Module 6 HESI Safety and Infection Control
TEST BANK MIDTERM EXAM NEWEST VERSION
WITH COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS \\ACTUAL EXAM WITH
VERIFIED ANSWERS ASSURED PASS GRADED A+
\\BRAND NEW
B The restraints are being released every 2 hours.
After discussing the use of C A safety knot has been used to secure the restraints.
restraints with a client and E The call light has been placed within reach of the client.
family, a physician has Rationale: Restraints should never be applied tightly,
written a prescription for because this could impair circulation. They should be
wrist restraints to be tied to the bed frame (not the siderail) with the use of a
applied to a client. The nurse safety knot. The client could sustain injury if the siderail
instructs the nursing were lowered with a restraint attached to it. A safety
assistant to apply the knot is used because it can easily be released in an
restraints. emergency. Restraints must be released every 2 hours
Which of the following to facilitate inspection of the skin, help ensure good
observations by the nurse circulation, and permit movement of the joint through
indicates that the nursing its range of motion. The call light must always be within
assistant is using the reach of the client in case he or she needs assistance.
restraints safely and
correctly? Select all that
apply.
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A A victim with respiratory distress
C A victim with partial amputation of the foot
Rationale: One rating system commonly used in the ED
consists of three tiers — emergent, urgent, and
nonurgent — with the categories sometimes identified
with color coding or numbers. The emergent
A triage nurse in an
classification (a.k.a. red or priority 1) is given to clients
emergency department (ED)
with life-threatening injuries (here, the clients with
is attending to the victims
respiratory distress [airway] and partial amputation of
of a train crash. All victims
the foot [bleeding/circulation]) who require immediate
are alert. Which of these
attention and continuous evaluation but have a high
clients does the nurse
chance of survival once their conditions have been
assign to the emergent
stabilized. The urgent (a.k.a. yellow or priority 2)
category? Select all that
classification is given to clients whose injuries and
apply.
complications are not life threatening (here, the client
with the fractured humerus), provided that they are
treated within 1 to 2 hours; such clients require
evaluation every 30 to 60 minutes thereafter. The
nonurgent (a.k.a. green or priority 3) classification is
given to clients with local injuries (here, the clients with
the forehead laceration and bruises of the arms and
legs) who do not have immediate complications and can
wait several hours for medical treatment; these clients
require evaluation every 1 to 2 hours thereafter.
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A Using tongs to collect any broken glass
A nurse is preparing to B Wearing gloves for the cleanup procedure
clean up a blood spill on E Disinfecting the area of the blood spill with a dilute bleach
solution
the client's bedside table
Rationale: The nurse should blot the spill with an
that occurred when a
absorbent disposable material such as disposable paper
blood tube containing a
towels or terry wipes, not a face cloth or towel. Tongs
specimen from the client
are used to pick up any broken glass, and gloves are
broke. What steps should
worn for the procedure. The broken glass is disposed
the nurse take to clean up
of in a puncture-resistant container. The area is
the blood spill? Select all
disinfected with a dilute bleach solution or other
that apply.
agency-accepted product.
B Positioning the sterile field so that it remains in full view
E Picking up a pair of sterile scissors from the sterile field with a
sterile gloved hand
F Pouring sterile wound cleansing solution into a sterile
A nurse, preparing a sterile cup before donning sterile gloves
field on which to perform a
dressing change, places the Rationale: The principles of surgical asepsis must be
sterile drape on the overbed followed in the preparation of a sterile field. Among
table. Which of these these principles: A sterile object remains sterile only
actions on the part of the when touched by other sterile objects; only sterile
nurse indicate correct objects may be placed on a sterile field; a sterile
understanding of the object or field out of the range of vision or an object
principles of aseptic held below the nurse's waist is to be considered
technique? Select all that contaminated; a sterile object or field becomes
apply. contaminated with prolonged exposure to air; when
a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field
becomes contaminated by way of capillary action; fluid
flows in the direction of gravity; a 1- inch edge of a
sterile field or container is to be considered
contaminated.
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D To prevent dislodgment of an intravenous line
F To prevent the use of the hands while allowing free arm
movement
In which of the following Rationale: A mitten restraint is a thumbless device used
situations would the nurse to restrain the hands. It prevents the use of the hands
use this type of restraint while allowing free arm movement. Mitten restraints are
(mitten restraint)? Select useful for the client who must be prevented from
all that apply. dislodging an intravenous line, indwelling urinary
catheter, nasogastric tube, other types of tubes, or
wound dressings. A belt restraint prevents the client
from falling out of a bed, a chair, or a stretcher. A
mitten restraint does not secure the shoulders and the
waist and is not used to prevent the client from
turning side to side.
A Call a poison control center
Rationale: When a poisoning occurs, a poison center
The mother of a 3-year-
should be called immediately. Vomiting should not be
old calls a neighbor who is a
induced if the victim is unconscious or if the
nurse and reports that her
substance ingested was a strong corrosive or
child just drank some
petroleum product. Also, vomiting should not be
window cleaner that had
induced unless a healthcare provider has given
been stored in a cabinet.
specific instructions to induce vomiting. Neither calling
The nurse should instruct
an ambulance nor calling the physician's answering
the mother to
service is the immediate action, because either would
immediately:
delay treatment. Additionally, the physician would
immediately make a referral to the poison control
center. The poison control center may advise the
mother to bring the child to the emergency
department; if this is the case, the mother should then
call an ambulance.
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