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test. y * Represents the correct answer. Question 1 A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST? A) Institute seizure precautions B) Assess neurologic status * C) Place in respiratory isolation D) Assess vital signs Review Information: The correct answer is: C) Place in respiratory isolation. The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis :Mosby. Pages 1708-1709 Ashwill, J. W. & Droske, S. C. (1997). Nursing care of children. Philadelphia: W. B. Saunders. p. 1246 Answers Correct C Student's C
Question 2 A client is diagnosed with methicillin resistant Answers Correct D staphylococcus aureus pneumonia. What type Student's C of isolation is MOST appropriate for this client? A) Reverse isolation B) Respiratory isolation
C) Standard precautions * D) Contact isolation Review Information: The correct answer is: D) Contact isolation. Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient''s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia. Ewald, G.A., & McKenzie, C.R. (Eds.) (1995). The Washington Manual, 28th Edition. Boston: Little Brown. Morita, M. (1993). Methicillin resistant staphylococcus aureus, past, present and future. Nursing Clinics of North America, 28(3), 625-637.
Question 3 Several clients are admitted to an adult Answers Correct B medical unit. The nurse would ensure airborne Student's C precautions for a client with which of the following medical conditions? A diagnosis of AIDS and cytomegalovirus A positive PPD with an abnormal chest * B) x-ray C) A tentative diagnosis of viral pneumonia D) Advanced carcinoma of the lung A) Review Information: The correct answer is: B) A positive PPD with an abnormal chest x-ray. The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray
for a suspicious tuberculin lesion. Black, J., Matassarin-Jacobs, E. (1997). Medical-Surgical Nursing: Clinical Management for Continuity of Care (5th ed.). Philadelphia: Saunders. Lewis, S., Collier, I., & Heitkemper, M. (1996). Medical-Surgical nursing: Assessment and management of clinical problems. (4th ed). St. Louis: Mosby
Question 4 Which of the following is the FIRST priority in preventing infections when providing care for a client? * A) Handwashing B) Wearing gloves Using a barrier between client's furniture C) and nurse's bag D) Wearing gowns and goggles Review Information: The correct answer is: A) Handwashing. Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag. Nelson, M. (1996, December). It''s As Easy As Washing Your Hands. Home Health FOCUS, 3(7), 51. Miranda, G. (1997). Universal Precautions. In KS Martin, BJ Larson, LA Gorski, and DM Hayko (Eds.) Answers Correct A Student's A
Question 5 When a client is diagnosed with tuberculosis, Answers Correct B the nurse notifies the public health department Student's B because A) Disease statistics must be maintained * B) Disease contacts need to be traced C) Incidence of tuberculosis is on the rise D) Additional tests must be done Review Information: The correct answer is: B) Disease contacts need to be traced. Tuberculosis is a reportable disease because persons who had contact with the client must be traced. Ashwill, J. W., and Droske, S. C. (1997) Nursing care of children: Principles and practice. Philadelphia: W. B. Saunders. pp. 898-899.
Question 6 The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The MOST appropriate information would be The classroom should be sprayed with an insecticide at the end of each day The transmission can be prevented by B) personal cleanliness Lice can be transmitted by hats and * C) combs D) Lice are carried by household pets A) Review Information: The correct answer is: C) Lice can be transmitted by hats and combs. Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair. Wong, D. (1999) Answers Correct C Student's C
Whaley and wong''s nursing care of infants and children (5th ed.) St. Louis: Mosby. pp. 783-785. Ball J. and Bindler, R. (1995). Pediatric nursing: Caring for children. Norwalk, CN: Appleton and Lange.p. 698.
Question 7 A client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the nurse should instruct the client that * A) Urine and saliva will be radioactive for 24 hours B) No solid food may be eaten for 24 hours C) No precautions will be necessary D) No visitors will be allowed Answers Correct A Student's A
Review Information: The correct answer is: A) Urine and saliva will be radioactive for 24 hours. The client''s urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6-8 hours. The client should void into a lead-lined container, use disposable utensils, and avoid close contact with children and pregnant women for 48 hours after ingestion. Nettina, Sandra (2000). The Lippincott Manual of Nursing Practice. Sixth Edition. Lippincott. Philadelphia - New York. 1966. Page 112. Luckmann, Joan. Saunders Manual of Nursing Care. W.B.Saunders Company. Philadelphia. 1997. Page 1397.
Question 8 Which of the following nursing diagnosis would place an 86 year-old client at GREATEST risk for falls? Answers Correct D Student's A
Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue Impaired gas exchange related to C) retained secretions Altered patterns of urinary elimination * D) related to nocturia A) Review Information: The correct answer is: D) Altered patterns of urinary elimination related to nocturia. Nocturia is especially problematic because many elders fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling and they may fall over furniture or carpets. Sloan, H. (1997). Preventing Falls among the Elderly. In KS Martin, BJ Larson, LA Gorski, and DM Hayko (Eds.), Mosby''s Home Health Client Teaching Guides: Rx for Teaching, IV G 1-8. St. Louis: Mosby.
Question 9 A ten year-old child has a history of tonicclonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the MOST important action would be to Insert a plastic airway to maintain respirations B) Restrain the child to prevent self-injury Provide privacy to prevent C) embarrassment * D) Protect the child from injury A) Review Information: The correct answer is: D) Protect the child from injury. The child must be protected from injury during a seizure. Place a pillow, folded blanket or your hands under the child''s head to prevent harm. Answers Correct D Student's D
Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Pages 1722. Ball, J.& Bindler, R. (1995). Pediatric nursing: Caring for children. Norwalk: Appleton & Lange. Page 444
Question 10 A child has been admitted after swallowing a household cleaner. Which of the following assessments suggests to the nurse that the poison is a corrosive? * A) Burning mouth and throat pain B) Bradycardia and orthopnea C) Oliguria and cyanosis D) Diarrhea and vomiting Review Information: The correct answer is: A) Burning mouth and throat pain. Local irritation of tissues points to corrosive poisoning. Wong, D (1995). Whaley and Wong''s Nursing care of infants and children. St. Louis: Mosby. page 691. Ashwill, J & Droske, S (1997). Nursing care of children. Philadelphia: Saunders. page 337. Answers Correct A Student's A
Question 11 The nurse assigned to the emergency room understands that syrup of ipecac is contraindicated in which of the following? * A) An infant has ingested a mouthful of gasoline A toddler ate a number of ibuprofen B) tablets Answers Correct A Student's A
A preschooler swallowed powdered plant food A school aged child took a handful of D) vitamins C) Review Information: The correct answer is: A) An infant has ingested a mouthful of gasoline. There is a risk of aspiration pneumonia if fumes from hydrocarbons are inhaled during vomiting. The poison control center should be contacted and the infant should be rushed to the emergency room. Wong, D (1995). Whaley and Wong''s nursing care of infants and children. (5th ed). St. Louis: Mosby page 688. Ashwill, J & Droske, S (1997). Nursing care of children. Philadelphia: Saunders, page 340.
Question 12 In caring for a client with salmonella infection, Answers Correct A the PRIMARY nursing intervention to limit Student's A transmission is * A) Wash hands thoroughly before and after client contact Wear gloves when in contact with body B) secretions Double glove when in contact with feces C) or vomitus Wear gloves when disposing of D) contaminated linens
Review Information: The correct answer is: A) Wash hands thoroughly before and after client contact. Gram-negative bacilli cause Salmonella infection. Two million new cases appear each year. Lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella. Springhouse. Handbook of Medical-Surgical Nursing. Second Edition.
Springhouse Corporation, Springhouse, PA. 1998. Pages 830-833.
Question 13 The mother of an infant who is being treated for pesticide poisoning asks why activated charcoal is the treatment. What is the nurse's BEST response? "Activated charcoal stimulates bowel A) evacuation, thus decreasing systemic absorption of the poison." "The charcoal absorbs the poison and * B) forms a compound that doesn't hurt your child." "This liquid causes vomiting which C) eliminates the poison from the body." "When it is absorbed from her veins, D) activated charcoal neutralizes the poison." Review Information: The correct answer is: B) "The charcoal absorbs the poison and forms a compound that doesn''t hurt your child.". This response is accurate information about the effectiveness of activated charcoal. Language is appropriate for a parent''s understanding. Wong, D (1995). Whaley and Wong''s Nursing care of infants and children. St. Louis: Mosby. page 682. Hodgson, B & Kizior, R (1998). Saunders nursing drug handbook 2001. Philadelphia: Saunders. . Answers Correct B Student's B
The nurse is caring for a newly admitted adult client with a diagnosis of Hepatitis A. The MOST significant routine infection control strategy, in addition to handwashing, is A) Implementing a ventilation flow B) Wearing a mask during care C) Using a gown to change linens * D) Gloving while handling bedpans Review Information: The correct answer is: D) Gloving while handling bedpans.
Answers Correct D Student's D
The specific measure to prevent the spread of hepatitis A is careful handling and protection while handling fecal material. Potter, P. & Perry, A. (2000). Fundamentals of Nursing: Concepts, Process and Practice. St. Louis: Mosby. Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (1993). Mosby''s Clinical Nursing. (3rd ed.). St. Louis: Mosby.
Question 15 The nurse is caring for a client with active Answers Correct D tuberculosis. Which of the following protocols Student's D would be ESSENTIAL for the nurse to implement? Place client in a room with another A) client with tuberculosis and staff should wear masks Place client in a negative pressure room B) and staff uses mask and gloves Place client in a private room and staff C) wears masks, gloves and gowns Place client in a negative pressure room * D) and staff uses masks Review Information: The correct answer is: D) Place client in a negative pressure room and staff uses masks.
A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Nettina, Sandra (2000). The Lippincott Manual of Nursing Practice. Sixth Edition. Lippincott. Philadelphia-New York. 1996. Page 224. Luckmann, Joan. Saunders Manual of Nursing Care. W.B.Saunders Company. Philadelphia. 1997. Page 949-951
SAFETY AND INFECTION CONTROL
Types 1. Carbon dioxide 2. Soda and acid 3. Dry Chemical
Use grease, electrical paper and rubbish rubbish, electrical
4. Antifreeze or water rubbish, grease, wood 1. In a fire, the nurse acts in PRC order: A. Protects clients from injury B. Reports the fire C. Contains the fire Get a clue Remember the kinds of Infection Control by remembering which link they attack: Six Links Pathogen Reservoir Host Port of Exit Five Control Mechanisms: AXIPPI Anti-drugs: Kill or weaken pathogens X-terminators: Kill nonhuman reservoirs & vectors Isolation & Precautions
Transmission Port of Entry Susceptible Host
Precautions Precautions Immunization
Strict Isolation 1. Designed for highly contagious infections that are spread by airborne droplet nuclei and contact transmission 2. Required in these diseases (among others): A. Varicella-zoster (chicken pox) B. Pharyngeal diphtheria C. Herpes zoster (shingles) D. Viral hemorrhagic fevers 3. Strict Isolation requires two techniques: PAN+MG A. Private room with Negative Airflow B. Everyone who enters the room must wear Mask, Gown and Gloves. Contact Isolation 1. Prevents highly transmissible infections that are not spread by airborne droplet nuclei, but are transmitted mainly by close and direct contact
2. Required in (for example): A. Viral respiratory infections in children (such as respiratory syncytial virus-RSV) B. Vancomycin-resistant enterococcus C. Disseminated herpes simplex D. Scabies E. Pediculosis (lice) F. Methicillin-resistant staphylococcus aureus 3. Contact Isolation Involves: PMG A. Private room, B. Masks for anyone providing close, direct care to the client, C. Gowns if soiling is likely, and D. Gloves for touching infective material Respiratory Isolation 1. Prevents transmission of diseases that spread short distances via the air (droplet transmission) 2. Required in (for example): A. Measles B. Meningococcal meningitis C. Pneumonia D. Mumps E. Pertussis (whooping cough) 3. Respiratory Isolation Involves: P (or C) +M A. Private room or cohorting clients with the same pathogen, and B. Masks for everyone providing close, direct care to the client
Drainage/Secretions Precautions 1. Prevents infections transmitted by direct or indirect contact with pus or other drainage from an infected body site 2. Used in, for example: A. Skin infection B. Minor abscess C. Conjunctivitis 3. Drainage/Secretion Precautions Involve: G; Gowns and gloves if contact with infective material is likely
Tuberculosis/Acid-Fast Bacillus (AFB Isolation)Used for clients with pulmonary or pharyngeal tuberculosis
1. AFB Isolation involves: PAN, M, G
A. Private room with negative airflow, and B. Mask for respiratory protection, and C. Gown only to prevent gross contamination Enteric Precautions 1. Used to prevent infections transmitted by direct or indirect contact with fecal material. 2. Required in (for example) A. Meningitis B. Infectious gastroenteritis C. Hepatitis A D. Clostridium difficile enterocolitis 3. Enteric Precautions Require: Pif Gif A. Private room only if the client has poor hygiene and likely to contaminate the environment, B. Gowns if soiling is probable C. Gloves for touching infective material Universal/Standard Precautions 1. Wear gloves during A. Venipuncture (giving shots, taking blood) B. Contact with: 1. Blood and body fluids 2. Mucus membranes 3. Items soiled with blood and body fluids 2. Change gloves between procedures for same client and between each client. 3. Wear masks and protective goggles and gowns/aprons when you expect contact with blood or body fluids. 4. Wash hands and other skin surfaces immediately on contact with blood or other body fluids. 5. Wash hands when you remove your gloves. 6. Put needles and sharp instruments in puncture-resistant containers for disposal. Do not recap or bend needles, or remove needle from the syringe.
Medical Asepsis 1. Is a clean technique 2. Includes procedures to reduce the number and spread of microorganisms 3. Examples: hand washing, changing bed linens daily Principles of Surgical Asepsis 1. A sterile object remains sterile only when touched by another sterile object. y Sterile touching sterile remains sterile. y Sterile touching clean becomes contaminated. y Sterile touching contaminated becomes contaminated.
2. 3. 4. 5. 6. 7. 8.
Sterile touching questionable is contaminated. Only sterile objects may be placed on a sterile field. A sterile object or field out of range of vision, or an object held below a person's waist, is contaminated. Never turn your back on a sterile field. A sterile object or field becomes contaminated by prolonged exposure to air. When a sterile surface comes in contact with a wet, contaminated surface, the object or field becomes contaminated by capillary action. Always hold your hands above the level of your elbows. The edges of a sterile field or container are considered contaminated.
y y y y y y y y
Know your institution's plan for fire drills and evacuation. Know the emergency phone number for reporting fire. Know locations of all fire alarms, exits, and extinguishers. PRC: first protect people, then report fire, then try to contain it. In a fire, never use an elevator. Turn off all oxygen supplies in the area of the fire. In a fire, close all doors and windows. In a power failure, only certain electrical outlets access the emergency generators, know which ones they are.
Never induce vomiting for these poisons: Iye, household cleaners, petroleum products, and furniture polish. If you suspect someone has taken poison, save any vomitus and take it with the victim to an emergency room.
y y y y y
A pathogen cannot infect if you break even one of the six links in the chain of transmission. Clients at high risk for infection get prophylactic antibiotics before surgical procedures. The major sites for nosocomial infections are urinary and respiratory tracts, blood, and wounds. All nosocomial infections that occur in hospitals must be tracked and recorded. The single most effective preventer of infection is hand washing.
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