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Module 6: Safety And Infection Control
Exam |Comprehensive Key Questions
With Answers And Rationales
A client with paraplegia has spasticity of the leg muscles. Which interventions
should be included in the plan of care for this client? Select all that apply.-correct-
answer-- Range-of-motion exercises of the affected limbs
- An as-needed prescription for a muscle relaxant
- Removal of potentially harmful objects near the client
- The use of padding against the client's legs when the client is sitting in a
wheelchair
Rationale: The use of limb restraints will not alleviate spasticity and could harm
the client, so restraints should be avoided. Range-of-motion exercises are
beneficial in stretching the muscles, which may diminish spasticity. The use of
muscle relaxants may be helpful if spasms are causing discomfort for the client or
pose a risk to the client's safety. Removing potentially harmful objects from the
vicinity of the client is a good basic safety measure. Padding will prevent injury to
the client's legs while the client is in the wheelchair.
A registered nurse is instructing a group of nursing assistants in the principles of
body mechanics. Which of these observations tell the nurse that a student is using
the principles appropriately? Select all that apply.-correct-answer-- The assistant
positions a box that is to be lifted between his knees.
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- The assistant keeps the object to be moved as close to his body as possible.
Rationale: When moving an object, the nursing assistant should position the
object between his knees. The assistant should keep the client or object to be
moved as close to his body as possible. When turning a client, the assistant should
keep his back straight and take small steps with the feet. The assistant should turn
his feet, rather than twisting his back, if a change in direction is necessary when
carrying an object or a client. The assistant should seek out assistance when
transferring a client who requires total care.
A nurse is performing sterile wound irrigation for an assigned client. A nursing
assistant enters the client's room and tells the nurse that a physician has
telephoned and has asked to speak to the nurse. What is the appropriate action
by the nurse?-correct-answer-Asking the nursing assistant to obtain a telephone
number from the physician so that the nurse may return the call after the wound
irrigation is complete
Rationale: Because wound irrigation is a sterile procedure and a risk for infection
exists with any open wound, the nurse should ask the nursing assistant to obtain a
telephone number from the physician so that the call may be returned after the
wound irrigation is complete. It is not appropriate to ask a physician to wait while
a procedure is being completed. It is best to return the call. It is not the
responsibility of the nursing assistant to take a message.
A home care nurse visits a client who lives in a small apartment to perform an
admission assessment. During the home safety assessment, the client asks the
,3|Page
nurse whether it is safe to use a space heater. What is the appropriate response
by the nurse?-correct-answer-"A space heater can be used as long as it's placed at
least 3 feet from anything that may ignite."
Rationale: Space heaters must be used appropriately because of the risk of fire. A
space heater should be placed at least 3 feet from anything that may ignite. A
space heater may be used in an apartment if there is ample space and safety
precautions are followed. A low setting does not reduce the risk of fire. Placing a
heater in a bedroom does not guarantee that it will be 3 feet from anything that
may ignite.
A nurse has provided instructions to a mother regarding the use of safety seats in
car travel for her newborn infant. Which statement by the mother indicates
understanding of the instructions?-correct-answer-"I'll put the baby's car seat in
the middle back seat, facing backward and reclined a little."
Rationale: The infant should be restrained in a car seat in a semireclined, rear-
facing position to allow the seat and infant's spine to bear the forces of impact
should a collision occur. The infant should never face forward or ride in the front
seat.
The unit supervisor of an emergency department (ED) is called at home and told
by an emergency department nurse who is on duty that an airplane crash has
occurred and numerous casualties will be arriving at the ED. What should the
initial response by the unit supervisor be?-correct-answer-Has the disaster plan
been activated?"
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Rationale: In an external disaster, many people will be brought to the ED for
treatment. Although ensuring that rooms are well stocked with supplies, calling
nursing staff to come to work, and finding stretchers are components of preparing
for the casualties, the initial nursing action must be activation of the disaster plan.
Therefore the initial response by the unit supervisor should be "Has the disaster
plan been activated?"
A registered nurse (RN) is watching as a new licensed practical nurse (LPN)
suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS).
Which of the following protective devices worn by the LPN would cause the RN to
determine that the LPN was performing the procedure safely?-correct-answer-
Gloves, gown, and face shield.
Rationale: The RN is responsible for supervising procedures performed by a new
LPN to ensure that safety is maintained and that policies and procedural
guidelines are followed. Standard precautions include use of gloves whenever
there will be actual contact with blood or body fluids or the potential for contact
exists. Therefore the LPN must wear gloves. The LPN also needs to protect the
eyes, nose, and mouth from contact with the client's respiratory secretions; a face
shield will provide this protection. A mask or protective eyewear does not provide
adequate protection. Gowns are worn in those instances when it is anticipated
that there will be contact with body fluid or blood.
Wrist restraints have been prescribed for a client who is constantly pulling at his
gastrostomy tube. Which of the following findings does the nurse, developing a
Module 6: Safety And Infection Control
Exam |Comprehensive Key Questions
With Answers And Rationales
A client with paraplegia has spasticity of the leg muscles. Which interventions
should be included in the plan of care for this client? Select all that apply.-correct-
answer-- Range-of-motion exercises of the affected limbs
- An as-needed prescription for a muscle relaxant
- Removal of potentially harmful objects near the client
- The use of padding against the client's legs when the client is sitting in a
wheelchair
Rationale: The use of limb restraints will not alleviate spasticity and could harm
the client, so restraints should be avoided. Range-of-motion exercises are
beneficial in stretching the muscles, which may diminish spasticity. The use of
muscle relaxants may be helpful if spasms are causing discomfort for the client or
pose a risk to the client's safety. Removing potentially harmful objects from the
vicinity of the client is a good basic safety measure. Padding will prevent injury to
the client's legs while the client is in the wheelchair.
A registered nurse is instructing a group of nursing assistants in the principles of
body mechanics. Which of these observations tell the nurse that a student is using
the principles appropriately? Select all that apply.-correct-answer-- The assistant
positions a box that is to be lifted between his knees.
,2|Page
- The assistant keeps the object to be moved as close to his body as possible.
Rationale: When moving an object, the nursing assistant should position the
object between his knees. The assistant should keep the client or object to be
moved as close to his body as possible. When turning a client, the assistant should
keep his back straight and take small steps with the feet. The assistant should turn
his feet, rather than twisting his back, if a change in direction is necessary when
carrying an object or a client. The assistant should seek out assistance when
transferring a client who requires total care.
A nurse is performing sterile wound irrigation for an assigned client. A nursing
assistant enters the client's room and tells the nurse that a physician has
telephoned and has asked to speak to the nurse. What is the appropriate action
by the nurse?-correct-answer-Asking the nursing assistant to obtain a telephone
number from the physician so that the nurse may return the call after the wound
irrigation is complete
Rationale: Because wound irrigation is a sterile procedure and a risk for infection
exists with any open wound, the nurse should ask the nursing assistant to obtain a
telephone number from the physician so that the call may be returned after the
wound irrigation is complete. It is not appropriate to ask a physician to wait while
a procedure is being completed. It is best to return the call. It is not the
responsibility of the nursing assistant to take a message.
A home care nurse visits a client who lives in a small apartment to perform an
admission assessment. During the home safety assessment, the client asks the
,3|Page
nurse whether it is safe to use a space heater. What is the appropriate response
by the nurse?-correct-answer-"A space heater can be used as long as it's placed at
least 3 feet from anything that may ignite."
Rationale: Space heaters must be used appropriately because of the risk of fire. A
space heater should be placed at least 3 feet from anything that may ignite. A
space heater may be used in an apartment if there is ample space and safety
precautions are followed. A low setting does not reduce the risk of fire. Placing a
heater in a bedroom does not guarantee that it will be 3 feet from anything that
may ignite.
A nurse has provided instructions to a mother regarding the use of safety seats in
car travel for her newborn infant. Which statement by the mother indicates
understanding of the instructions?-correct-answer-"I'll put the baby's car seat in
the middle back seat, facing backward and reclined a little."
Rationale: The infant should be restrained in a car seat in a semireclined, rear-
facing position to allow the seat and infant's spine to bear the forces of impact
should a collision occur. The infant should never face forward or ride in the front
seat.
The unit supervisor of an emergency department (ED) is called at home and told
by an emergency department nurse who is on duty that an airplane crash has
occurred and numerous casualties will be arriving at the ED. What should the
initial response by the unit supervisor be?-correct-answer-Has the disaster plan
been activated?"
, 4|Page
Rationale: In an external disaster, many people will be brought to the ED for
treatment. Although ensuring that rooms are well stocked with supplies, calling
nursing staff to come to work, and finding stretchers are components of preparing
for the casualties, the initial nursing action must be activation of the disaster plan.
Therefore the initial response by the unit supervisor should be "Has the disaster
plan been activated?"
A registered nurse (RN) is watching as a new licensed practical nurse (LPN)
suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS).
Which of the following protective devices worn by the LPN would cause the RN to
determine that the LPN was performing the procedure safely?-correct-answer-
Gloves, gown, and face shield.
Rationale: The RN is responsible for supervising procedures performed by a new
LPN to ensure that safety is maintained and that policies and procedural
guidelines are followed. Standard precautions include use of gloves whenever
there will be actual contact with blood or body fluids or the potential for contact
exists. Therefore the LPN must wear gloves. The LPN also needs to protect the
eyes, nose, and mouth from contact with the client's respiratory secretions; a face
shield will provide this protection. A mask or protective eyewear does not provide
adequate protection. Gowns are worn in those instances when it is anticipated
that there will be contact with body fluid or blood.
Wrist restraints have been prescribed for a client who is constantly pulling at his
gastrostomy tube. Which of the following findings does the nurse, developing a
