RN Safety and Infection Control

RN Safety and Infection Control Related

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At the scene of a train crash, the nurse triages the victims. Which clients should be coded for triage as most urgent or the first priority? Select all that apply.

  • A. Is dead
  • B. Has chest pain
  • C. Has a leg sprain
  • D. Has a chest wound
  • E. Has multiple fractures
  • F. Has full-thickness burns over 30% of the body
Correct Answer: B,D,F

Rationale: In a disaster situation, saving the greatest number of lives is the most important goal. During a disaster the nurse would triage the victims to maximize the number of survivors and sort the treatable from the untreatable victims. First priority victims (most urgent and coded red) have life-threatening injuries and are experiencing hypoxia or near hypoxia. Examples of injuries in this category are shock, chest wounds, internal hemorrhage, head injuries producing loss of consciousness, partial- or full-thickness burns over 20% of the body surface, and chest pain. Second priority victims (urgent and coded yellow) have injuries with systemic effects but are not yet hypoxic or in shock and can withstand a 2-hour wait without immediate risk (e.g., a victim with multiple fractures). Third priority victims (coded green) have minimal injuries unaccompanied by systemic complications and can wait for more than 2 hours for treatment (leg sprain). Dying or dead victims have catastrophic injuries, and the dying victims would not survive under the best of circumstances (coded black).

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A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse should ensure that which medication is available if the client develops a significant bleeding problem?

  • A. Retaplase
  • B. Phytonadione
  • C. Protamine sulfate
  • D. Fresh frozen plasma
Correct Answer: C

Rationale: Protamine sulfate is the antidote for heparin sodium. Fresh frozen plasma may be used for bleeding related to warfarin therapy. Retaplase is a thrombolytic agent used to dissolve blood clots. Phytonadione is the antidote for warfarin.

The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager should note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse?

  • A. Uses sterile technique for needle insertion
  • B. Wears full protective clothing such as goggles, mask, gown, and gloves
  • C. Covers the connection site with a bath blanket to enhance extremity warmth
  • D. Puts on a mask and gives one to the client to wear during connection to the machine
Correct Answer: C

Rationale: While the client is receiving hemodialysis, the connection site should not be covered, and it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the procedure. Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both the nurse and client are extremely important. It is also imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and a gown.

Which clinical situation should justifiably be viewed as an assault?

  • A. The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior.
  • B. The client requests a medical discharge, but the nurse physically forces the client to stay.
  • C. The charge nurse sends an email to a staff member that includes a poor performance evaluation about another person.
  • D. The nurse overhears the primary health care provider making derogatory remarks to the client about the nurse's level of competency.
Correct Answer: A

Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive act. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation.

The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?

  • A. Administer a PRN antianxiety medication immediately.
  • B. Provide isolation for the client in the unit's 'time-out' room.
  • C. Observe the client in an ongoing manner but do not intervene.
  • D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D

Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.

A client with a diagnosis of chronic kidney disease has an indwelling peritoneal catheter in the abdomen for peritoneal dialysis. While bathing, the client spills water on the abdominal dressing. Which action should the nurse perform to best assure client safety?

  • A. Change the dressing.
  • B. Reinforce the dressing.
  • C. Flush the peritoneal dialysis catheter.
  • D. Scrub the catheter with povidone-iodine.
Correct Answer: A

Rationale: Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.

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