Asepsis pt:2
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 admitted with tuberculosis. The client asks why the nurse wears a respirator, gown, and gloves whenever they are in the room. How should the nurse respond?
"Because of the tuberculosis, I need to follow airborne precautions for protection."
A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus?
"I probably got the virus when I sat on the toilet seat in a dirty bathroom."
A client with a localized inflammatory response asks the nurse why the area is reddened. Which response by the nurse would be most appropriate?
"It is the result of blood accumulating in the dilated vessels."
A client who has had repeated infections asks the nurse what he can do to improve his ability to resist infection. Which suggestion would be least appropriate for the nurse to give?
"Limit your intake of water each day to about 4 to 5 glasses."
A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?
"Stress leads to increased secretion of cortisol, which suppresses your immune response."
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."
Routine nasal and rectal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized with MRSA. The client is surprised at this finding, since he enjoys generally robust health. What should the client's nurse teach him about this diagnostic finding?
"This means that this organism in present on your skin, but it doesn't necessarily mean that you will become sick."
A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse?
"We are giving you broad spectrum antibiotics because they are active for many types of bacteria."
The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator?
"Wearing an N95 respirator is critical when I care for clients in droplet precautions."
The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?
"Your infant's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."
A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?
"Your white blood cells have increased in the area."
A nurse has finished giving care to a client who has a communicable respiratory infection. In which order should the personal protective equipment (PPE) be removed? 1. Gloves 2. Respirator 3. Gown 4. Goggles
1, 4, 3, 2
A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection?
18,000 cells/mm
The local high school has been exposed to methicillin-resistant Staphylococcus aureus (MRSA) infection and the school nurse is preparing an education plan on prevention of MRSA. Which steps should the nurse include?
20-second handwashing use of hand sanitizer when necessary keep draining wounds covered
In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.
5, 7, 2, 1, 3, 4, 6
Which client presents the most significant risk factors for the development of Clostridioides difficile infection?
81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
The medical nurse is caring for several clients who are receiving treatment for infection. Which client is most likely to be experiencing a healthcare associated infection (HAI)?
A client being treated for a Clostridium difficile infection
A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?
A commercially packaged surgical item is not considered sterile if past expiration date.
The nurse determines that which client is at greatest risk for a wound infection?
A two-day postoperative client
The nurse is speaking to the health care provider regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridioides difficile infection". Which part of the SBAR communication will this statement fall into?
A= Assessment
A client is fighting an infection because foreign particles have entered the client's body, stimulating an immune response. These foreign particles are described as what?
Antigens
A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area?
Area of active drainage
About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?
Avoid contact with mosquitoes
A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?
Avoid touching the outer surfaces of the gown.
A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes?
Basophils Neutrophils Eosinophils
Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?
Client receiving chemotherapy
The nurse is assigned to four clients who have varying risks for infection and who each have elevated temperature. Which client should the nurse see first?
Client who undergoing chemotherapy for the treatment of lung cancer
Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?
Client with a urinary catheter
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole
The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?
Create an area for sterile field and opening packages
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?
Decontaminate hands using an alcohol-based hand rub.
Which client goal related to infection control is a priority?
Demonstrate adequate knowledge on infection control.
When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?
Discard the bottle and get a new one because the saline has expired.
The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take?
Drop the item from 6 in (15 cm) above the sterile field.
Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?
Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.
The nurse is aware of the high incidence of healthcare-associated infections (HAI's) and should prioritize what action to prevent them?
Ensuring urinary catheters are only used when necessary and removed as soon as possible
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 Clostridioides difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?
Exogenous healthcare-associated
Which mask should the nurse don when caring for a client with tuberculosis?
Filtered respirator
Which nursing action is a component of medical asepsis?
Handwashing after removing gloves
A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to the manufacturer's directions. What is the next step?
Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm).
The nurse is caring for a client who is on neutropenic precautions following a bone marrow transplant. When applying infection control principles to this client's care, the nurse will perform what action?
House the client in a private room with a securely closing door
A nurse is inserting a male client's indwelling urinary catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he has brought the wrong-sized catheter to the bedside. What is the nurse's best action?
Illuminate the client's call light and have a colleague bring the correct catheter to the bedside
A nurse is administering a client's prescribed insulin subcutaneously. To reduce the risk of a needlestick injury after administration, which action should the nurse perform?
Immediately deposit the uncapped needle into a puncture-proof plastic container.
The nurse is caring for an older adult with pneumonia. What action by the nurse will help the client prevent further pulmonary infections?
Immunize the client with the pneumococcal vaccination once in a lifetime
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?
Incentivizing health care workers to utilize hand hygiene
Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.
Incubation period Prodromal stage Full stage of illness Convalescent period
A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?
Inform the health care provider about this finding.
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?
MRSA is in the wound
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
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?
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. During some care activities for an individual client, nurses may need to change gloves more than once.
The nurse is assessing a client who has symptoms consistent with an infection. When palpating the client's lymph nodes, what action should the nurse perform?
Palpate the side of the client's neck with three fingertips
An older adult client from a long-term care facility is being admitted to the hospital with an infected wound on the left foot. What action should the nurse perform upon admission related to the client's residential occupancy?
Perform a nasal swab to identify colonization with methicillin-resistant Staphylococcus aureus (MRSA).
An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?
Perform surgical hand scrub using detergent.
The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
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 is caring for a client with a latex sensitivity. Which resource would be most appropriate for the nurse to access when developing the client's plan of care?
Policy for clients with latex sensitivity
A nurse at the health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action(s) is appropriate by the nurse when using masks?
Position the mask so that it covers the nose and mouth. Avoid touching the mask once it is in place. Change the mask if it becomes damp. Touch only the strings of the mask during removal.
The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?
Pour the liquid into a sterile container within the sterile field.
The nurse is assigned to clean a client's wound before applying a sterile dressing. Which action by the nurse demonstrates maintaining a sterile field?
Pouring the sterile solution slowly from 6 in (15 cm) above the container.
During an interaction with a client who is HIV-positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period?
Prodromal period
Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?
Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)
What is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled.
The nurse is preparing a sterile field for a dressing change. How would the nurse add paper-wrapped sterile items to the sterile field?
Separate the sealed flaps and drop contents onto field.
A client with an intact immune system has been exposed to Mycobacterium tuberculosis, initiating a cellular immune response. This response will begin with what physiological process?
Stimulation of T lymphocytes
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?
T-lymphocytes
What assessment finding most clearly suggests that a client is experiencing the second line of defense to microbial invasion?
The client is experiencing inflammation
The nurse is caring for a client whose immunizations are several years out of date. What aspect of the client's health history would contraindicate the safe and effective administration of many vaccines?
The client is immunocompromised
A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?
The client's immune system became further weakened
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in (4 cm) from the outer edges.
A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles?
The nurse carries soiled items away from the body. The nurse moves soiled equipment away from the body when cleaning it. The nurse cleans least soiled areas first and then moves to more soiled ones.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene?
The nurse keeps fingernails less than 1/4 in (0.63 cm) long.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?
The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.
The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this nurse's action?
To remove disease-producing organisms from the nurse's skin
The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding confirms the client has developed an infection?
Urine culture is positive for vancomycin-resistant enterococci (VRE).
The nurse is preparing to insert a peripheral intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?
Use a sterile intravenous catheter.
A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?
WBC of 25,000 mcL
A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?
Wear gloves whenever entering the client's room.
The community nurse is educating a family about infection control measures. What teaching will the nurse include?
Wear personal protective equipment (PPE) when appropriate. Standard precautions should be used when family members have active infections. Do not share drinking glasses with family members who are ill. Keep the entire living environment as clean as possible.
The community nurse is educating a family about infection control measures. What teaching will the nurse include? Select all that apply.
Wear personal protective equipment (PPE) when appropriate. Standard precautions should be used when family members have active infections. Do not share drinking glasses with family members who are ill. Keep the entire living environment as clean as possible.
The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?
When hands are visibly soiled
The client was exposed to an infectious microorganism but did not develo a systemic infection because phagocytosis took place. What process took place during this response to microbes?
White blood cells ingested and destroyed microorganisms
Surgical asepsis is defined as:
absence of all microorganisms.
An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate?
airborne
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
airborne
Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)?
airborne precautions droplet precautions contact precautions
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
A client presents with a sore throat, malaise, and loss of appetite. The nurse assesses the client and identifies white-yellow exudates in the back of the throat and a fever. The nurse should ensure the primary care provider assesses the client for:
an infectious disease.
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria
The laboratory calls the nurse to report the client's white cell differential reveals a shift to the left. The nurse will assess the client for signs and symptoms of what medical diagnosis?
bacterial infection
The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection?
contact
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
The nurse is admitting a client who has a draining wound that is contaminated with methicillin-resistant Staphylococcus aureus. What type of precautions should the nurse initiate for this client?
contact precautions
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?
contact precautions
After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:
decreased cellular immunity
An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measure will the nursing staff implement to help prevent the spread of MRSA to clients who are currently negative for MRSA?
diligent hand hygiene
The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin?
droplet
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
After teaching a group of nursing students about the function of the various white blood cells, the instructor determines that the teaching was successful when the students identify which cell as being involved with allergic reactions?
eosinophils
When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)?
fold soiled side to the inside and roll with inner surface exposed
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?
fungi
A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to don PPE. Which would be appropriate?
gloves gown mask with face shield
The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?
handwashing
Which nursing action is a component of medical asepsis?
handwashing after removing gloves
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
A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?
helps to determine prescribed antibiotic therapy
The nurse is admitting a client who has been receiving prescribed antibiotics for pneumonia. The client reports experiencing loose, watery stools for the past 4 days. What would be the initial action for the nurse to take?
implementing contact isolation
A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses?
increased respiratory rate, lymph node enlargement, fever
The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?
inserting an arm within each sleeve while touching the outer surface of the gown
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 receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?
into a private room
A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?
intravenous antibiotic administration
The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?
keeping sterile field above waist level
The nurse has been collaborating with a colleague on a client's wound care, and the colleague is now removing gloves after completing the task. The nurse observes the colleague performing the above pictured action inside the client's room. What is the nurse's correct response?
no further action
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?
noncommunicable disease
The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as:
parasite
Any microorganism capable of disrupting normal physiologic body processes is a
pathogen
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?
perform hand hygiene before and after entering the client's room
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
The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse?
pouring the sterile solution from a height of 5 in. (13 cm)
A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?
prodromal
The school nurse performs frequent assessments of young school-aged children. Due to their high incidence and prevalence, the nurse should prioritize assessment for what types of infections?
respiratory
The nurse notes that the client's temperature is 101.2°F (38.4°C) at 8 a.m. Elevated temperature may be due to several factors. What could be the reason for this?
respiratory infection
are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease.
rickettsiai
A client is scheduled for an inguinal hernia repair and is concerned about the possibility of developing a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?
surgical asepsis
The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?
the client who is 48-hours postsurgical procedure
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
urinary catheter
Which factor has contributed to resistant microbial strains?
use of antibiotics in clients with viral infections
A team of nurses is caring for a client with tuberculosis. They have not been fitted for N95 respirators. How will the team proceed with care?
utilize a powered air purifying respirator (PAPR)
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
vehicle
Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?
virus
The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:
within normal limits/ A normal white blood cell count is 5,000 to 10,000 cells/mm3.