NCLEX Safety and Infection Control All Answers Correct

NCLEX Safety and Infection Control All Answers Correct The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? Select all that apply. 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor. 4. Using a depilatory cream. 2. Removing the hair with clippers. (2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery.) The nurse is planning to teach a group of assisted living residents about tuberculosis (TB) infection. What should the nurse include? Select all that apply. 1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 4. Obtain a yearly chest x-ray. 5. Proper disposal of tissues. 2. Proper handwashing. 3. Obtain a TB skin test. 5. Proper disposal of tissues. 1. Cover mouth when coughing. (1., 2., 3. & 5. Correct: In an effort to prevent transmission of TB to others, the nurse should carefully instruct about the importance of hygiene measures, including mouth care, covering the mouth when coughing and sneezing, proper disposal of tissues, and hand hygiene. A TB skin test is especially important when living in tight quarters such as an assisted living center. 4. Incorrect: Chest x-rays are not needed yearly, especially without signs and symptoms of TB.) Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough 4. Whooping cough (4. Correct: Droplet isolation precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should wear a surgical mask while in the room. Mask must be discarded in trash after leaving the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. 1. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room {examples: MRSA, VRE, diarrheal illnesses, open wounds, Respiratory syncytial virus (RSV)}. Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. 2. Incorrect: Airborne isolation precautions are used for diseases or very small germs that are spread through the air from one person to another (examples: Tuberculosis (TB), measles, varicella). Healthcare workers should ensure client is placed in an appropriate negative air pressure room (a room where the air is gently sucked outside the building) with the door shut. Wear a fit-tested NIOSH-approved N-95 or higher level respirator while in the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. Ensure the client wears a surgical mask when leaving the room. Instruct visitors to wear a mask while in the room. 3. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room (examples: MRSA, VRE, diarrhea A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 3. "Come to the 4. "Have you thought about getting a family member to help with the baby?" clinic now so that we can help you." (3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby.) The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? Select all that apply. 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain 2. Drainage 1. Color Changes 3. Odor 4. Fever 6. Increased Pain (1., 2., 3., 4. & 6. Correct: Infections may cause color changes, drainage, odor, fever, & increased pain. Bleeding is a sign of hemorrhage, trauma, anemia or other blood disorders but not infection. 5. Incorrect: Bleeding is not a sign of infection. It may occur along with an infection but will not be caused by it.) The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? 1. Apply gauze padding beneath the tubing. 2. Use petroleum jelly on the nares and cheeks. 3. Provide mouth and nose care every 4 hours as needed. 4. Place the oxygen tubing above the ears. 2. Use petroleum jelly on the nares and cheeks. (2. Correct: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy. 1. Incorrect: The charge nurse would not need to intervene if the new nurse applied gauze padding beneath the tubing to protect the client's skin. This is acceptable. 3. Incorrect: The charge nurse would not need to intervene if the new nurse provided mouth and nose care every four hours as needed to protect the client's skin and mucous membranes. This is acceptable. 4. Incorrect: The charge nurse would not need to intervene if the new nurse placed the oxygen mask straps well above the client's ears to protect the client's skin. This is acceptable.) The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container 2. In a chemotherapy sharps container (2. Correct: Empty vials and sharps such as needles and syringes used in delivering chemotherapy agents should be disposed of in a chemotherapy sharps container. These waste containers are designed to protect workers from injuries and are disposed of by incineration at regulated medical waste facilities. 1. Incorrect: Hazardous, drug-contaminated sharps should not be placed in red biohazard containers that are used for infectious wastes, since these are often autoclaved or microwaved. 3. Incorrect: Biohazard waste containers are not designed for sharps and can cause injuries. 4. Incorrect: Chemical containers are not designed for sharps and can cause injuries.) These clients have arrived at the emergency depa