asepsis and infection control
The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?
"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."
The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required?
"I can leave my room any time I want as long as I wear a mask."
The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?
"This antibiotic is the best choice since the causative organism is not known."
A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:
"You may have infection in your birth canal that you are unaware of."
A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?
1500 Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest.
After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter?
Alcohol-based hand rub
which client presents the most significant risk factors for the development of a c dif infection
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Two common factors that increase a persons risk of becoming infected with C difficle are age greater than 65 and current or recent use of antibiotic
About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?
Avoid contact with mosquitoes
The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?
Don another pair of sterile gloves.
The nurse reviews principles of infection prevention during yearly safety training. Which action(s) would the nurse use as an example of safe practice? Select all that apply.
Donning gloves and gowns as a substitute for handwashing in some circumstances Sterilizing any item entering the vascular system
Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.
During some care activities for an individual client, nurses may need to change gloves more than once. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract
An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?
Exogenous healthcare-associated The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.
A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply.
Hepatitis B Hepatitis C HIV
A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?
Migration of leukocytes to the area of the wound During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation. Antibody production is characteristic of the immune response to infection.
The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply.
Nonsterile gloves Hand hygiene
The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply.
Pain with redness and swelling Localized heat Purulent or malodorous drainage
The nurse is caring for a client with full-thickness (third-degree) burns. What aseptic intervention(s) would the nurse implement for this client when admitted to the general medical unit? Select all that apply.
Place the client in a private room with protective isolation. Instruct all staff, the client, and family members to practice strict and meticulous hand washing. Restrict visitors to family members who are not ill.
The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply.
Redness Swelling Pain Exudate
Which should be documented by the nurse?
The fact that sterile technique was used for a given procedure
The charge nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction?
The new nurse drops the item from the wrapper into the side of the sterile field.
The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands soap and water? Select all that apply.
The nurse is going from one room to another to introduce self at the start of the shift. The nurse has entered the client room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client room.
A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles?
The nurse removes her gown and then removes her gloves.
A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply.
The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field
which guideline is accurate for using transmission based precautions when caring for a client with MRSA
Wear gloves whenever entering the client's room
A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?
Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.
The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?
be sure that there are gloves of various sizes and gowns for use
The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?
contact
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?
contact precautions VRE is transmitted via contact. The nurse caring for a client with VRE should implement contact precautions which is wearing a gown and gloves while in the client's room. Droplet precautions include wearing a surgical mask while in the room. Special masks for airborne precautions are used for, but are not limited to: measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis. Standard precautions are used with all clients.
The school nurse is educating a group of teenagers about ways in which human immunodeficiency virus (HIV) can be transmitted. Which methods of infection transmission will the nurse educate the group about? Select all that apply.
contact with blood via sexual contact contact with wound openings via mucous membranes via syringes shared between the client and others
The nurse is caring for an older adult with influenza. Which precautions will the nurse begin?
droplet
The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin?
droplet
The nurse is admitting a client to the unit who needs frequent airway suctioning. Which precautions will the nurse select for the client?
droplet Droplet precautions are selected because microorganisms exit the body during coughing, sneezing, and procedures such as suctioning. Airborne precautions are not used, because droplets do not remain suspended in air. The other answers are incorrect.
Personal protective equipment for use with standard precautions includes which items? Select all that apply.
face mask disposable gloves eye protection fluid-repellent gown
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
hand washing Hand washing technique is the single most important procedure in reducing the spread of microorganisms from either the client to the surroundings or the surroundings to the client
which nursing action is a component of medical sepsis
handwashing after removing gloves Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood).
A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?
has manicured nails that are 1-in. (2.5-cm) long
The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply.
infectious disease communicable disease contagious disease
The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense?
intact skin and mucous membranes
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease
The nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent clients from getting the infection?
perform meticulous hand hygiene and don a new mask with each client encounter Hand hygiene alone will not control transmission of the infection. All clients are at risk for infection, not just those who are immune compromised. The window for being contagious varies dependent on the microorganism. The absence of a fever is not always an indication that the microorganisms can't be transmitted. Gloves are not specifically needed if hand washing procedures are followed with each contact.
The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?
remind the student that a fitted N95 respirator is required
The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?
remove gloves, remove gown, wash hands
The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?
to eliminate disease-producing organisms from the nurse's skin
most common client site for development of healthcare associated infections
urinary tract
Which factor has contributed to resistant microbial strains?
use of antibiotics in clients with viral infections