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NCLEX SAFETY/INFECTION CONTROL FUNDAMENTALS PART 1 QUESTIONS AND ANSWERS ELABORATIONS!!
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NCLEX SAFETY/INFECTION CONTROL FUNDAMENTALS PART 1 QUESTIONS AND ANSWERS ELABORATIONS!!
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NCLEX SAFETY/INFECTION CONTROL FUNDAMENTALS PART1 QUESTIONS AND ANSWERS ELABORATIONS!!
When selecting catheter size, the need for rapid fluid administration and the type of
fluid administered versus client discomfort should be assessed. A lower IV catheter
gauge number corresponds to a larger bore IV catheter.
Answers :A 14-gauge (large-bore) catheter may be used for administering fluids
and drugs in an emergency or prehospital setting, or for hypovolemic shock.
In somewhat stable adult clients who require large amounts of fluids or blood, an
18-gauge catheter is preferred.
A 20-22-gauge catheter is sufficient for administering general IV fluids and
medications to adult clients; a 20-gauge is acceptable for blood transfusion.
However, 20-22-gauge is not preferred for blood administration.
A 24-gauge catheter is recommended for children and some older adults with
small, fragile veins.
Liver Biopsy
Answers :Administer vitamin K, npo morning of exam 6 hours, give sedative
The client's coagulation status is checked before the liver biopsy using PT/INR and
PTT. The liver ordinarily produces many coagulation factors and is a highly
vascular organ. Therefore, bleeding risk should be assessed and corrected prior to
the biopsy.
,Blood should be typed and crossmatched in case hemorrhage occurs.
After the procedure, frequent vital sign monitoring is indicated as the early signs of
hemorrhage are rising pulse and respirations, with hypotension occurring later.
*The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine
with the right arm over the head and holding the breath 5-10 sec.
*The client must lie on the right side for a minimum of 2-4 hours to splint the
incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any
bleeding.
The client stays on bed rest for 12-14 hours.
Following a needlestick injury
Answers :the nurse's immediate actions should be to remove their gloves and
thoroughly wash the affected area with soap and water.
Exposure should be reported to the nurse's supervisor and the facility exposure
hotline as soon as possible to facilitate the evaluation process.
The nurse should then seek evaluation and treatment from the employee health
clinic or emergency department.
Blood should be drawn for baseline testing, and postexposure prophylaxis will be
given based on the risk of exposure.
,Postexposure prophylaxis for HIV infection is most effective when given within
two hours of an exposure incident.
The key aspects related to radiation exposure
Answers :are time and distance.
The greater the distance, the less dosage received.
Acute radiation syndrome has the following phases: prodromal, latent, manifest,
and recovery or death. Initially, all victims will appear well; however, the damage
is mainly internal, leads to cell destruction, and manifests later on.
Victims farthest away from the radiation source are the most salvageable.
The principle of disaster nursing is to do the most good for the most people with
the available resources.
Low-grade temperature and cough
Answers :could indicate the presence of an infection, and the nurse should report
these findings to the HCP as soon as possible before surgery.
The administration of anesthesia in a client with a fever and cough can exacerbate
an unknown viral or bacterial condition, increase the risk for postoperative
pneumonia, and interfere with the postoperative healing process.
The HCP may prescribe further testing, consult the anesthesia professional,
postpone the elective surgery, or proceed with the surgery depending on the
individual situation and type of surgery scheduled.
, Normal ranges:
*Hemoglobin (13.2-17.3 g/dL)
*hematocrit (39%-50%)
*platelet count (150,000- 400,000/mm3)
*INR is 0.75-1.25
Interventions to promote safety when using crutches in the home include the
following:
Answers :Keep the environment free of clutter and remove scatter rugs to reduce
fall risk.
Look forward, not down at the feet, when walking to maintain an upright position,
which will help prevent muscle and joint strain, maintain balance, and reduce fall
risk.
Use a small backpack, fanny pack, or shoulder bag to hold small personal items
(eg, eyeglasses, cell phone), which will keep hands free when walking.
Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk.
Rest crutches upside down on the axilla crutch pads when not in use to prevent
them from falling and becoming a trip hazard.
Keep crutch rubber tips dry. Replace them if worn to prevent slipping.
Chemical restraints are medications (eg, benzodiazepines, psychotropics)
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