Safety and Infection Control

During a 12-hour night shift, the nurse has a "near miss" and catches an error before giving a new medication. Which statement might explain the reason for the near miss? (Select all that apply.)

• The nurse is interrupted when preparing the medication

• The nurse is sleep-deprived

• The unit is short-staffed

• The nurse works in the intensive care unit (ICU)

A child is admitted with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first?

• Notify of changes in neurologic status

• Monitor and record vital signs every 30 minutes

• Seizure precautions

• Droplet precautions

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?

• Ignore the behavior

• Call the health care provider

• Quickly leave the room and ask the UAP to assist the client

• Complete an incident report

The nurse listens to the report about a newly admitted client who has a skin ulcer that's tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions must be taken for this hospitalized client? (Select all that apply.)

• Place the client in a single room

• Keep all equipment in the client's room for his/her sole use

• Perform hand hygiene after direct contact with the client and before leaving the room

• Keep the door to the room closed, with a notice for visitors

The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders?

• Apply a restraint to keep the client in a chair when awake

• Explain the risk of walking with no purpose

• Frequently reorient the client to time, person and place

• Attach a monitoring band to the client's wrist

The nurse is attending an in-service about healthcare-associated infections (HAIs). Which factor is identified as the most common cause of HAIs in the acute care setting?

• Inadequate fluid intake over 72 hours

• Decreased mobility for a week or longer

• Existence of an intravenous access device

• Presence of an indwelling urinary catheter

Which situation requires handwashing or hand sanitation from the nurse? (Select all that apply.)

• Prior to eating

• Before having direct contact with a client

• After cleaning a wound

• After contact with inanimate objects in the immediate vicinity of the client

• After making a chart entry

A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school-age children when speaking at a teacher’s conference. The nurse should plan to include which information?

• The classroom should be sprayed with an insecticide before winter and spring vacations

• Each child should wash his or her hands after recess break

• Children should not share or wear other children's coats, hats and scarves

• The heads of children should be checked monthly for nits (lice eggs)

Four clients are admitted to an adult medical unit on the same shift. The nurse should expect to implement airborne precautions for the client with which of the following diagnoses?

• Advanced carcinoma of the lung

• Confirmed AIDS with cytomegalovirus (CMV)

• Positive Mantoux test with an abnormal chest x-ray

• Suspected viral pneumonia

The parents of a toddler ask, "How long will our child have to sit in a rear facing car seat when riding in a car?” What would be the best response by the nurse?

• "When the child is 50 inches tall."

• "When the child weighs 40 pounds."

• "Until the child is about 2 years-old."

• "Whenever the child is content to sit in a booster seat."