Final Assessment. Safety and Infection Control.

A client who has had recent exposure to Ebola while traveling in Africa arrives in the emergency department with fever, headache, vomiting, and multiple ecchymoses. Which action should the nurse take first?

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first?

The nurse is caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza (“bird flu”). Which of these prescribed actions will the nurse implement first?

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the client? Select all that apply.

Four clients arrive simultaneously at the emergency department. Which client requires the most rapid action by the triage nurse to protect other clients from infection?

The nurse is caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection?

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN?

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells the nurse about having frequent watery stools. Which action will the nurse take first?

The nurse notes white powder on the arms and chest of a client who arrives at the emergency department and reports possible anthrax contamination. Which action included in the hospital protocol for possible anthrax exposure will the nurse take first?

A pregnant client in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important?

The nurse at the infectious disease clinic has four clients waiting to be seen. Which client should the nurse see first?

The nurse notices that the health care provider omits hand hygiene after leaving a client’s hospital room. Which action by the nurse is best at this time?

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client’s care?

A client who has been diagnosed with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take first?

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)?

The nurse is preparing to change the linens on the bed of a client who has a sacral wound infected by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) items will be used? Select all that apply.

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN/LVN?

Which action by the infection control nurse in an acute care hospital will be most effective in reducing the incidence of health care–associated infections?

When the nurse is educating a group of women of childbearing age about the Zika virus, which information will be included? Select all that apply.

When the community health nurse is counseling a client who has an acute Zika virus infection, which information is most important to include?

Which policy implemented by the infection control nurse will most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)?

The nurse admits four clients with infections to the medical unit, but only one private room is available. Which client is most appropriate to assign to the private room?

Which information about a client who has meningococcal meningitis is the best indicator that the nurse can discontinue droplet precautions?

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin-resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply.

The nurse would perform which action when washing hands as part of medical asepsis before caring for a client in an outpatient clinic? Select all that apply.

The nurse’s forearm becomes splattered with blood while inserting an intravenous catheter. What action should the nurse take?

A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply.

An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted?

The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route?

Which of these actions is the primary nursing intervention designed to limit transmission of a client’s Salmonella infection?

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?

A client is scheduled to receive an oral solution of radioactive iodine (I131). In order to reduce hazards, the priority information for the nurse to include in client teaching is which of these statements?

A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply.

A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precaution does the nurse understand is most appropriate to help ensure the safety of this client?

A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls?

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.

A community health nurse is asked to assist in developing a community disaster plan. The nurse determines that this responsibility is a component of which disaster management phase identified by the Federal Emergency Management Agency (FEMA)?

A community health nurse prepares a presentation about decreasing the risk of spreading influenza in the community. The presentation most likely includes which information?

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is:

A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line-related sepsis is diagnosed. The nurse interprets this finding as meaning that this infection is:

A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to:

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.

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 nurse whether it is safe to use a space heater. What is the appropriate response by the nurse?

A home health nurse has been called to the home of an older postoperative cardiovascular client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed?

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.

A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin’s disease. Which of the following precautions should the nurse take while working with this intravenous (IV) infusion?

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis?

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply.

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.

A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise:

The unlicensed assistive personnel (UAP) is preparing to provide post-mortem care to a client with a questionable diagnosis of anthrax. Which instruction is the priority for the RN to provide to the UAP?

A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim  for neutropenia. Which lunch selection suggests the client has learned about necessary dietary changes?

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply.

A nurse manager tells the nursing staff that the agency’s disaster preparedness plan will be distributed to all employees for review. The nurse manager states that the plan is an important component of disaster readiness because it primarily:

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply.

A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action should the nurse take?

A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure?

A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client’s plan of care?

A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first?

A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation?

A nurse, assessing a client’s readiness for discharge, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further? Select all that apply.

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 a correct understanding of the principles of aseptic technique? Select all that apply.

A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims:  “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby. ” Which of these comments would be the best tool for the nurse to determine if the child has swallowed a corrosive substance?

A physician writes a prescription for the application of a heating pad to a client’s back. Which of the following actions should the nurse take when implementing this prescription? Select all that apply.

A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse?

A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home?

The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these interventions would be a priority for the nurse to implement?