Nokea
The nurse is observing a student nurse wash their hands with soap and water. Which observation requires follow-up? The student nurse
- A. washes their hands using warm water.
- B. dries hands thoroughly from wrists to fingers with paper towel.
- C. wets their wrists and hands with fingers pointed downward.
- D. pushes wristwatch and long uniform sleeves above wrists.
Correct Answer: C
Rationale: Fingers should point upward during handwashing to ensure soap and water reach all surfaces effectively.
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The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.
The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.
- A. Obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.
- B. Places the BP cuff over the client's clothing garment.
- C. Requests the client remove their hearing aid before obtaining a tympanic temperature.
- D. Assesses the client's respirations after obtaining the pulse rate.
- E. Obtains blood pressure by placing the client's upper extremity at the level of their heart.
- F. Places the pulse oximeter probe on the client's finger that has edema.
Correct Answer: B,F
Rationale: Placing the BP cuff over clothing and using an edematous finger for pulse oximetry can yield inaccurate readings. Other actions are correct.
The nurse has attended a continuing education conference about infection control precautions. It would indicate a correct understanding of the education if the nurse is observed?
- A. using dedicated client-care equipment for a client with Clostridium difficile.
- B. wearing a particulate respirator mask (N95) while caring for a client with epiglottitis, due to Haemophilus influenzae type b.
- C. placing a surgical mask on a client being transported with radiology who has infectious mononucleosis.
- D. keeping the door closed for a client with cryptococcal meningitis.
Correct Answer: A
Rationale: Dedicated equipment for C. difficile prevents transmission. N95 is not needed for epiglottitis, masks are not required for mononucleosis transport, and cryptococcal meningitis does not require a closed door.
The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that
- A. staff wears a surgical mask when providing client care.
- B. disposable utensils and dishware are used for meals.
- C. dietary staff wears a face shield when preparing client meals.
- D. commonly touched surfaces be disinfected with a bleach solution.
Correct Answer: D
Rationale: Norovirus requires contact precautions, including bleach disinfection of surfaces. Masks, disposable utensils, and face shields are not standard.
The nurse recognizes which of the following is considered an external disaster?
- A. Computer system failure
- B. A walkout and strike by nursing staff
- C. Mass shooting at a nearby park
- D. Chemical leak in the critical care units
Correct Answer: C
Rationale: A mass shooting at a nearby park is an external disaster, as it occurs outside the facility and impacts hospital operations. The others are internal disasters.