A nurse on a medical-surgical unit is evaluating an assistive personnel’s use of infection control precautions. Which of the following actions by the AP indicates correct use of the precautions?
The AP wears a surgical mask when caring for a client who has respiratory tuberculosis
The AP uses alcohol-based hand sanitizer after emptying the bed pan on a client who has Clostridum-difficle
The AP bundles the client side of linen inward when changing the sheets for a client who has an infected surgical wound
The AP removes her gloves before leaving the room of a client who has MRSA
Correct Answer : C
a. The AP wears a surgical mask when caring for a client who has respiratory tuberculosis.
Incorrect. AP should wear an N95 Mask when caring for a client with respiratory tuberculosis helps prevent the spread of airborne pathogens, protecting both the healthcare worker and others in the environment.
b. The AP uses alcohol-based hand sanitizer after emptying the bedpan of a client who has Clostridium difficile.
This action is incorrect. Alcohol-based hand sanitizers are not effective against the spores of Clostridium difficile. Handwashing with soap and water is necessary to effectively remove the spores.
c. The AP bundles the client side of linen inward when changing the sheets for a client who has an infected surgical wound.
When handling soiled linen, it is essential to fold the client side of the linen inward to minimize the spread of contaminants. This helps to ensure that any contaminated surfaces do not come into contact with other surfaces, which is crucial for preventing the spread of infection.
d. The AP removes her gloves before leaving the room of a client who has MRSA.
For MRSA (Methicillin-resistant Staphylococcus aureus), the AP should remove gloves and perform hand hygiene before leaving the room.
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Correct Answer is C
Explanation
a. Green:
Green triage tags are typically used for "walking wounded" or patients with minor injuries who can wait longer for treatment. These patients are considered to have non-life-threatening injuries and can be managed after more critical patients have been stabilized.
b. Yellow:
Yellow triage tags are used for patients with moderate injuries who require medical attention but are not in immediate danger of death. These patients may have significant injuries that require timely treatment but do not have life-threatening conditions.
c. Black:
The black tag is used for patients who are not expected to survive due to severe injuries or critical conditions. In the case of full-thickness burns covering a large percentage of the body (such as 72%), the patient’s prognosis is poor, and immediate care resources should be allocated to those with a higher chance of survival.The black tag indicates that the patient’s injuries are incompatible with life, and comfort measures may be provided, but resuscitation efforts are not a priority.
d. Red:
Red triage tags are used for patients with life-threatening injuries who require immediate medical attention to survive. These patients have critical conditions that require rapid assessment, stabilization, and treatment to prevent further deterioration and improve outcomes.
Correct Answer is D
Explanation
a. "You should contact the provider about your wishes for your family member."
While the provider may ultimately be involved in decision-making, it's important for the nurse to address the conflicting wishes and provide guidance on the appropriate steps to take in such situations.
b. "You should speak with the facility’s ethics committee about your concerns."
In cases of conflicting wishes or ethical dilemmas, involving the ethics committee can be beneficial. However, this response might not address the immediate need for clarification and guidance.
c. "We’ll need to have the nursing supervisor review the client’s advance directives."
Reviewing advance directives with the nursing supervisor is a reasonable step to ensure that the client's wishes are documented and followed. However, it might not directly address the conflicting wishes or provide immediate resolution.
d. "As the health care surrogate, the client’s partner can make this decision."
This is the correct response. The health care surrogate, appointed by the client or legally recognized as such, has the authority to make medical decisions on behalf of the unconscious client. It's important to follow the client's advance directives and legal designations regarding
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