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Study guide · Safe and Effective Care Environment

Safety and Infection Prevention and Control

10 to 16% of the exam · 17 activity statements

Safety and Infection Prevention and Control covers how the nurse protects clients, visitors and staff from injury, infection, errors and hazards: precautions, client identification, safe orders and equipment, restraints, emergencies and a safe workplace. NCLEX items ask you to pick the safest action, the correct precaution or PPE, the right sequence (rescue before extinguishing, assess before moving a client who fell) and the correct response to an error or unsafe practice.

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 (17 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
17
Key terms
14

What this guide covers, statement by statement

  1. Use infection control measures such as hand hygiene, isolation and sterile technique
  2. Keep the client from getting hurt
  3. Check that a treatment order is correct and suitable
  4. Handle hazardous and biohazardous materials by the set procedures
  5. Follow the facility's security procedures, for example for infant safety or violence
  6. Apply good body mechanics and ergonomics while giving care
  7. Admit to and record errors and near misses in practice
  8. Confirm the client's identity correctly before giving care
  9. Make sure equipment is used correctly and safely
  10. Teach the client about risks to their safety
  11. Take part in planning for and responding to emergencies
  12. Meet the rules that govern restraint use
  13. Teach clients and staff how to prevent infection
  14. Check the client for allergies and act on what you find
  15. Report or escalate unsafe staff practice, such as impairment or poor care
  16. Check the client's surroundings for safety
  17. Support the safety of staff and the workplace

1Use infection control measures such as hand hygiene, isolation and sterile technique

  • Standard precautions apply to every client; add transmission-based precautions for the organism: contact (gown and gloves, e.g., MRSA, C. difficile, scabies), droplet (surgical mask within close contact, e.g., influenza, pertussis, mumps, meningococcal meningitis) and airborne (fit-tested N95 or higher respirator in an airborne infection isolation room with negative pressure and the door closed, e.g., tuberculosis, measles, varicella).
  • Use alcohol-based hand rub for routine care when hands are not visibly soiled; wash with soap and water when hands are visibly soiled and after caring for a client with C. difficile or norovirus diarrhea, because alcohol does not reliably kill spores.
  • Don PPE in this order: gown, mask or respirator, goggles or face shield, gloves. Remove gloves first (the most contaminated), then goggles or face shield, gown, and mask or respirator last, removing a respirator after leaving the room; perform hand hygiene after removing all PPE.
  • Sterile technique: only sterile touches sterile; the outer 1 inch (2.5 cm) border of a sterile field and anything below the waist or out of sight are considered contaminated; never turn your back on a sterile field; if in doubt, consider it contaminated and replace it.
  • Enhanced barrier precautions in nursing homes: wear gown and gloves during high-contact care (bathing, dressing, transferring, toileting, changing linens, device and wound care) for residents with an MDRO infection or colonization, a chronic wound or an indwelling device; the resident is not confined to the room.
  1. In practiceA client with diarrhea positive for C. difficile is in a private room on contact precautions. The nurse wears a gown and gloves for all care, uses dedicated equipment such as a stethoscope, and washes hands with soap and water on leaving the room, because alcohol rub does not remove the spores.
  2. Where questions turnChoosing alcohol hand rub after C. difficile care, or a surgical mask instead of a fit-tested N95 respirator for tuberculosis, measles or varicella.
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2Keep the client from getting hurt

  • Assess fall risk on admission, after any change in condition, after a transfer and after a fall, using the agency's validated tool.
  • Universal fall measures: bed in the lowest position with wheels locked, call light and personal items within reach, nonskid footwear, clear pathways, good lighting and a scheduled toileting plan for clients at risk.
  • After a client falls, stay with the client and assess for injury (airway, level of consciousness, pain, deformity) before moving them, call for help, notify the primary health care provider and complete a safety event report.
  • Seizure precautions: during a seizure, protect the head, turn the client to the side to keep the airway clear, loosen restrictive clothing, put nothing in the mouth, do not restrain, and time the seizure; keep oxygen and suction ready at the bedside.
  • Prevent burns and other injuries: check bath water and heat application temperature, inspect skin under devices and reposition clients who cannot move themselves to prevent pressure injury.
  1. In practiceAn older adult on a medical unit is found sitting on the floor beside the bed. The nurse stays with the client, checks responsiveness, pain and the limbs for deformity, and uses enough staff or a lift to return the client to bed only after injury is ruled out, because moving a client with a hip or spinal injury can worsen it.
  2. Where questions turnRaising all four side rails to prevent falls, which can act as a restraint and raises the risk of serious injury when a confused client climbs over them.
Practise this activity

3Check that a treatment order is correct and suitable

  • A complete prescription includes the client's name, date and time, the medication, dose, route, frequency and the prescriber's signature; an order for treatment states what, how and when.
  • Before carrying out any order, check it against the client's condition, allergies, current laboratory values and other prescriptions; an order that is unclear, incomplete or unsafe for this client is held and clarified with the prescriber.
  • The nurse who carries out an order is accountable for it, even when the prescriber wrote it; following an order known to be harmful is not a defense.
  • Read back verbal and telephone orders in full and have them signed per policy; use them only when a written or electronic order is not possible, such as in an emergency.
  • Avoid error-prone abbreviations and notations: write out unit and daily, never use a trailing zero (5 mg, not 5.0 mg) and always use a leading zero (0.5 mg, not .5 mg).
  • If the prescriber insists on an order the nurse believes is unsafe, do not carry it out; escalate through the chain of command (charge nurse, supervisor) and document.
  1. In practiceA client with heart failure has a prescription for furosemide 40 mg IV, and the morning potassium is 2.9 mEq/L (reference range 3.5 to 5.0 mEq/L). The nurse holds the dose and contacts the prescriber, because a loop diuretic will lower the potassium further and raise the risk of dysrhythmias.
  2. Where questions turnGiving a prescribed dose that does not fit the client's current findings because the order is valid on paper, instead of holding it and clarifying.
Practise this activity

4Handle hazardous and biohazardous materials by the set procedures

  • Discard sharps immediately into a puncture-resistant sharps container at the point of use; never recap a used needle (use the safety device), and replace the container when it reaches the fill line.
  • After a needlestick or splash, wash the area with soap and water (flush mucous membranes with water), report it at once and get a post-exposure evaluation, because post-exposure prophylaxis works best when started within hours.
  • Clean a blood or body fluid spill wearing gloves: absorb it, then disinfect with an approved disinfectant such as a diluted bleach solution, per policy.
  • Hazardous drugs such as chemotherapy: wear chemotherapy-tested gloves (often doubled) and an impermeable gown, dispose of waste in labelled hazardous containers, and handle the client's body fluids with precautions for the period the agency sets.
  • Radiation safety uses time, distance and shielding; wear a dosimeter badge, and if a sealed radioactive implant is dislodged, pick it up with long-handled forceps and place it in the lead container, never with hands.
  • Check the Safety Data Sheet (SDS) for how to handle, store and clean up any hazardous chemical.
  1. In practiceA nurse caring for a client with a sealed cervical radiation implant finds the implant in the bed linen. The nurse uses the long-handled forceps kept in the room to place it in the lead container and notifies the radiation safety officer, because touching the source exposes the nurse to radiation.
  2. Where questions turnRecapping a used needle with two hands, or picking up a dislodged radioactive source by hand.
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5Follow the facility's security procedures, for example for infant safety or violence

  • Newborn security: the parent and newborn wear matching identification bands, checked every time the infant is brought to the parent; staff wear visible photo identification, and the parent is taught to hand the infant only to staff with that identification.
  • Move a newborn in the hospital in a bassinet, never carried in arms through hallways, and never leave the infant unattended.
  • Know the early signs of escalating violence (pacing, clenched fists, raised voice, threats); keep a clear exit path, keep a safe distance, use a calm voice and call security early.
  • Controlled access: badge entry to restricted units, never hold a secured door for someone you do not know, and challenge or report an unidentified person.
  • For a bomb threat by phone, keep the caller talking, note every detail and notify per protocol; never touch a suspicious package; if a newborn or client is missing, activate the facility's code at once.
  1. In practiceA person wearing scrubs comes into a postpartum room and says the baby needs to go to the nursery for a test. The parent was taught to check for the unit's photo identification badge and refuse to hand over the infant without it, and the nurse confirms with the parent that no test was ordered and alerts security.
  2. Where questions turnHanding an infant to someone because they wear scrubs, without checking the unit's photo identification.
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6Apply good body mechanics and ergonomics while giving care

  • Use a wide base of support, bend at the hips and knees rather than the waist, keep the load close to the body and tighten the abdominal muscles.
  • Avoid twisting: turn by pivoting the feet, and face the direction of movement.
  • Raise the bed to a working height near the nurse's waist before giving care, and lower it again when finished for the client's safety.
  • Slide, roll, push or pull rather than lift; use friction-reducing sheets to reposition clients in bed.
  • Use safe patient handling equipment (mechanical lifts, sit-to-stand devices) and enough staff for clients who cannot bear weight or help; body mechanics alone do not make manual lifting of a dependent adult safe.
  1. In practiceA client who cannot bear weight after a stroke needs to move from bed to chair. The nurse uses a full-body mechanical lift with a second staff member rather than lifting the client manually, because manual lifting of a dependent adult causes back injuries in staff and falls in clients.
  2. Where questions turnRelying on good body mechanics to lift a totally dependent client manually instead of using a mechanical lift.
Practise this activity

7Admit to and record errors and near misses in practice

  • After an error, the first priority is the client: assess the client, take steps to limit harm and notify the primary health care provider.
  • Document in the client's record only the facts: what was given or done, the assessment findings, who was notified and the interventions and the client's response.
  • Complete a safety event (incident or occurrence) report per policy; it is a quality improvement tool, is not part of the client's record and is not mentioned in the chart.
  • Report near misses (errors caught before they reached the client) as well, because they reveal system weaknesses before harm occurs.
  • A just culture focuses on fixing systems and supporting honest reporting rather than blaming individuals; disclose errors to the client per agency policy.
  1. In practiceA nurse realizes a client received 10 units of insulin instead of the prescribed 4 units. The nurse checks the client's blood glucose and condition, notifies the prescriber, follows the orders for monitoring, records the facts in the chart, and completes a safety event report without referring to it in the record.
  2. Where questions turnWriting 'incident report completed' in the client's record, or filing the report before assessing the client.
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8Confirm the client's identity correctly before giving care

  • Use at least two client identifiers, such as full name and date of birth or medical record number, before giving medications or blood, collecting specimens or doing procedures; a room or bed number is never an identifier.
  • Ask the client to state their name and date of birth (an open question) and compare them with the identification band and the medication record or order; do not ask 'Are you Mr. Lee?'
  • Label specimen containers at the bedside, in the client's presence, right after collection.
  • Before a blood transfusion, two qualified staff verify the client's identity and the blood product against the order, per policy.
  • Before an invasive procedure, a time-out confirms the right client, procedure and site with the whole team; a client without an identification band gets one before nonemergency care.
  1. In practiceA client on a busy unit has just been moved to a different room. Before giving a medication, the nurse asks the client to state their full name and date of birth and checks both against the band and the medication administration record, because names and rooms change and a confused client may answer yes to any name.
  2. Where questions turnIdentifying a client by room number or by asking a yes or no question about their name.
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9Make sure equipment is used correctly and safely

  • Inspect equipment before use: intact cords, three-prong grounded plugs and a current safety inspection tag; do not use equipment that sparks, smokes or is damaged.
  • Take faulty equipment out of service, label it and report it to biomedical engineering per policy; do not try to repair it yourself.
  • When an alarm sounds, assess the client first, then the equipment; never silence or turn off an alarm without finding the cause.
  • Use infusion pumps with dose error reduction software as intended, and check the rate, the solution and the line at the start of the shift and with every change.
  • If a client is receiving an electrical shock, turn off or disconnect the power before touching the client; around oxygen, no open flames or smoking, and use only safe electrical devices.
  1. In practiceA cardiac monitor alarms for a client and shows a flat line. The nurse looks at the client first and finds them talking with a lead detached, then reattaches the lead, because an alarm is treated as real until the client has been assessed.
  2. Where questions turnSilencing or adjusting an alarm before assessing the client.
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10Teach the client about risks to their safety

  • Fall prevention at home: remove throw rugs and clutter, add night lights and good lighting, install grab bars and handrails, and wear well-fitting nonskid footwear.
  • Install smoke detectors and carbon monoxide detectors, test them regularly and have a home escape plan.
  • Prevent poisoning: keep medications and chemicals in their original containers, locked and out of children's reach, and keep the poison control number handy.
  • Prevent scalds by setting the hot water heater to 120 F (49 C) or lower; store firearms unloaded and locked, with ammunition stored separately.
  • Home oxygen: no smoking or open flames near the oxygen, post no-smoking signs, keep the tank upright and away from heat sources.
  • Confirm learning with teach-back (the client explains it in their own words) or return demonstration, not by asking 'Do you understand?'
  1. In practiceAn older adult with poor vision is going home after a hip fracture repair. The nurse teaches the client and family to remove loose rugs, add night lights between the bedroom and bathroom and install bathroom grab bars, then asks the client to describe the changes, because most falls happen in the home.
  2. Where questions turnAccepting 'yes, I understand' as proof of learning instead of using teach-back or return demonstration.
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11Take part in planning for and responding to emergencies

  • Fire: RACE, in order: Rescue clients in immediate danger, Alarm (activate it), Contain the fire by closing doors and windows, then Extinguish if the fire is small or Evacuate.
  • Fire extinguisher: PASS: Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side.
  • Evacuate those in immediate danger first, then usually ambulatory clients, then those in wheelchairs, then those confined to bed, moving horizontally past fire doors before going down stairs; do not use elevators in a fire.
  • Mass casualty triage does the greatest good for the greatest number: red (immediate: life-threatening but survivable, such as airway compromise or uncontrolled bleeding), yellow (delayed: serious but stable), green (minor: walking wounded), black (expectant or dead).
  • During a disaster, the nurse identifies stable clients who can be discharged or transferred safely to free beds, and follows the facility's emergency operations plan and assigned role.
  1. In practiceA nurse sees smoke coming from a client's room. The nurse removes the client from the room first, activates the alarm, closes the door to contain the smoke and then uses an extinguisher only if the fire is small, because rescuing the client comes before fighting the fire.
  2. Where questions turnFighting the fire or pulling the alarm before rescuing a client in immediate danger, or tagging a client unlikely to survive as red in a mass casualty.
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12Meet the rules that govern restraint use

  • Try the least restrictive alternatives first (reorientation, a sitter, bed or chair alarms, diversion, treating pain or need to void) and use a restraint only when the client is a danger to self or others and alternatives have failed.
  • A restraint requires an order from the primary health care provider or other authorized practitioner after a face-to-face assessment; it is time-limited and renewed per law and policy, and never ordered as needed (PRN).
  • In an emergency the nurse may apply a restraint to prevent immediate harm and must obtain the order promptly, per policy.
  • Tie a restraint to the movable part of the bed frame with a quick-release knot, never to a side rail, and check that two fingers fit under it.
  • Monitor often for circulation, skin, breathing and comfort; release regularly (commonly every 2 hours) for range of motion, skin care, toileting, fluids and nutrition; document behavior, alternatives tried and the client's response.
  • Restraints are never used for staff convenience or as punishment, and are removed as soon as the client is safe.
  1. In practiceA confused client keeps pulling at a nasogastric tube despite reorientation and a family member at the bedside. After the prescriber assesses the client and writes a time-limited order for mitt restraints, the nurse applies them, checks circulation and skin, and removes them regularly for care, because a restraint must be the last option and closely monitored.
  2. Where questions turnTying a restraint to the side rail or accepting a PRN restraint order.
Practise this activity

13Teach clients and staff how to prevent infection

  • Teach hand hygiene: soap and water for at least 20 seconds when hands are visibly dirty, alcohol-based rub otherwise, before eating and after using the toilet.
  • Teach respiratory hygiene: cover coughs and sneezes with a tissue or the elbow, throw tissues away and clean hands; offer a mask to a coughing client in a waiting area and seat them apart from others.
  • Teach visitors how to don and remove the PPE posted for the client's precautions, and ask ill visitors to stay home.
  • For a client with neutropenia: hand hygiene, avoiding crowds and people who are ill, food safety, and avoiding tasks such as cleaning litter boxes or bird cages.
  • Antibiotics treat bacterial, not viral, infections; teach clients to take the full course as prescribed and never share or save antibiotics.
  • Staff protect clients by staying home when ill, keeping vaccinations current, including annual influenza vaccine, and following hand hygiene and precautions.
  1. In practiceA client starting chemotherapy has a low neutrophil count and asks about going to a family gathering. The nurse teaches the client to avoid crowds and anyone who is ill, to clean hands often and to report a temperature of 100.4 F (38 C) or higher right away, because infection can become life-threatening when neutrophils are low.
  2. Where questions turnTeaching a client to stop antibiotics once they feel better, or that antibiotics will treat a cold.
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14Check the client for allergies and act on what you find

  • Ask about allergies to medications, foods, latex and contrast before giving any medication, blood or contrast, and ask what reaction happened, to tell a true allergy from a side effect or intolerance.
  • Record allergies in the record and apply an allergy band per policy; check them again before every new medication.
  • Anaphylaxis: stop or remove the trigger (stop the infusion), call for help, maintain the airway and give epinephrine intramuscularly in the anterolateral thigh as the first medication; oxygen, IV fluids, antihistamines and corticosteroids are added after.
  • Latex allergy: provide a latex-free environment and equipment; clients with latex allergy may react to banana, avocado, kiwi and chestnut.
  • A prior reaction to contrast media must be reported to the provider before an imaging study; a seafood allergy alone is not a reason to withhold iodinated contrast, but it is still recorded and reported.
  1. In practiceTen minutes into an IV antibiotic, a client reports throat tightness and develops hives and wheezing. The nurse stops the infusion, calls for help, keeps the airway open and gives epinephrine intramuscularly as prescribed, because epinephrine reverses the airway swelling and hypotension of anaphylaxis.
  2. Where questions turnGiving an antihistamine first in anaphylaxis instead of epinephrine.
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15Report or escalate unsafe staff practice, such as impairment or poor care

  • The nurse's duty is to the client: intervene at once if a colleague's action puts a client in immediate danger, then report it.
  • Signs of possible substance misuse in staff include frequent wastage, controlled substance count discrepancies, clients reporting unrelieved pain on that nurse's shift, frequent absences from the unit and changes in behavior.
  • Report suspected impairment or unsafe practice to the charge nurse or supervisor through the chain of command; do not investigate or confront the colleague alone, and do not cover for them.
  • If an assignment seems unsafe, raise the concern with the charge nurse and document it per policy (for example an assignment despite objection form); leaving after accepting an assignment without a handoff is abandonment.
  • When assistive personnel provide improper care, stop the unsafe action, ensure the client is safe, then give feedback and report per policy; reporting to the regulatory body follows the jurisdiction's law.
  1. In practiceA nurse notices that a coworker often wastes opioids without a witness and that the coworker's clients report pain relief that does not last. The nurse reports the pattern to the nurse manager rather than confronting the coworker, because the manager can review the records and protect clients while the colleague is assessed.
  2. Where questions turnConfronting the colleague privately or waiting for more proof instead of reporting through the chain of command.
Practise this activity

16Check the client's surroundings for safety

  • At the start of the shift, look at the room: clear floors and pathways, spills wiped up, adequate lighting, call light in reach and bed low and locked.
  • Check emergency equipment needed for this client at the bedside and working: suction and oxygen for a client at risk of seizure or aspiration, a tracheostomy kit with an obturator for a client with a tracheostomy.
  • For a client at risk of suicide, remove items that can be used for self-harm: cords, belts, plastic bags, sharps and medications.
  • Check that the isolation sign and PPE supplies match the client's precautions, and that equipment is clean and in working order.
  • Consider noise, temperature and privacy, which affect rest, comfort and confidentiality.
  1. In practiceA nurse receives a client after a thyroidectomy. The nurse checks that suction, oxygen and a tracheostomy tray are at the bedside and working, because swelling or bleeding at the neck can obstruct the airway suddenly.
  2. Where questions turnAssuming the room is safe after handoff instead of checking the environment and emergency equipment personally.
Practise this activity

17Support the safety of staff and the workplace

  • Workplace violence is never part of the job: use de-escalation, keep an exit path, know the panic button and code, call security early and report every incident.
  • Wear a breakaway lanyard and avoid necklaces or items a client could grab.
  • Use sharps with safety devices, receive hepatitis B vaccination and other recommended vaccines, and have a respirator fit test before first use and on the schedule the employer sets.
  • Home and community visits: share the schedule with the agency, assess the setting on arrival and leave if it becomes unsafe.
  • Report fatigue, unsafe staffing and hazards through the proper channels; take breaks, because fatigue leads to errors and injuries.
  1. In practiceDuring a home visit, the nurse hears shouting and sees a family member holding a weapon. The nurse leaves at once, goes to a safe place, calls the police and the agency and documents the event, because staff safety comes first and the visit can be rescheduled with an escort.
  2. Where questions turnStaying alone with an escalating or threatening person to finish care instead of leaving and calling for help.
Practise this activity

Key terms

Standard precautions
Infection prevention practices used for every client, treating all blood, body fluids, nonintact skin and mucous membranes as potentially infectious.
Contact precautions
Gown and gloves for any contact with the client or environment, used for organisms spread by touch such as MRSA and C. difficile.
Droplet precautions
A surgical mask within close contact for organisms spread in large respiratory droplets, such as influenza and pertussis.
Airborne precautions
A fit-tested N95 or higher respirator and an airborne infection isolation room with negative pressure, for tuberculosis, measles and varicella.
Enhanced barrier precautions
Gown and gloves during high-contact care of nursing home residents with an MDRO, a chronic wound or an indwelling device.
Near miss
An error caught before it reached the client; reported so the system can be fixed.
Safety event report
A confidential quality improvement report of an error or hazard, kept out of the client's record (also called an incident or occurrence report).
Two identifiers
Two client-specific details, such as name and date of birth, checked before care; never a room number.
Time-out
A pause by the whole team before a procedure to confirm the right client, procedure and site.
RACE
The fire response: Rescue, Alarm, Contain, Extinguish or Evacuate.
PASS
Using an extinguisher: Pull, Aim at the base, Squeeze, Sweep.
Restraint
Any physical or chemical means that limits a client's freedom of movement; needs an order, alternatives first and close monitoring.
Mass casualty triage
Sorting many victims so the greatest number survive: red immediate, yellow delayed, green minor, black expectant.
Chain of command
The order of authority used to escalate a concern: charge nurse, then supervisor or manager, and upward.

After this guide: After this guide you should be able to choose the correct precaution and PPE sequence, keep clients safe from falls, errors, hazards and unsafe practice, and act in the right order in emergencies.

Practise Safety and Infection Prevention and Control