ATI Nursing Fundamentals - Chapter 10-15: Safety and Infection Control

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field?

A. Keep the sterile field at least 6 ft away from the client's bedside

B. Instruct the client to refrain from coughing and sneezing during the dressing change

C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound

D. Keep a box of facial tissues nearby for the client to use during the dressing change

A. It would be difficult for the nurse to maintain a sterile field away from the bedside. But more important, this might not have any effect on the transmission of some micro-organisms

B. The client might be unable to refrain from coughing and sneezing during the dressing change

C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the dressing change

D. Keeping tissues close by for the client to use still allows contamination of the surgical wound

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

A. The flap closest to the body

B. The right side flap

C. The left side flap

D. The flap farthest from the body

A. The flap closest to the nurse's body is the innermost flap and the last one to unfold

B. The nurse should unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap the nurse should unfold first

C. The nurse should unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap the nurse should unfold first

D. CORRECT: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply)

A. A bottle containing a sterile solution

B. The edge of the sterile drape at the base of the field

C. The inner wrapping of an item on the sterile field

D. An irrigation syringe on the sterile field

E. One gloved hand with the other gloved hand

A. A bottle of sterile solution is sterile on the inside and nonsterile on the outside. The nurse must prepare the sterile container of solution on the field before putting on sterile gloves

B. The 1-inch border at the outer edge of the sterile field is not sterile. The nurse may not touch it with sterile gloves

C. CORRECT: The inner wrappings of any objects the nurse dropped onto the sterile field are sterile. The nurse may touch them with sterile gloves

D. CORRECT: Any objects the nurse dropped onto the sterile field during the setup are sterile. The nurse may touch the syringe with sterile gloves

E. CORRECT: One sterile gloved hand may touch the other sterile gloved hand because both are sterile

A nurse is reviewing hand hygiene techniques with a group of assistive personnel(AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply)

A. Apply 3 to 5 mL of liquid soap to dry hands

B. Wash the hands with soap and water for at least 15 seconds

C. Rinse the hands with hot water

D. Use a clean paper towel to turn off hand faucets

E. Allow the hands to air dry after washing

A. The APs should apply alcohol rubs to dry hands, and wet the hands first before applying soap for handwashing

B. CORRECT: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes

C. The APs should use warm water to minimize the removal of protective skin oils

D. CORRECT: If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands

E. The APs should dry their hands with a clean paper towel. This helps prevent chapped skin

Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field? (Select all that apply)

A: The provider drops a sterile instrument onto the near side of the sterile field

B: The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field

C: The procedure is delayed 1hr because the provider receives an emergency call

D: The nurse turns to speak to someone who enters through the door behind nurse

E: The client's hand brushes against the outer edge of the sterile field

A. As long as the provider has not reached over the sterile field, such as by placing the instrument on a near portion of the field, the field remains sterile

B. CORRECT: Fluid permeation of the sterile drape or barrier contaminates the field

C. CORRECT: Prolonged exposure to air contaminates a sterile field

D. CORRECT: Turning away from a sterile field contaminates the sterile field because the nurse cannot see if a piece of clothing or hair made contact with the field

E. The 1-inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field, the field remains sterile

A nurse is reviewing with a newly licensed nurse the procedure for putting on sterile gloves.

Description of Skill:

List the steps involved in putting on a pair of sterile gloves

-With the cuff side pointing toward the body, use the nondominate hand to pick up the dominant-hand glove by grasping the folded bottom edge of the cuff and lifting it up and away from the wrapper

-While picking up the edge of the cuff, pull the dominant glove onto the hand

-With the sterile dominant-gloved hand, place the fingers of the dominant hand inside the cuff of the nondominant glove, lifting it off the wrapper and putting the nondominant hand into it

-Adjust the fingers

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply)

A. Planning and evaluating control and prevention strategies

B. Determining public health priorities

C. Ensuring proper medical treatment

D. Identifying endemic disease

E. Monitoring for common-source outbreaks

A. CORRECT: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies

B. CORRECT: Reporting of communicable and infectious diseases assists with determining public health policies

C. CORRECT: Reporting of communicable and infectious diseases assists with ensuring proper medical treatment is available

D. Endemic disease is already prevalent within a population, so reporting is not necessary

E. CORRECT: Reporting of communicable and infectious diseases assists with monitoring for common-source outbreaks

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions?

A. Allergic reaction

B. Ringworm

C. Systemic lupus erythematosus

D. Herpes zoster

A. A pink body rash is a manifestation of an allergic reaction

B. Red circles with white centers is a manifestation of ringworm

C. A red edematous rash bilaterally on the cheeks is a manifestation of systemic lupus erythematosus

D. CORRECT: Vesicles that follow along a unilateral dermatome is a manifestation of herpes zoster

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A. Prodromal

B. Incubation

C. Convalescence

D. Illness

A. The prodromal stage consists of nonspecific manifestation of the infection

B. The incubation period consists of the time when the pathogen first enters the body prior to the appearance of any manifestations of infection

C. During convalescence, manifestations of the infection fade

D. CORRECT: The illness stage is when the client experiences manifestations specific to the infection

A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply)

A. Fever

B. Malaise

C. Edema

D. Pain or tenderness

E. Increase in pulse and respiratory rate

A. CORRECT: A fever indicates that the infection is affecting the whole body, and therefore systemic

B. CORRECT: Malaise indicates that the infection is affecting the whole body, and therefore systemic

C. Edema is a localized manifestation indicating a localized, not systemic, infection

D. Pain and tenderness is a localized manifestation indicating a localized, not systemic, infection

E. CORRECT: An increase in pulse and respiratory rate indicates that the infection is affecting the whole body, and therefore systemic

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply)

A. Place the client in a room that has negative air pressure of at least 6 exchanges per hour

B. Wear a mask when providing care within 3 ft of the client

C. Place a surgical mask on the client if transportation to another dept is unavoidable

D. Use sterile gloves when handling soiled linens

E. Wear a gown when preforming care that might result in contamination from secretions

A. A nurse should place a client in a private room and initiate droplet precautions if he has pertussis. Negative-pressure airflow is required for a client who is on airborne precautions

B. CORRECT: The nurse should wear a mask when within 3 ft of the client

C. CORRECT: The nurse should place a surgical mask on the client during transport to another area of the facility

D. The nurse should wear a gown and non-sterile gloves when performing care that might result in contamination from body fluids

E. CORRECT: A gown should be worn if the nurse's clothing or skin might be contaminated with body secretions or excretions

A nurse educator is teaching a module on the chain of infection during nursing orientation to a group of newly licensed nurses.

Related Content:

List the six links in the chain of infection that must be present for an infection to occur

The infection process (chain of infection)

-Causative agent

-Reservoir

-Portal of exit (means of leaving) from the host

-Mode of transmission

-Portal of entry to the host

-Susceptible host

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply)

A. Place a belt restraint on the client when he is sitting on the bedside commode

B. Keep the bed in its lowest position with all side rails up

C. Make sure that the client's call light is within reach

D. Provide the client with nonskid footwear

E. Complete a fall-risk assessment

A. By restraining the client, the nurse risks liability for false imprisonment.

B. Full side rails for this client puts the client at risk for a fall because he might attempt to climb over the rails to get out of bed

C. CORRECT: Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light

D. CORRECT: Nonskid footwear keeps the client from slipping

E. CORRECT: A fall-risk assessment serves as the basis for a plan of care the nurse can then individualize for the client

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

A. "I will place the client on his side"

B. "I will go to the nurses' station for assistance"

C. "I will administer his medications"

D. "I will prepare to insert an airway"

A. During a seizure, the nurse should place the client in a side-lying position to allow for drainage of secretions and to prevent his tongue from occluding the airway

B. CORRECT: During a seizure, the nurse should stay with the client and use the call light to summon assistance

C. The nurse should administer any medications the provider prescribes

D. The nurse should place nothing in the client's mouth except an oral airway, if he needs it. A tongue blade can cause injury and airway obstruction

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority?

A. Extinguish the fire

B. Activate the fire alarm

C. Move clients who are nearby

D. Close all open doors on the unit

A. Although extinguishing the fire is part of the protocol for responding to a fire, it is not the priority action

B. Although activating the fire alarm is part of the protocol for responding to a fire, it is not the priority task

C. CORRECT: The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. The nurse should protect and move clients in close proximity to the fire

D. Although containing the fire by closing doors and windows is part of the protocol for responding to a fire, it is not the priority action

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority?

A. Complete a fall-risk assessment

B. Educate the client and family about fall risks

C. Eliminate safety hazards from the client's environment

D. Make sure the client uses assistive aids in his possession

A. CORRECT: The first action the nurse should take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures

B. IT is important for family members to be aware of the client's risk for falls. Providing instruction to the client and family is an appropriate nursing action, but this is not the priority action

C. It is important to eliminate safety hazards from the client's environment, but this is not the priority action

D. It is important for the clients to use aids such as eyeglasses, hearing aids, canes, and walkers. However, this is not the priority action

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station?

A. A middle adult who is postoperative following a laparoscopic cholecystectomy

B. A middle adult who requires telemetry for a possible myocardial infarction

C. A young adult who is postoperative following an open reduction internal fixation of the ankle

D. An older adult who is postoperative following a below-the-knee amputation

A. Although this client just had surgery, the client's age and type of surgery puts him at low risk for falls

B. Although this client requires telemetry, the client does not have as many risk factors as another client the nurse will admit

C. Although this client just had surgery, the client's age and type of surgery puts him at low risk for falls

D. CORRECT: the nurse should assign this client to a room near the nurses' station due to risk factors that include client's age plus the immobility and balance issues that result from this type of surgery. The client will also receive analgesics, which increase the risk fro drowsiness, dizziness, and confusion

A nurse educator is addressing the safe use of seclusion and restraints with a group of newly licensed nurses. What information should the nurse include?

Nursing Interventions:

Describe at least six nursing responsibilities when caring for a client in either seclusion or restraints?

Nursing Interventions:

-Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary

-Ask the client or guardian to sign a consent form

-Review the manufacturer's instructions for correct application

-Assess skin integrity, and provide skin care according to the facility's protocol, usually every 2 hr

-Offer food and fluid

-Provide a means for hygiene and elimination

-Monitor vital signs

-Offer range-of-motion exercises of extremities

-Pad bony prominences to prevent skin breakdown

-Use a quick-release knot to tie the restraints to the bed frame (loose knots that are easy to remove) where they will not tighten when raising or lowering the bed

-Make sure the restraints are loose enough for range of motion and that there is enough room to fit two fingers between the restraints and the client

-Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limbs

-Conduct an ongoing evaluation of the client

A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply)

A. Family members who smoke must be at least 10 ft from the client when oxygen is in use

B. Nail polish should not be used near a client who is receiving oxygen

C. A "No Smoking" sign should be placed on the front door

D. Cotton bedding and clothing should be replaced with items made from wool

E. A fire extinguisher should be readily available in the home

A. The nurse should remind family members who smoke to do so outside

B. CORRECT: The nurse should remind the client not to use nail polish or other flammable materials in the home

C. CORRECT: The nurse should have the client place a "No Smoking" sign near the front door, and possibly on the client's bedroom door

D. The nurse should tell the client to choose cotton materials for clothing and bedding. Woolen and synthetic materials create static electricity and could cause a fire

E. CORRECT: The nurse should remind all individuals to have a fire extinguisher at home. This is especially important for a client who is receiving oxygen

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?

A. Hypotension

B. Bradycardia

C. Clammy skin

D. Bradypnea

A. CORRECT: Hypotension is a manifestation of heat stroke

B. Tachycardia is a manifestation of heat stroke

C. Hot, dry skin is a manifestation of heat stroke

D. Dyspnea is a manifestation of heat stroke

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions?

A. "I will set my water heater at 130°F."

B. "Once my baby can sit up, he should be safe in the bathtub"

C. "I will place my baby on his stomach to sleep"

D. "Once my infant starts to push up, I will remove the mobile from over the crib"

A. The nurse should instruct the parent to set the home water heater temperature to 120°F or less

B. Although the baby can hold his head above the water by sitting up, this does not make the child safe in the bathtub. The nurse should warn the parent to never leave an infant or toddler alone in the bathtub.

C. The nurse should remind the parent to place the infant on his back to sleep, and to remove suffocation hazards from the crib

D. CORRECT: The parent should plan to remove crib toys, such as mobiles, from over the bed as soon as the infant beings to push up so the infant is unable to touch them

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling?

A. Carbon monoxide has a distinct odor

B. Water heaters should be inspected every 5 years

C. The lungs are damaged from carbon monoxide inhalation

D. Carbon monoxide binds with hemoglobin in the body

A. The nurse should include that carbon monoxide cannot be seen, smelled, or tasted

B. The nurse should tell the client to inspect gas-burning furnaces, water heaters, and appliances annually

C. The nurse should inform the client that carbon monoxide impairs the body's ability to use oxygen, but the lungs are not damaged

D. CORRECT: The nurse should warn the client that carbon monoxide is very dangerous because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply)

A. Most food poisoning is caused by a virus

B. Immunocompromised individuals are at risk for complications from food poisoning

C. Clients who are at high risk should eat or drink only pasteurized dairy products

D. Healthy individuals usually recover from the illness in a few weeks

E. Handling Raw and fresh food separately can prevent food poisoning

A. The nurse should include that most food poisoning is caused by bacteria such as Escherichia coli, Listeria monocytogenes, and Salmonella

B. CORRECT: The nurse should warn the client that very young, very old, immunocompromised, and pregnant individuals are at risk for complications from food poisoning

C. CORRECT: The nurse should include that clients who are at high risk should follow a low-microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, and other dairy products

D. The nurse should inform the client that healthy individuals usually recover from the illness in a few days

E. CORRECT: The nurse should include interventions to prevent food poisoning, such as performing proper hand hygiene, cooking meat and fish to the correct temperature, handling raw and fresh food separetely to avoid cross-contamination, and refrigerating perishable items

A nurse educator is teaching a module on the basic principles of creating a home safety plan during nursing orientation to a group of newly appointed home health nurses.

Nursing Interventions:

List four key elements that a home safety plan should include

A home safety plan should include the following:

-Keep emergency numbers near the phone for prompt use in the event of an emergency of any type

-Ensure that the number and placement of fire extinguishers and smoke alarms are adequate, that they are operable, and that family members know how to operate them. Set a time to routinely change the batteries in the smoke alarms (for example, in the fall when the clocks are set to standard time and spring when set to Daylight Savings Time)

-Have a family exit plan for fires that the family reviews and practices regularly. Be sure to include closing windows and doors if able and to exit a smoke filled area by covering the mouth with a damp cloth and getting down as close to the floor as possible

-Review with clients of all ages that in the event that the client's clothing or skin is on fire, the client should use the mnemonic "stop, drop, and roll" to extinguish the fire

-Review oxygen safety measures. Because oxygen can cause materials to combust more easily and burn more rapidly, the client and family must be provided with information on use of the oxygen delivery equipment and the dangers of combustion

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?

A. Supine

B. Semi-Fowler's

C. Semi-prone

D. Trendelenburg

A. In the supine position, the client lies on his back with his head and shoulders elevated on a pillow. This angle will not prevent regurgitation

B. CORRECT: In the semi-Fowler's position, the client lies supine with the head of the bed elevated 15° to 45° (typically 30°). This position helps prevent regurgitation and aspiration by clients who have difficult swallowing. This is the safest position for clients receiving enteral tube feedings

C. In the semi-prone or Sims' position, the client is on his side halfway between lateral and prone positions. This position is not safe because it promotes regurgitation

D. In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe because it promotes regurgitation

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

A. Obtain a walker for the client to use to transfer back to bed

B. Call for additional staff to assist with the transfer

C. Use a transfer belt and assist the client back into bed

D. Determine the client's ability to help with the transfer

A. Although this might be a necessary assistive device for this client, obtaining a walker is not the priority action the nurse should take

B. Although this might be necessary for a safe transfer, calling for assistance is not the priority action the nurse should take

C. Although this might be a necessary assistive device for the transfer of this client, using a transfer belt is not the priority action the nurse should take

D. CORRECT: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine the client's ability to help with transfers and then proceed with a safe transfer

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understand the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night?

A. Lie on her back with her head and shoulders on a pillow

B. Lie flat on her stomach with her head to one side

C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table

D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her

A. The client is describing the supine position, not the orthopneic position

B. The client is describing the prone position, not the orthopneic position

C. CORRECT: The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD

D. The client is desecriving the lateral or side-lying position, not the orthopneic position

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply)

A. Request assistance when repositioning a client

B. Avoid twisting your spine or bending at the waist

C. Keep your knees slightly lower than your hips when sitting for long periods of time

D. Use smooth movements when lifting and moving clients

E. Take a break from repetitive movements every 2 to 3 hrs to flex and stretch your joints and muscles

A. CORRECT: To reduce the risk of injury, at least two staff members should reposition clients

B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury

C. When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back

D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements helps prevent injury

E. It is important to take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply)

A. "My line of gravity should fall outside my base of support"

B. "The lower my center of gravity, the more stability I have"

C. "To broaden my base of support, I should spread my feet apart

D. "When I lift an object, I should hold it as close to my body as possible"

E. "When pulling an object, I should move my front foot forward"

A. To reduce the risk of falling, the line of gravity should fall within the base of support, not outside it

B. CORRECT: Being closer to the ground lowers the center of gravity, which leads to greater stability and balance

C. CORRECT: Spreading the feet apart increases and widens the base of support

D. CORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevent injury and instability

E. To promote stability, the nurse should move the rear leg back when pulling on an object

A nurse is presenting the basic principles of proper lifting to a group of assistive personnel.

Underlying Principles:

List four key elements of proper lifting techniques

Underlying Principles:

-Use the major muscle groups to prevent back strain, and tighten the abdominal muscles to increase support to the back muscles

-Distribute your weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and to avoid strain on smaller muscles

-When lifting an object from the floor, flex your hips, knees, and back. Bring the object to thigh level, bending your knees and keeping your back straight. Stand up while holding the object as close as possible to your body, bringing the load to the center of gravity to increase stability and decrease back strain.

-Use assistive devices whenever possible, and seek assistance whenever you need it

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority?

A. A client who received crush injuries to the chest and abdomen and is expected to die

B. A client who has a 4 inch laceration to the head

C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest

D. A client who has a fractured fibula and tibia

A. The nurse should give the lowest priority to a client who is not expected to live. The nurse should provide comfort measures for this client (Expectant Category: Class IV)

B. The nurse should give third priority to the client who has minor injury that is not life-threatening, such as a laceration to the head (Nonurgent Catergory: Class III)

C. CORRECT: The nurse should give first priority to the client who has the greatest chance of survival with prompt intervention. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is otherwise expected to live. Therefore, this client is the highest priority (Emergency Catergory: Class I)

D. The nurse should give second priority to the client who has major fractures (Urgent Category: Class II)

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply)

A. Open doors to client rooms

B. Place blankets over clients who are confined to beds

C. Move beds away from the windows

D. Draw shades and close drapes

E. Instruct ambulatory clients in the hallways to return to their rooms

A. The nurse should close all client doors to minimize the threat of flying glass and debris

B. CORRECT: The nurse should place blankets over clients to protect them from shattering glass or flying debris

C. CORRECT: The nurse should move all beds away from windows to protect clients from shattering glass or flying debris

D. CORRECT: The nurse should draw shades and close drapes to protect clients against shattering glass

E. The nurse should instruct ambulatory clients to go to the hallways, away from windows, or other secure location designated by the facility

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?

A. Irrigate the affected area with running water

B. Wash the affected area with antibacterial soap

C. Brush the chemical off the skin and clothing

D. Leave the clothing in place until emergency personnel arrive

A. The nurse should not apply water to a dry chemical exposure because it could activate the chemical and cause further harm

B. The nurse should wash the skin with antibacterial soap in the vent of a biological exposure

C. CORRECT: The nurse should use a brush to remove the chemical off the skin and clothing

D. The nurse should plan to remove the client's clothing following appropriate decontamination

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?

A. "I will get the caller off the phone as soon as possible so I can alert the staff"

B. "I will begin evacuating clients using the elevators"

C. "I will not ask any questions and just let the caller talk"

D. "I will listen for background noises"

A. In the event of a bomb threat, the nurse should keep the caller on the line in order to trace the call and to collect as much information as possible

B. The nurse should avoid using the elevators so that they are free for the authorities to use, and should not evacuate clients unless directed to by facility protocol

C. The nurse should ask the caller about the location of the bomb and the time it is set to explode in order to gather as much information as possible

D. CORRECT: In order to identify the location of the caller, the nurse should listen for background noises such as church bells, train whistles, or other distinguishing noises

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply)

A. A client who is dehydrated and receiving IV fluid and electrolytes

B. A client who has a nasogastric tube to treat a small bowel obstruction

C. A client who is scheduled for elective surgery

D. A client who has chronic hypertension and blood pressure 135/85 mm Hg

E. A client who has acute appendicitis and is scheduled for an appendectomy

A. The nurse should recognize that a client who is receiving IV fluid and electrolytes requires ongoing nursing care and is therefore unstable for discharge

B. The nurse should recognize that a client who has a nasogastric tube requires ongoing nursing care and is therefore unstable for discharge

C. CORRECT: The nurse should identify a client who is scheduled elective surgery is stable and is therefore appropriate to recommend for discharge

D. CORRECT: A blood pressure 135/85 mm Hg is within the reference range for prehypertension. The nurse should identify this client as stable and appropriate to recommend for discharge

E. The nurse should recognize that a client who has an acute illness and is scheduled for surgery requires ongoing nursing care and is therefore unstable for discharge

A nurse educator is teaching a module on biological pathogens during orientation to a group of newly hired nurses. What information should the nurse educator include?

Related Content:

List four manifestations and the recommended treatment for anthrax, botulism, pneumonic plague, and tularemia

**Anthrax**

Manifestations

-Fever, cough, shortness of breath, muscle aches, meningitis, shock

Nursing interventions

Ciprofloxacin, One or two additional antibiotics, such as vancomycin or penicillin

**Botulism**

Mainfestations

-Difficulty swallowing, double vision, slurred speech, descending progressive weakness, nausea, vomiting, abdominal cramps, difficulty breathing

Nursing Interventions

-Airway management, antitoxin, elimination of toxin

**Pneuomonic plague**

Manifestations

-Fever, headache, weakness, rapidly developing pneumonia, shortness of breath, chest pain, cough, bloody or water sputum

Nursing Inteventions

-Early treatment is essential, Streptomycin, gentamicin, the tetracyclines

**Tularemia**

Manifestations

-Sudden fever, chills, headache, diarrhea, muscle aches, joint pain, dry cough, progressive weakness, If airborne, life-threatening pneumonia and systemic infection

Nursing Interventions

-Streptomycin IV or gentamicin IV or IM are the drugs of choice

-In mass casualty, use doxycycline or ciprofloxacin