive personnel to obtain a new sterile gauze from the supply room demonstrates that the nurse is aware of the contamination of the gauze and that it should not be used. The nurse would not leave the room as this would also cause a break in sterile technique. Using sterile gloves to place the gauze back on the tray contaminates both the sterile gloves and the sterile dressing tray. Using the dressing with the noncontaminated side next to the wound puts the client at risk for infection. The nurse is providing teaching to an expectant mother about breastfeeding. What statement made by the mother would require immediate follow-up by the nurse? "I was treated for gonorrhea 2 years ago." "I was told I had a heart murmur when I was a child." "I have been HIV positive for 4 years." "I had difficulty becoming pregnant because of endometriosis." "I have been HIV positive for 4 years." Explanation: A mother who has HIV is strongly discouraged from breastfeeding because of the risk of transmitting the infection to the neonate. Newborns born to HIV-positive mothers are generally treated with the antiviral medication zidovudine for the first 6 weeks after birth. A mother with a history of endometriosis may breastfeed and should not have symptoms of the condition until menses resume. Having a heart murmur may be a benign condition in childhood and is not a contraindication for breastfeeding. A past history of gonorrhea is not a contraindication to breastfeeding.