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NCLEX safety & infection control
Terms in this set (92)
slight fever, malaise, anorexia, pruritic rash that begins as macule and progresses to vesicle
-isolation until all vesicles are crusted
-communicable 1 day before rash
*airborne AND contact precautions in hospital
low-grade fever, hoarseness, malaise, lymphadenitis
HALLMARK: white/gray pharyngeal membrane
*contact and droplet precautions until 2 negative nose/throat cultures
*administer antitoxin therapy
upper respiratory infection, severe cough with high-pitched whooping sound, vomiting
*hospitalization required in infants
*contact and droplet precautions
complications of pertussis:
pneumonia, dehydration, hemorrhage, hernia, and airway obstruction
low fever & sore throat
-maculopapular rash that appears on the face first then spreads to the rest of the body
*contact and droplet precautions
who should be protected from a child with rubella?
*risk of fetal deformity
rare complications of rubella:
encephalitis and arthritis
fever and malaise followed by cough
HALLMARK: Koplik's spots on buccal mucosa
*red rash on face, turns brown after 3 days
what precautions should you initiate for a client diagnosed with Rubeola?
droplet & seizure
*antipyretics, dim lights, humidifier for room
high fever with vomiting, chills, and malaise
HALLMARK: exudate on tonsils & strawberry tongue
what precautions are necessary for a client with scarlet fever?
droplet for first 24 hours after the start of antibiotics
malaise, headache, fever parotid gland swelling
*can lead to deafness, meningitis, encephalitis
-keep door closed to a private negative air pressure room
-N95 mask required
-can only place client in a room with someone who is infected with exact same organism (private is best)
-place mask on client if being transported
measles, varicella, disseminated herpes zoster =
diptheria, Group A streptococcal pneumonia, meningitis, H. influenzae tybe B, rubella, mumps, pertussis =
-happens during coughing, sneezing, talking, or suctioning
-wear a mask if in close contact
-maintain separation of 3 feet between clients & visitors unless they wear a mask
-door may remain open
-place mask on client if being transported
-private room or with client with same infection
-clean, non-sterile gloves for contact with client or contaminated surfaces
-remove gloves before leaving the environment & wash hands with antimicrobial soap
-wear a gown when entering the room & remove before leaving room
-dedicated equipment or clean & disinfect between every client
MRSA, herpes simplex, herpes zoster, c. diff, pediculosis, scabies, rotavirus, hepatitis A =
teaching for a client with TB
-cover mouth and nose with tissue when coughing, sneezing, or laughing
-place all tissues in a plastic bag
-wear a mask in crowds
-must take full course of medications
-return for sputum smears
-increased iron, protein, and vitamins B&C in diet
Positive Mantoux test
15mm or greater induration (hard area under skin)
*will need a CXR to confirm; this just shows exposure
*read in 48-72 hours
fatigue, jaundice, yellow sclera, anorexia, RUQ pain, malaise
clay colored stools & tea colored urine
elevated ALT, AST & alkaline phosphatase
Hepatitis (assessment findings)
can a client diagnosed with Hepatitis A ever donate blood?
how is hepatitis A prevented?
improved sanitation (survives on hands)
*implement contact precautions
complications from hep B?
cirrhosis & liver cancer
when is HIV considered AIDS +?
CD4/TC counts below 200
rash that develops at a bug bite, rings develop with bull's-eye, lesion enlarges quickly
what can happen with lyme disease in stage 2?
cardiac conduction defects
neurologic disorders (facial paralysis, non-permanent paralysis)
what can happen if lyme disease progresses to stage 3?
arthralgia, chronic fatigue, and cognitive disorders
opportunistic infections with HIV/AIDS:
p. jiroveci pneumonia
c. albicans stomatitis
c. neoformans (meningitis)
CMV (most deadly)
Kaposi's sarcoma (most common malignancy)
what is used to slow progression of HIV/AIDS
zidovudine, acyclovir (AZT)
prevention of poisoning
propper storage (locked cabinets)
never take medicine in front of children (kids mimic parents)
never leave medication in purse, on table, or on kitchen counter
leave medicines & cleaning supplies in original containers
provide activities and play materials for children (discourage them from exploring)
teach need for supervision of small children
in case of suspected poison ingestion
-recognize s/s of accidental poisoning
-initiate steps to stop exposure
-call poison control center (substance name, amount, route & child age/weight)
-PCC will advise to treat at home or bring to ED
-save any substance, vomits, stool, urine
what is no longer used to treat accidental poisoning?
syrup of ipecac
*do not induce vomiting at home unless the PCC or HCP tells you to
contraindications to induce vomiting:
-risk of aspiration (decreased LOC, shock, seizing)
-substance is lighter fluid, kerosene, or paint remover because of increased risk aspiration
-substance is acid/alkali drain cleaner (do more damage on the way back up)
what can help dilute toxin if accidental poisoning occurs?
water (but avoid giving in large amounts, may accelerate gastric emptying)
*milk may delay vomiting
when should you intubate a client that has accidentally ingested poison?
comatose, seizing, absent gag reflex
how is gastric lavage done?
-intubated and head position down/left
-lare oro/NG tube inserted and repeated irrigations of NS until clear (no more than 10 mL / kg)
what helps to absorb poisonous compunds?
how to give activated charcoal
-give within 30 min of ingestion
-mix with water to make syrup; give PO or via gastric tube
tinnitus, nausea, sweating, dizziness
early: respiratory alkalosis
late: metabolic acidosis
how to treat a salicylate overdose?
1. induce vomiting (gastric lavage with activated charcoal)
2. monitor vitals and lab values
3. maintain IV hydration and electrolyte replacement
4. reduce temp
5. IV sodium bicarb enhances excretion
when does acetaminophen become toxic?
*s/s: nausea, vomiting, sweating, pallor, hypothermia, slow and weak pulse
Antidote for acetaminophen toxicity
What is the biggest worry with acetaminophen overdose?
Watch ALT & AST levels
hazardous materials causing immediate threat to life:
*treat, then decontaminate
clients with occluded airway or hemorrhaging:
clients with moderate burn or eye injury:
broken bone or needs stitches
how to treat clients in an emergency?
2. lab tests
3. diagnostic procedures
itching with small papule or vesicle
-enlarged painless lesion with necrotic center forms
-black eschar forms, sloughs off
how to treat a client with anthrax cutaneous?
-clothes in plastic bags & labeled
-have client shower with soap, water, and shampoo
-wear gloves, gown, and respiratory protection
-decontaminate surfaces with bleach solution
sore throat, mild fever, malaise
*abrupt onset of respiratory failure, shock, fever, and hemorrhagic meningitis
how to treat anthrax inhalation
IV & PO ciprofloxacin/doxycycline
drooping eyelids, weakened jaw clench, dysphasia, blurred vision, symmetric descending weakness
what to do if you suspect botulism?
what to do if you suspect pneumonic plague?
droplet precautions until 72 hours of antibiotic therapy
administer: streptomycin, ciprofloxacin, doxycycline
fever, myalgia, and rash on face / extremities (palms and soles of feet)
*considered public health emergency
*airborne, contact, AND droplet precuations
what to do if a patient has smallpox?
identify s/s immediately and go to top of triage list
take them to private room immeiately with negative air pressure and door closed
decontaminate person & items
administer vaccination within 3 days of contact if exposed
client with a brain injury keeps trying to get out of bed without assistance.
should you re-instruct client to not get out of bed?
*cannot remember the information and may get agitated
client is admitted to ED with suspected ruptured appendicitis with perforation. what is the PRIORITY nursing assessment?
monitor for increasing pain and rigidity of the abdomen (s.s that it ruptured)
*do not check McBurney's point, because it could rupture the appendix
*increase in temp would not help (non-specific)
why would a nurse discussing a client's prognosis with family require and incident report?
violating HIPAA- the HCP is responsible for discussing prognosis with client and only those individuals designated by the client
when giving a pre-op medication, what is the nurses PRIORITY action when administering the med?
check that the ID band is in place
PPE needed with ebola virus:
single use impermeable gown
PAPR or N95 respirator
single use boot covers
single use apron
2 pairs of clean gloves (extended cuffs)
safest approach for transferring a client with left hemiplegia from the bed to a wheelchair?
using a mechanical life
*when lifting physically impaired client, a lift is the safest for both staff & client
how to use a mechanical lift:
roll client onto sling
attach lift loots
allow machine to do work
client in 3rd trimester of pregnancy arrives at ED room with general illness. client is noted to have blood glucose of 390. primary HCP orders 30 units of NPH insulin.
why should you question the order?
NPH is intermediate acting, onset is too long.
client should have been prescribed regular insulin
client is admitted to pediatric unit with diagnosis to rule out TB. what room assignment should the charge nurse make?
client diagnosed with VRE UTI, what instructions should be included?
clean bathroom and kitchen with warm water and bleach
wash hands after using bathroom and before preparing food
gloves are needed to prevent spread of infection
what position should infants be when sleeping/napping?
supine (preventing SIDS is crucial)
leading cause of infant deaths:
motor vehicle accidents
(rear-facing, approved carseat)
safety precautions for a client diagnosed with Parkinson's disease?
-install grab bars on tubs
-place night lights in hallways
-add bran and fiber to daily diet
-remover scatter rugs or loose cords
-keep bedroom dark, cool, quiet
what should you never do to a walker?
put tennis balls on wheels
why would providing socks for a client post total-hip replacement be a safety concern?
would require the client to flex hips to put them on
*leading cause of hip dislocation following surgery
when should a primary HCP be notified of a medication incident?
client is harmed (or dies)
nurse administers an incorrect dosage
who do you contact first if abuse is suspected: primary HCP or child services?
difference between Hepatitis B and HIV?
Hepatits B is more readily transmitted via needle sticks than HIV
*both transmitted by contacting body fluids (ex. toilet seats, birth, sex, blood)
how to ensure a client in a long-term care facility who is legally blind and deaf?
-research established protocols utilized by emergency groups
-discuss communication methods with client and family
*do not assign specific UAP or roommate to escort out (not roommate or family members responsibility)
home safety: fires
fire extinguisher should be kept on each level of the home (near an exit and out of reach from kids)
keep matches and lighters away from kids by storing them in a locked cabinet
install carbon monoxide and smoke alarms. test monthly.
have planned route of exit and a place where all family members will meet
always turn off christmas lights when no one is home or when people go to bed (doesn't matter if tree is real or fake)
what to do before ANY procedure or medication?
check ID band!!
what should be reported immediately when caring for an infant who was born with a myelomeningocele?
high pitched cry
eyes fixed downwards
increasing head circumference
*all s/s increasing ICP & development of hydrocephalus
role of a nurse while working on a disaster response plan?
identify individuls in charge of a given client area
remain alert to potential security issues
consider ethical conflicts that may impact care
provide emotional support and make referrals to mental health resources
*nurses may be expected to perform duties that are out of their area of expertise
what to do if 2 sibling clients are in the same room and take off their ID bands?
notify family to come in and identify clients in person
*even a blood type is not definite enough (may have same type of blood)
priority action for client receiving ECT?
provide suctioning as needed
*airway is more important that monitoring vitals
chicken pox =
cleaning and dressing a foot ulcer of diabetic client:
wear sterile gloves
clean ulcer with normal saline
clean in a full circle, beginning in center and working towards outside
*solution room temp, do not heat it
patient with a cast reports pain is increasing even though they are receiving morphine on a PCA.
what do you do?
perform neurovascular checks
prepare for possible bivalving of cast
notify primary HCP (compartment syndrome)
what to do after discovering a medication error, verifying the client is stable, and completing an incident report?
give the report to hospitals risk management team
*only notify HCP of clients condition, don't give them the report
housekeeper called to med-surg unit for multiple tasks. what is a priority?
spilled coffee (liquid on floor is a hazard to anyone in the area)
client has a Holt monitor for a 24 hour ECG. what should they avoid?
taking shower or bath
working around high-voltage equipment
being screened at airport security
can a client with hepatitis A donate blood when they are well?
This set is often in folders with...
NCLEX: infection control bank
Infection Control (NCLEX REVIEW)
Nclex Safety and Infection Control
Study Guide #7 Ch. 28, 29, 30, & 31
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