PN LESSON 2 SAFETY & INFECTION CONTROL PRACTICE TEST QUESTIONS AND ANSWERS

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 To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client. A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client's dinner. What action should the nurse take next? Serve the dinner in the seclusion room, maintaining observation Seclusion is ordered by a physician and requires continuous observation, unless the order is discontinued or amended. It is incorrect to amend the seclusion or mealtime. Meals can be eaten in the seclusion room with the nurse continuing the 1:1 observation. Meals must be offered on time and should not be withheld. Contracts for safe behavior are meaningless in the presence of psychotic behavior (mania). Brainpower Read More 0:03 / 0:15 Four clients are admitted to an adult medical unit on the same shift. The nurse should implement airborne precautions for which client? The client with a productive cough who just returned from vacation in India India has the greatest incidence of tuberculosis (TB) in the world and a client who develops a cough after spending time in India should be tested for TB or other contagious respiratory infections. Until the testing is complete, the client should be placed in airborne transmission-based precautions, which require a private, negative-pressure room. Health care workers would have to use a N-95 mask when in the room providing care for the client. The CMV virus is not highly contagious, but it can be transmitted by close, direct contact with infectious body fluids. Contact transmission-based precautions might be indicated. Clients with VAP and lung cancer are not considered contagious and do not require airborne precautions. A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client? (Select all that apply.) -Place personal protective equipment (PPE) at the door to the room. -Place the client in a private room. -Perform hand hygiene after contact with the client and before leaving the room. -Keep all equipment in the client's room for their sole use. Contact precautions are recommended in acute care settings for MRSA when there is a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and their environment and before leaving the isolation room. Contact precautions require health care workers to wear PPE such as gloves and a gown, which should be readily available. It is not required to keep the door closed at all times. The nurse is caring for an 80-year-old client who requires wrist restraints. What client behaviors would support the need to continue to use restraints? (Select all that apply.) -The client is resisting care and attempting to hit the staff. -The client is confused and trying to pull out an IV catheter. Physical restraints should only be used as a last resort. If restraints are indicated, the least restrictive device available should be used to restrain the client. The restraint should protect the individual, but also allow for freedom of movement. Circumstances that require the use of physical restraints include when clients attempt to remove life-support equipment, when clients interfere with therapy or treatment (e.g., enteral feedings, intravenous infusions, tracheostomy tubes, etc.) and when clients are combative and a risk to others. Restraints are not indicated for the convenience of hospital staff. Examples of physical restraints include hand mitts, arm sleeves, lap belts and limb restraints. The nurse is caring for a client with bilateral wrist restraints. Which intervention(s) should the nurse include in the client's plan of care? (Select all that apply.) -Remove restraints every two hours to allow for movement of involved extremity. -Routinely assess if the client is ready for restraint discontinuation. -Monitor the client's emotional response to the restraints. Ongoing assessment of clients who require restraints is essential. Restraints should be removed every two hours to allow the nurse to assess the neurovascular status of the restrained extremity, skin integrity under and around the restraint, the client's response to the restraint and the client's emotional state. A new restraint order must be obtained every 24 hours. Assessment of the client with restraints should be documented in the client's medical record at least every 2 to 4 hours. Nurses should frequently assess clients to determine readiness for restraint discontinuation. Restraints should remain in place when client has visitors to ensure client and visitor safety. 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? Instruct the nursing assistant to wash their hands again with soap and water. Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nurse assistant and to correct practice errors as needed. C. diff is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by this bacterium, the nurse should require the nursing assistant to wash their hands with soap and water, especially after providing care for this client. 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 To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client. A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client's dinner. What action should the nurse take next? Serve the dinner in the seclusion room, maintaining observation Seclusion is ordered by a physician and requires continuous observation, unless the order is discontinued or amended. It is incorrect to amend the seclusion or mealtime. Meals can be eaten in the seclusion room with the nurse continuing the 1:1 observation. Meals must be offered on time and should not be withheld. Contracts for safe behavior are meaningless in the presence of psychotic behavior (mania). Brainpower Read More 0:03 / 0:15 Four clients are admitted to an adult medical unit on the same shift. The nurse should implement airborne precautions for which client? The client with a productive cough who just returned from vacation in India India has the greatest incidence of tuberculosis (TB) in the world and a client who develops a cough after spending time in India should be tested for TB or other contagious respiratory infections. Until the testing is complete, the client should be placed in airborne transmission-based precautions, which require a private, negative-pressure room. Health care workers would have to use a N-95 mask when in the room providing care for the client. The CMV virus is not highly contagious, but it can be transmitted by close, direct contact with infectious body fluids. Contact transmission-based precautions might be indicated. Clients with VAP and lung cancer are not considered contagious and do not require airborne precautions. A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client? (Select all that apply.) -Place personal protective equipment (PPE) at the door to the room. -Place the client in a private room. -Perform hand hygiene after contact with the client and before leaving the room. -Keep all equipment in the client's room for their sole use. Contact precautions are recommended in acute care settings for MRSA when there is a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and their environment and before leaving the isolation room. Contact precautions require health care workers to wear PPE such as gloves and a gown, which should be readily available. It is not required to keep the door closed at all times. The nurse is caring for an 80-year-old client who requires wrist restraints. What client behaviors would support the need to continue to use restraints? (Select all that apply.) -The client is resisting care and attempting to hit the staff. -The client is confused and trying to pull out an IV catheter. Physical restraints should only be used as a last resort. If restraints are indicated, the least restrictive device available should be used to restrain the client. The restraint should protect the individual, but also allow for freedom of movement. Circumstances that require the use of physical restraints include when clients attempt to remove life-support equipment, when clients interfere with therapy or treatment (e.g., enteral feedings, intravenous infusions, tracheostomy tubes, etc.) and when clients are combative and a risk to others. Restraints are not indicated for the convenience of hospital staff. Examples of physical restraints include hand mitts, arm sleeves, lap belts and limb restraints. The nurse is caring for a client with bilateral wrist restraints. Which intervention(s) should the nurse include in the client's plan of care? (Select all that apply.) -Remove restraints every two hours to allow for movement of involved extremity. -Routinely assess if the client is ready for restraint discontinuation. -Monitor the client's emotional response to the restraints. Ongoing assessment of clients who require restraints is essential. Restraints should be removed every two hours to allow the nurse to assess the neurovascular status of the restrained extremity, skin integrity under and around the restraint, the client's response to the restraint and the client's emotional state. A new restraint order must be obtained every 24 hours. Assessment of the client with restraints should be documented in the client's medical record at least every 2 to 4 hours. Nurses should frequently assess clients to determine readiness for restraint discontinuation. Restraints should remain in place when client has visitors to ensure client and visitor safety. 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? Instruct the nursing assistant to wash their hands again with soap and water. Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nurse assistant and to correct practice errors as needed. C. diff is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by this bacterium, the nurse should require the nursing assistant to wash their hands with soap and water, especially after providing care for this client.