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Study guide · Safe and Effective Care Environment

Safety and Infection Prevention and Control

10 to 16% of the exam · 14 activity statements

Safety and Infection Prevention and Control covers how the practical nurse protects clients, staff and visitors from injury and infection: identifying clients, checking orders and allergies, moving clients safely, using restraints only as a last resort, responding to fires, disasters and security alerts, reporting errors and applying standard and transmission-based precautions. Items test what to do first to prevent harm and which precaution or device fits the situation.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements NCSBN lists for this category (14 of them), in our words; NCSBN's wording is in its Test Plan.

At a glance

Safe and Effective Care Environment
10 to 16%

of the exam (NCSBN's range)

Activity statements
14
Key terms
12

What this guide covers, statement by statement

  1. Make sure care equipment is on hand and working safely
  2. Check that a prescriber's order suits the client
  3. Confirm who the client is before giving care
  4. Move and handle clients safely, using good body mechanics
  5. Find out the client's allergies and act on them
  6. Get ready for and help respond to disasters inside or outside the facility, such as fires or severe weather
  7. Spot unsafe conditions in care settings and homes and deal with them
  8. Use the least restrictive form of restraint or seclusion
  9. Carry out scheduled client checks, such as safety rounds, by protocol
  10. Help teach the client how to stay safe, or reinforce that teaching
  11. Raise and respond to security alerts, such as a missing infant or a client at risk of leaving
  12. Own up to and record mistakes and near misses, for example in an incident report
  13. Use devices that help move clients, such as gait belts, slide boards and lifts
  14. Prevent infection with protective equipment, standard precautions, isolation and aseptic technique

1Make sure care equipment is on hand and working safely

  • Check equipment before use: electrical cords intact, safety inspection current, alarms on and audible, batteries charged, suction and oxygen working at the bedside.
  • Take a faulty or damaged device out of service, tag it per policy and report it; never use it or try to repair it yourself.
  • Use three-prong grounded plugs, keep liquids away from electrical equipment and avoid extension cords.
  • Keep emergency equipment (crash cart, suction, oxygen, bag-valve mask) stocked and checked per policy.
  • Do not silence or turn off alarms without checking the client; set alarm limits as ordered.
  1. In practiceWhile setting up a feeding pump, the nurse notices the power cord is frayed near the plug. She removes the pump from service, labels it, reports it to the charge nurse and obtains another pump, because damaged cords can cause shock or fire.
  2. Where questions turnUsing equipment that is damaged or overdue for inspection because no replacement is handy, or silencing an alarm without checking the client.
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2Check that a prescriber's order suits the client

  • Before carrying out an order, check that it suits this client: the dose for age and weight, allergies, current vital signs, laboratory results and other medications.
  • Hold and clarify an order that seems unsafe, for example a sedative for a client with a respiratory rate of 10, or digoxin with a pulse of 52 (below the parameter in the order or policy).
  • Know common hold parameters taught in practice and those written in the order or policy, such as apical pulse before digoxin and blood pressure before antihypertensives.
  • Contact the prescriber to question the order, report to the RN and document the reason the order was held and who was notified.
  • Never carry out an order you believe is harmful just because it was written; you are accountable for what you do.
  1. In practiceA client with a potassium of 5.9 mEq/L (reference 3.5 to 5.0 mEq/L) has a scheduled potassium chloride supplement. The nurse holds the dose and contacts the prescriber and the RN, because giving more potassium could cause a dangerous rhythm.
  2. Where questions turnGiving a medication as ordered without checking the data that make it unsafe for this client.
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3Confirm who the client is before giving care

  • Use at least two identifiers, such as full name and date of birth, before medications, blood products, specimen collection, treatments and procedures.
  • Room number, bed number and the client's diagnosis are never identifiers.
  • Compare the identifiers on the wristband with the medication record, order or label, and ask the client to state them when able.
  • For a client who cannot respond (confused, sedated, a newborn), rely on the wristband and policy; never ask "Are you Mr. Smith?" since a confused client may say yes.
  • Label specimens at the bedside in front of the client, and replace a missing or illegible wristband before care continues.
  1. In practiceA confused resident in a long-term care facility is not wearing her identification band when her medications are due. The nurse holds the medications until identity is confirmed per policy, using the facility's photo identification and another staff member, and has the band replaced, because two identifiers are required before any medication.
  2. Where questions turnIdentifying a client by room number or by asking a yes-or-no question about the name.
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4Move and handle clients safely, using good body mechanics

  • Keep a wide base of support, bend at the hips and knees, keep the load close to your body and avoid twisting; turn with your feet.
  • Raise the bed to a working height and lower it when finished.
  • Get help and use equipment: safe client handling programs recommend lifts and devices over manual lifting for clients who cannot bear most of their own weight.
  • Know the client's weight-bearing status, strength and cognition before moving them, and tell the client what you will do.
  • Pull or push rather than lift when possible, and use friction-reducing sheets to reposition a client in bed.
  1. In practiceTwo nurses need to move a client up in bed. They lower the head of the bed, use a friction-reducing sheet, set the bed at waist height, bend their knees and move on a count, because good body mechanics and devices prevent injury to both client and staff.
  2. Where questions turnChoosing to lift a dependent client manually, alone, rather than getting help and the right device.
Practise this activity

5Find out the client's allergies and act on them

  • Ask about allergies to medications, foods, latex and environmental agents, and the type of reaction, at every admission and before new medications.
  • Mark allergies on the wristband and record per policy; check before every first dose.
  • Latex allergy is linked with reactions to bananas, avocado, kiwi and chestnuts; use latex-free equipment and a latex-safe room.
  • Signs of anaphylaxis include hives, throat or tongue swelling, wheezing, stridor, hypotension and a sense of doom.
  • For a suspected reaction: stop the medication or exposure, stay with the client, call for help and the RN, keep the airway open and give epinephrine per protocol or order.
  1. In practiceTen minutes after an intramuscular antibiotic, a client says his throat feels tight and the nurse hears wheezing. The nurse calls for help and the RN, stays with him, positions him to breathe and has epinephrine given per the anaphylaxis protocol, because anaphylaxis can close the airway within minutes.
  2. Where questions turnLeaving the client to look up the reaction or call the provider before calling for help and treating the airway.
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6Get ready for and help respond to disasters inside or outside the facility, such as fires or severe weather

  • For a fire, use RACE: Rescue clients in immediate danger, Alarm (pull the alarm, call the code), Contain (close doors and windows), Extinguish or Evacuate.
  • Use a fire extinguisher with PASS: Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side.
  • Evacuate horizontally first (to the other side of fire doors), then vertically; clients who can walk go first, then those in wheelchairs, then those in bed.
  • In a mass casualty event, triage sorts clients so the most good is done for the most people; to free beds, clients who are stable, ambulatory and near discharge can be discharged first.
  • Know your role in the facility's emergency plan, where equipment and exits are, and take part in drills.
  1. In practiceThe nurse smells smoke and sees flames in a resident's wastebasket. She moves the resident out of the room, pulls the alarm, closes the door and then uses the extinguisher if it is safe, because rescuing the person in danger comes first.
  2. Where questions turnFighting the fire before rescuing the client, or taking an elevator during a fire evacuation.
Practise this activity

7Spot unsafe conditions in care settings and homes and deal with them

  • Fall prevention: bed low and locked, call light and items within reach, nonskid footwear, adequate lighting, clear paths, scheduled toileting.
  • In the home, remove throw rugs and clutter, add grab bars and night lights, keep stairs lit with rails, and store medications and chemicals out of children's reach.
  • Check smoke and carbon monoxide detectors; never use a gas stove or generator to heat a home indoors.
  • Oxygen in use: no smoking or open flames, keep tanks secured, and post a sign as policy requires.
  • Correct a hazard at once when you can (wipe a spill), and report what you cannot fix.
  1. In practiceDuring a home visit, the nurse sees an older client's oxygen tubing running across a throw rug in a dim hallway. She moves the rug, routes the tubing along the wall, suggests a night light and reports the fall risk to the RN, because the home has several fixable hazards.
  2. Where questions turnNoting a hazard and leaving it for someone else when you can make it safe now.
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8Use the least restrictive form of restraint or seclusion

  • Restraints and seclusion are a last resort, used only when less restrictive measures have failed and the client is a danger to self or others.
  • Try alternatives first: frequent observation, reorientation, toileting, a bed alarm, a low bed with floor mats, diversion, treating pain, moving the client near the nurses' station.
  • A restraint needs a provider order that is time-limited and renewed per law and policy; it is never written as needed (PRN) and never used for staff convenience or punishment.
  • Tie with a quick-release knot to the bed frame (not a side rail), leave room for two fingers under the device, and pad bony areas.
  • Monitor per policy: circulation, sensation, skin, breathing, hydration, toileting and range of motion, releasing the restraint at the intervals policy sets, and document each check.
  1. In practiceA client recovering from surgery keeps pulling at his urinary catheter. The nurse first checks for pain and a full bladder, covers the catheter with his gown, reorients him and asks family to sit with him, and reports to the RN that the behavior continues, because restraint is considered only after these measures fail.
  2. Where questions turnChoosing a restraint first, tying it to the side rail, or treating a PRN restraint order as acceptable.
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9Carry out scheduled client checks, such as safety rounds, by protocol

  • Some clients need checks at set intervals by policy or order: every 15 minutes for suicide risk, more often or one-to-one for high risk, set intervals for restraints or seclusion.
  • A check means seeing the client and the client's breathing, safety and environment, not just glancing at a closed door.
  • Document each check at the time it is done, with the client's location and behavior.
  • Vary the exact timing within the interval when policy allows, so a client cannot predict the next check.
  • Report any change in behavior or risk to the RN at once.
  1. In practiceA client on every-15-minute safety checks is in bed with the blanket over her head. The nurse enters and confirms she is breathing and has nothing harmful with her, because a check must confirm the client is safe, not only present.
  2. Where questions turnDocumenting checks that were not done, or doing them in advance.
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10Help teach the client how to stay safe, or reinforce that teaching

  • Reinforce the teaching the RN or provider began: call-light use, asking for help before getting up, using assistive devices, and medication safety.
  • Teach to the client's needs: fall risk for older adults, safe sleep and car seats for infants, poisoning and drowning prevention for toddlers, helmets for children and teens.
  • Use teach-back and return demonstration to confirm understanding.
  • Include family and caregivers who will help at home.
  • Report to the RN when a client cannot or will not follow safety precautions.
  1. In practiceA client on an anticoagulant is going home. The nurse reinforces the RN's teaching: use a soft toothbrush and electric razor, report black stools or unusual bruising, and keep regular blood tests, and the client repeats the points back, because bleeding is the main risk of this drug.
  2. Where questions turnAccepting "I understand" without teach-back, or the PN starting new teaching on a new diagnosis.
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11Raise and respond to security alerts, such as a missing infant or a client at risk of leaving

  • Know your facility's codes and what to do for each: infant or child abduction, a missing client, an armed intruder, a bomb threat.
  • Infant security: matching identification bands for parent and infant, staff with photo identification, infants carried in a bassinet not in arms in halls, never leaving an infant unattended.
  • Report suspicious behavior (someone asking about the nursery layout or carrying a large bag on the unit) and call the code at once if an infant is missing.
  • Clients at risk of leaving (flight risk, wandering, involuntary admission) need close observation, door alarms or electronic monitoring as policy allows.
  • When a client is missing, search per policy, notify the RN and security immediately and give a description.
  1. In practiceA mother says a woman in scrubs without a badge took her baby "for a test." The nurse calls the infant abduction code immediately and stays with the mother, because the first minutes matter most in locking down exits.
  2. Where questions turnSearching quietly or waiting to confirm before raising the alert.
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12Own up to and record mistakes and near misses, for example in an incident report

  • Report every error and near miss promptly per policy, whether or not harm occurred.
  • First check and care for the client, then notify the RN and provider, then complete the incident report.
  • In the client's record, document the facts and the care given; do not write that an incident report was completed or blame anyone.
  • The incident report is a confidential quality document, not part of the record and not a disciplinary tool.
  • Be honest about your own errors; a just culture separates system problems from reckless behavior.
  1. In practiceThe nurse realizes she gave a resident 10 mg of a medication ordered as 5 mg. She checks the resident's vital signs and condition, notifies the RN and provider, documents the dose given and the client's response in the record and then completes an incident report, because the client's safety comes before paperwork.
  2. Where questions turnCompleting the incident report before checking the client, or mentioning the incident report in the client's record.
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13Use devices that help move clients, such as gait belts, slide boards and lifts

  • A gait or transfer belt goes around the client's waist over clothing, snug enough to slip fingers under, to steady the client during transfers and walking.
  • If a client starts to fall while walking, widen your stance, hold the belt and ease the client to the floor while protecting the head; do not try to hold them up.
  • A slide board bridges a gap for a client who can sit and use the arms; lock both surfaces at the same height.
  • A mechanical (full-body) lift is for clients who cannot bear weight or help; use the sling size and lift per policy, usually with two staff.
  • Lock wheelchair and bed brakes, and move toward the client's stronger side.
  1. In practiceA client with left-sided weakness after a stroke is moving from bed to wheelchair. The nurse places the wheelchair on the client's right side, locks the brakes, applies a gait belt and pivots the client toward the right, because moving toward the stronger side is safer.
  2. Where questions turnLifting a dependent client manually instead of using the lift, or trying to hold up a falling client instead of easing them down.
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14Prevent infection with protective equipment, standard precautions, isolation and aseptic technique

  • Standard precautions for every client: hand hygiene before and after contact, gloves for body fluids, and gown, mask and eye protection when splashing is likely; alcohol rub is not enough after caring for a client with Clostridioides difficile, so wash with soap and water.
  • Contact precautions (gown and gloves; for example C. difficile, MRSA in wounds, scabies), droplet precautions (a surgical mask within close range; for example influenza, pertussis, bacterial meningitis) and airborne precautions (a fit-tested N95 respirator and a negative-pressure room; for example tuberculosis, measles, varicella).
  • Don PPE in this order: gown, mask or respirator, eye protection, gloves. Remove gloves first, then eye protection, gown and mask or respirator last, with hand hygiene after (or follow the facility's approved method).
  • In nursing homes, enhanced barrier precautions call for gown and gloves during high-contact care (bathing, dressing, wound or device care) for residents with wounds, indwelling devices or certain resistant organisms.
  • Surgical asepsis: anything below the waist or out of sight is unsterile, a 1-inch (2.5 cm) border of the sterile field is unsterile, and if in doubt, it is contaminated.
  1. In practiceA resident has new diarrhea and a positive test for C. difficile. The nurse places her on contact precautions, uses gown and gloves for care, cleans equipment with a sporicidal agent per policy and washes her hands with soap and water after care, because alcohol does not kill the spores.
  2. Where questions turnChoosing a surgical mask for airborne illness, using alcohol rub after C. difficile care, or removing the mask before the gloves.
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Key terms

Two identifiers
Two pieces of client-specific information, such as full name and date of birth, checked before care; never the room number.
RACE
Rescue, Alarm, Contain, Extinguish or Evacuate: the order of response to a fire.
PASS
Pull, Aim, Squeeze, Sweep: how to use a fire extinguisher.
Least restrictive measure
The option that keeps the client safe while limiting freedom the least; restraint is the last resort.
Near miss
An error caught before it reached the client; reported like any other event.
Incident report
A confidential quality document describing an error or unusual event; not part of the client's record.
Standard precautions
Infection control practices used for every client, treating all blood and body fluids as potentially infectious.
Transmission-based precautions
Contact, droplet or airborne precautions added to standard precautions for known or suspected infections.
Enhanced barrier precautions
Gown and glove use during high-contact care of nursing home residents with wounds, devices or certain resistant organisms.
Surgical asepsis
Sterile technique that keeps an area free of all microorganisms.
Gait belt
A belt worn around the client's waist that gives the nurse a secure hold during transfers and walking.
Triage
Sorting clients by urgency so care and resources go where they do the most good.

After this guide: You can identify clients correctly, catch unsafe orders and allergies, move clients safely, choose alternatives before restraints, respond to fires, disasters and security alerts, report errors properly and choose the right infection precautions.

Practise Safety and Infection Prevention and Control