1. Answer C. 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.
2. Answer D. 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.
3. Answer B. 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.
4. Answer A. 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.
5. Answer B. Hands are the primary method of transmission of the common cold. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils.
6. Answer D. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.
7. Answer B. Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage must be reported immediately.
8. Answer D. The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Putting the client in a bright, busy area would probably add to his confusion. The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.
9. Answer B. The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours after insertion), the client is no longer contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place.
10. Answer C. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask, gown, and gloves.
11. Answer D. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing and before donning the sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. However, the nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.
12. Answer A. To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate. The amount of regular exercise is not the most important factor to assess. It is only indirectly related. The resting pulse rate is not related to preventing falls. The salt intake is not directly related to preventing falls.
13. Answer C. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. The 4 X 4s should be soaked prior to donning the sterile gloves. Once the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a need for further instruction.
14. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client’s hygiene is poor.
15. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client’s hygiene is poor.
16. Answer C. Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an instrument such as a hemostat should be used to recap. The hand should never be used. Gloves are not necessary when feeding, since there is no contact with mucus membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin. Masks and protective eye wear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions.
17. Answer A. Direct contact is the mode of transmission for staphylococcus. Staph is not spread by coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not spread through oral secretions.
18. Answer A. The AIDS virus is spread through direct contact with body fluids such as blood and through sexual intercourse. Casual contact with other people does not pose a risk of transmission of AIDS. Unless the client is feeling very ill, there is no need for him to drop his college classes. Contact sports are not contraindicated unless there is a significant chance of bleeding and direct contact with others. Casual contact with other people does not pose a risk of transmission of AIDS. There is no need to limit casual contact with children.
19. Answer D. Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for AIDS. Birth control methods are important to prevent a baby from being born with the AIDS virus. The age at which sexual activity began it not relevant as it does not usually provide information that identifies the presence of risk factors for AIDS.
20. Answer C. Independently ambulating around the unit is not appropriate because the unit environment can change and injury could result. Assistance is necessary because of the client’s visual deficit. It is unlikely the client can see well enough to read the materials. Maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely. Using the bedpan is an unnecessary restriction on the client as she can be oriented to the bathroom or to call for assistance.