CH 5 Safety and Infection Control
1. In which order will the nurse take these actions before doing wound irrigation and a
dressing change for a client who has a wound infected with methicillin-
resistant Staphylococcus aureus(MRSA)?
Correct Answers: Your Answers:
Perform hand hygiene.
1 Perform hand hygiene.
Put on gown.
2 Put on gown.
Put on mask to cover nose and mouth.
3 Put on mask to cover nose and mouth.
Place goggles over eyes.
4 Place goggles over eyes.
Don gloves.
5 Don gloves.
Rationale:
Centers for Disease Control and Prevention guidelines recommend initially hand hygiene and
then donning of gown, mask, goggles, and finally gloves to protect staff members and limit
the spread of contamination. Goggles and a mask (or use of a face shield) will be needed
with this dressing change because of the possibility of splashing during wound irrigation.
2. 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?
1 Place the client in a private room.
.
2 Obtain heart rate and blood pressure.
.
3 Notify the hospital infection control nurse.
.
4 Ask the client to describe type of Ebola exposure.
.
Rationale:
Centers for Disease Control and Prevention guidelines recommend that the initial action be
to place the client in a private room and implement standard, contact, and droplet
precautions. Further assessment of the type of possible Ebola exposure, obtaining vital
signs, and notification of the infection control nurse will also be needed but should be done
after measures to minimize transmission of Ebola are implemented.
3. 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?
1 Give acetaminophen 650 mg PO.
.
2 Administer ondansetron 4 mg IV.
.
3 Infuse normal saline at 500 mL/hr.
.
4 Increase oxygen flow rate to 6 L/min.
, .
Rationale:
Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been
demonstrated to improve outcomes, the nurse's first action will be to infuse normal saline.
Treatment of nausea and headache are appropriate and should be implemented next. There
is no indication that this client is hypoxemic, although clients with Ebola may develop
multiorgan failure and require respiratory support.
4. 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?
1 Start oxygen using a nonrebreather mask.
.
2 Infuse 5% dextrose in water at 100 mL/hr.
.
3 Administer the first dose of oral oseltamivir.
.
4 Obtain blood and sputum specimens for testing.
.
Rationale:
Because the respiratory manifestations associated with avian influenza are potentially life
threatening, the nurse's initial action should be to start oxygen therapy. The other
interventions should be implemented after addressing the client's respiratory problems.
5. The nurse is preparing to leave the room after performing oral suctioning on a client who
is on contact and airborne precautions. In which order will the nurse perform the following
actions?
Correct Answers: Your Answers:
Remove gloves.
1 Remove gloves.
Take off goggles.
2 Take off goggles.
Take off gown.
3 Take off gown.
Remove N95 respirator.
4 Remove N95 respirator.
Perform hand hygiene.
5 Perform hand hygiene.
Rationale:
This sequence will prevent contact of the contaminated gloves and gown with areas (e.g.,
the hair) that cannot be easily cleaned after client contact and stop transmission of
microorganisms to the nurse and to other clients. If the nurse is wearing a disposable gown,
the gown and gloves can be removed simultaneously by grasping the front of the gown and
breaking the ties and then peeling the gloves off while removing the gown. The correct
method for donning and removal of PPE has been standardized by agencies such as the
Centers for Disease Control and Prevention and the Occupational Safety and Health
Administration.
6. 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.
1 Surgical face mask
1. In which order will the nurse take these actions before doing wound irrigation and a
dressing change for a client who has a wound infected with methicillin-
resistant Staphylococcus aureus(MRSA)?
Correct Answers: Your Answers:
Perform hand hygiene.
1 Perform hand hygiene.
Put on gown.
2 Put on gown.
Put on mask to cover nose and mouth.
3 Put on mask to cover nose and mouth.
Place goggles over eyes.
4 Place goggles over eyes.
Don gloves.
5 Don gloves.
Rationale:
Centers for Disease Control and Prevention guidelines recommend initially hand hygiene and
then donning of gown, mask, goggles, and finally gloves to protect staff members and limit
the spread of contamination. Goggles and a mask (or use of a face shield) will be needed
with this dressing change because of the possibility of splashing during wound irrigation.
2. 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?
1 Place the client in a private room.
.
2 Obtain heart rate and blood pressure.
.
3 Notify the hospital infection control nurse.
.
4 Ask the client to describe type of Ebola exposure.
.
Rationale:
Centers for Disease Control and Prevention guidelines recommend that the initial action be
to place the client in a private room and implement standard, contact, and droplet
precautions. Further assessment of the type of possible Ebola exposure, obtaining vital
signs, and notification of the infection control nurse will also be needed but should be done
after measures to minimize transmission of Ebola are implemented.
3. 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?
1 Give acetaminophen 650 mg PO.
.
2 Administer ondansetron 4 mg IV.
.
3 Infuse normal saline at 500 mL/hr.
.
4 Increase oxygen flow rate to 6 L/min.
, .
Rationale:
Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been
demonstrated to improve outcomes, the nurse's first action will be to infuse normal saline.
Treatment of nausea and headache are appropriate and should be implemented next. There
is no indication that this client is hypoxemic, although clients with Ebola may develop
multiorgan failure and require respiratory support.
4. 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?
1 Start oxygen using a nonrebreather mask.
.
2 Infuse 5% dextrose in water at 100 mL/hr.
.
3 Administer the first dose of oral oseltamivir.
.
4 Obtain blood and sputum specimens for testing.
.
Rationale:
Because the respiratory manifestations associated with avian influenza are potentially life
threatening, the nurse's initial action should be to start oxygen therapy. The other
interventions should be implemented after addressing the client's respiratory problems.
5. The nurse is preparing to leave the room after performing oral suctioning on a client who
is on contact and airborne precautions. In which order will the nurse perform the following
actions?
Correct Answers: Your Answers:
Remove gloves.
1 Remove gloves.
Take off goggles.
2 Take off goggles.
Take off gown.
3 Take off gown.
Remove N95 respirator.
4 Remove N95 respirator.
Perform hand hygiene.
5 Perform hand hygiene.
Rationale:
This sequence will prevent contact of the contaminated gloves and gown with areas (e.g.,
the hair) that cannot be easily cleaned after client contact and stop transmission of
microorganisms to the nurse and to other clients. If the nurse is wearing a disposable gown,
the gown and gloves can be removed simultaneously by grasping the front of the gown and
breaking the ties and then peeling the gloves off while removing the gown. The correct
method for donning and removal of PPE has been standardized by agencies such as the
Centers for Disease Control and Prevention and the Occupational Safety and Health
Administration.
6. 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.
1 Surgical face mask
