Module 6: Safety and Infection Control EXAM
QUESTIONS & ANSWERS
A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a
blood tube containing a specimen from the client broke. What steps should the nurse take to
clean up the blood spill? Select all that apply. - ✔✔- Using tongs to collect any broken glass
- Wearing gloves for the cleanup procedure
- Disinfecting the area of the blood spill with a dilute bleach solution
Rationale: The nurse should blot the spill with an absorbent disposable material such as
disposable paper towels or terry wipes, not a face cloth or towel. Tongs are used to pick up any
broken glass, and gloves are worn for the procedure. The broken glass is disposed of in a
puncture-resistant container. The area is disinfected with a dilute bleach solution or other
agency-accepted product.
A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape
on the overbed table. Which of these actions on the part of the nurse indicate correct
understanding of the principles of aseptic technique? Select all that apply. - ✔✔- Positioning
the sterile field so that it remains in full view
- Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand
- Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves
Rationale: The principles of surgical asepsis must be followed in the preparation of a sterile
field. Among these principles: A sterile object remains sterile only when touched by other
sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of
the range of vision or an object held below the nurse's waist is to be considered contaminated;
a sterile object or field becomes 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.
In which of the following situations would the nurse use this type of restraint (mitten restraint)?
Select all that apply. - ✔✔- To prevent dislodgment of an intravenous line
,- To prevent the use of the hands while allowing free arm movement
Rationale: A mitten restraint is a thumbless device used to restrain the hands. It prevents the
use of the hands while allowing free arm movement. Mitten restraints are useful for the client
who must be prevented from 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.
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank
some window cleaner that had been stored in a cabinet. The nurse should instruct the mother
to immediately: - ✔✔Call a poison control center
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting
should not be induced if the victim is unconscious or if the substance ingested was a strong
corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare
provider has given specific instructions to induce vomiting. Neither calling an ambulance nor
calling the physician's answering service is the immediate action, because either would 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.
A home care nurse is visiting an older client who has been recovering from a mild brain attack
(stroke) affecting her left side. The client lives alone but receives regular assistance from her
daughter and son, who both live within 10 miles. Which of the following actions should the
nurse take to assess the client's safety risk? Select all that apply. - ✔✔- Assessing the client's
visual acuity
- Observing the client's gait and posture
- Evaluating the client's muscle strength
- Looking for any hazards in the home environment
Rationale: To conduct a thorough client assessment, the nurse looks for risk factors related to
safety. The assessment should include the assessment of visual acuity, gait and posture, and
muscle strength, because alterations in these areas increase the client's risk for falls and injury.
,The nurse should also assess the home environment, looking for any hazards or obstacles that
might affect safety. Asking a family member to move in with the client until recovery is
complete and requesting that the client transfer to an assisted living environment for at least 1
month are not assessment activities. Additionally, nothing in the question indicates that these
actions are necessary; therefore, these options are unrealistic and unreasonable.
A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to
climb out of bed. Which of these safety devices that the nurse might suggest is the least
restrictive? - ✔✔Ambularm
Rationale: The Ambularm device, worn on the leg, signals when the client's leg is in a
dependent position. It is used for clients who climb out of bed and are at risk for falling.
Ambularm devices that may be attached to the bed or chair or to the client's mattress or
nightgown are also available. A belt restraint is a device that is wrapped around the client's
waist to secure the client to bed or to a stretcher. A wrist restraint is a device used to
immobilize an arm. An elbow restraint consists of a piece of fabric with slots into which tongue
blades are inserted, after which the device is wrapped around the elbow area to immobilize it.
Of the options provided, the Ambularm is the least restrictive safety device.
A home health nurse has instructed a client about safety measures during the use of an oxygen
concentrator in the home. Which statement by the client indicates to the nurse that the client
has understood the directions? Select all that apply. - ✔✔- "I need to follow the oxygen
prescription exactly."
- "I have to keep the oxygen concentrator out of direct sunlight."
- "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the
oxygen concentrator."
Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or
other equipment that could emit sparks should be avoided while oxygen is in use, because fire
and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and
slightly away from walls and corners to permit adequate air flow. The client should not allow
smoking or any type of flame within 10 feet of the oxygen source. Other measures include
having telephone numbers for the physician, nurse, and oxygen vendor available and teaching
the client signs and symptoms requiring emergency care.
, A nurse educator is providing an inservice program to emergency department nurses about the
signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of
inhalation anthrax is: - ✔✔Flulike symptoms
Rationale: Inhalation anthrax is caused by the inhalation of spores from Bacillus anthracis,
which multiply in the alveoli. This form of anthrax begins with the same symptoms as the flu,
including fever, muscle aches, and fatigue. Symptoms suddenly become more severe with the
development of breathing problems and shock. Toxins from the anthrax spores cause
hemorrhage and destruction of lung tissue.
A home health nurse teaches a client about home modifications to reduce the risk of falls.
Which statements by the client indicate a need for further teaching? Select all that apply. -
✔✔- "I need to remove my wall-to-wall carpeting."
- "I should walk barefoot as much as possible so that I'll know about any wet spots on the
floor."
Rationale: Home modifications to reduce the risk of falls include ensuring ample lighting,
removing scatter rugs, placing handrails in bathrooms, and using handrails on all staircases. The
client should wear flat rubber-soled shoes to prevent slips and falls. Walking barefoot will not
reduce the risk of injury; in fact, it could actually increase the risk of foot injury and of slipping
and falling. Removal of wall-to-wall carpeting is not necessary.
Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus
(MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the
client, tells the assistant: - ✔✔To wear gloves and a gown when changing the client's bed
linen.
Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client
contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during
interventions that may produce splashes of blood or body fluids, secretions, or excretions. The
client should be placed in a private room or, if a private room is not available, in a semiprivate
room with another client who has active infection with the same microorganism but no other
infection. The nursing assistant would remove the protective gear before leaving the client's
room.
QUESTIONS & ANSWERS
A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a
blood tube containing a specimen from the client broke. What steps should the nurse take to
clean up the blood spill? Select all that apply. - ✔✔- Using tongs to collect any broken glass
- Wearing gloves for the cleanup procedure
- Disinfecting the area of the blood spill with a dilute bleach solution
Rationale: The nurse should blot the spill with an absorbent disposable material such as
disposable paper towels or terry wipes, not a face cloth or towel. Tongs are used to pick up any
broken glass, and gloves are worn for the procedure. The broken glass is disposed of in a
puncture-resistant container. The area is disinfected with a dilute bleach solution or other
agency-accepted product.
A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape
on the overbed table. Which of these actions on the part of the nurse indicate correct
understanding of the principles of aseptic technique? Select all that apply. - ✔✔- Positioning
the sterile field so that it remains in full view
- Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand
- Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves
Rationale: The principles of surgical asepsis must be followed in the preparation of a sterile
field. Among these principles: A sterile object remains sterile only when touched by other
sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of
the range of vision or an object held below the nurse's waist is to be considered contaminated;
a sterile object or field becomes 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.
In which of the following situations would the nurse use this type of restraint (mitten restraint)?
Select all that apply. - ✔✔- To prevent dislodgment of an intravenous line
,- To prevent the use of the hands while allowing free arm movement
Rationale: A mitten restraint is a thumbless device used to restrain the hands. It prevents the
use of the hands while allowing free arm movement. Mitten restraints are useful for the client
who must be prevented from 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.
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank
some window cleaner that had been stored in a cabinet. The nurse should instruct the mother
to immediately: - ✔✔Call a poison control center
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting
should not be induced if the victim is unconscious or if the substance ingested was a strong
corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare
provider has given specific instructions to induce vomiting. Neither calling an ambulance nor
calling the physician's answering service is the immediate action, because either would 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.
A home care nurse is visiting an older client who has been recovering from a mild brain attack
(stroke) affecting her left side. The client lives alone but receives regular assistance from her
daughter and son, who both live within 10 miles. Which of the following actions should the
nurse take to assess the client's safety risk? Select all that apply. - ✔✔- Assessing the client's
visual acuity
- Observing the client's gait and posture
- Evaluating the client's muscle strength
- Looking for any hazards in the home environment
Rationale: To conduct a thorough client assessment, the nurse looks for risk factors related to
safety. The assessment should include the assessment of visual acuity, gait and posture, and
muscle strength, because alterations in these areas increase the client's risk for falls and injury.
,The nurse should also assess the home environment, looking for any hazards or obstacles that
might affect safety. Asking a family member to move in with the client until recovery is
complete and requesting that the client transfer to an assisted living environment for at least 1
month are not assessment activities. Additionally, nothing in the question indicates that these
actions are necessary; therefore, these options are unrealistic and unreasonable.
A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to
climb out of bed. Which of these safety devices that the nurse might suggest is the least
restrictive? - ✔✔Ambularm
Rationale: The Ambularm device, worn on the leg, signals when the client's leg is in a
dependent position. It is used for clients who climb out of bed and are at risk for falling.
Ambularm devices that may be attached to the bed or chair or to the client's mattress or
nightgown are also available. A belt restraint is a device that is wrapped around the client's
waist to secure the client to bed or to a stretcher. A wrist restraint is a device used to
immobilize an arm. An elbow restraint consists of a piece of fabric with slots into which tongue
blades are inserted, after which the device is wrapped around the elbow area to immobilize it.
Of the options provided, the Ambularm is the least restrictive safety device.
A home health nurse has instructed a client about safety measures during the use of an oxygen
concentrator in the home. Which statement by the client indicates to the nurse that the client
has understood the directions? Select all that apply. - ✔✔- "I need to follow the oxygen
prescription exactly."
- "I have to keep the oxygen concentrator out of direct sunlight."
- "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the
oxygen concentrator."
Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or
other equipment that could emit sparks should be avoided while oxygen is in use, because fire
and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and
slightly away from walls and corners to permit adequate air flow. The client should not allow
smoking or any type of flame within 10 feet of the oxygen source. Other measures include
having telephone numbers for the physician, nurse, and oxygen vendor available and teaching
the client signs and symptoms requiring emergency care.
, A nurse educator is providing an inservice program to emergency department nurses about the
signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of
inhalation anthrax is: - ✔✔Flulike symptoms
Rationale: Inhalation anthrax is caused by the inhalation of spores from Bacillus anthracis,
which multiply in the alveoli. This form of anthrax begins with the same symptoms as the flu,
including fever, muscle aches, and fatigue. Symptoms suddenly become more severe with the
development of breathing problems and shock. Toxins from the anthrax spores cause
hemorrhage and destruction of lung tissue.
A home health nurse teaches a client about home modifications to reduce the risk of falls.
Which statements by the client indicate a need for further teaching? Select all that apply. -
✔✔- "I need to remove my wall-to-wall carpeting."
- "I should walk barefoot as much as possible so that I'll know about any wet spots on the
floor."
Rationale: Home modifications to reduce the risk of falls include ensuring ample lighting,
removing scatter rugs, placing handrails in bathrooms, and using handrails on all staircases. The
client should wear flat rubber-soled shoes to prevent slips and falls. Walking barefoot will not
reduce the risk of injury; in fact, it could actually increase the risk of foot injury and of slipping
and falling. Removal of wall-to-wall carpeting is not necessary.
Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus
(MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the
client, tells the assistant: - ✔✔To wear gloves and a gown when changing the client's bed
linen.
Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client
contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during
interventions that may produce splashes of blood or body fluids, secretions, or excretions. The
client should be placed in a private room or, if a private room is not available, in a semiprivate
room with another client who has active infection with the same microorganism but no other
infection. The nursing assistant would remove the protective gear before leaving the client's
room.
