A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

A staff member places a midstream urine sample in a specimen refrigerator after-collecting it.

A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill.

A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster.

A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture

Answer and Explanation

The Correct Answer is D

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it:

This is a proper practice. Refrigerating the sample after collection helps preserve its integrity and prevents bacterial growth until it can be analyzed.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill:

This is a proper infection control practice. Chlorhexidine is an effective disinfectant, and cleaning the area following a blood spill helps prevent the spread of infectious agents.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster:

This is a proper practice. Alcohol-based antiseptic is effective in killing a broad spectrum of germs, and hand hygiene is crucial, especially after contact with a client who may have an infectious condition.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture:

This is an infection control hazard. Sterile saline irrigation should not be poured onto an open wound before specimen collection, as it can introduce contaminants and interfere with the accuracy of culture results. Specimens should be collected using aseptic technique to avoid contamination.

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Correct Answer is A

Explanation

A. Use of the Braden scale for clients who are immobile.

The Braden Scale is a widely used tool for assessing the risk of pressure ulcer development. It includes various factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. For clients who are immobile, the Braden Scale helps identify their risk for skin breakdown and guides the implementation of preventive measures.

B. Daily weighing of clients who have heart failure:

Daily weighing of clients with heart failure is important for monitoring fluid status, but it is not specifically focused on decreasing the risk of skin breakdown. Skin breakdown is more closely related to factors such as immobility, pressure, and friction.

C. Documentation of PAINAD scale for clients who have dementia:

The PAINAD scale is used to assess pain in clients with advanced dementia. While managing pain is important for overall well-being, it is not a direct measure for decreasing the risk of skin breakdown. Skin breakdown prevention is more related to factors like pressure relief and moisture management.

D. Implementation of incentive spirometry for clients who are postoperative:

Incentive spirometry is primarily aimed at promoting lung expansion and preventing respiratory complications after surgery. While postoperative care is essential, it does not directly address the risk of skin breakdown. Skin breakdown prevention involves interventions related to pressure relief, repositioning, and skin care.

Correct Answer is ["0.7"]

Explanation

To calculate the volume (mL) that the nurse should administer, we can follow these steps:

Convert the weight from pounds to kilograms.

1 lb=0.453592 kg.

66 lb×0.453592 kg/lb≈29.937 kg

Calculate the total dose using the weight and prescribed dose:

Total Dose (mg)=Dose per kg×Weight (kg)

Total Dose=0.55 mg/kg×29.937 kg≈16.465 mg

Determine the volume using the concentration of the available solution:

Volume (mL) =Total Dose (mg)/Concentration (mg/mL)

Volume=16.465mg/25 mg/mL≈ 0.6586 mL

Therefore, the nurse should administer approximately 0.7 mL of chlorpromazine for the 0.55 mg/kg IM dose, rounded to the nearest tenth.

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A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

Correct Answer is A

Explanation

A nurse is preparing to administer chlorpromazine 0.55 mg/kg IM to a child who weighs 66 lb. Available is chlorpromazine 25 mg/mL for injection. How many mL should the nurse administer? (Round the answer to the nearest tenths. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.7"]

Explanation

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