Ch 24 prepu
A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?
"All visitors who enter the room must wear N95/surgical masks."
The nurse is caring for a postpartum mother who delivered her second child yesterday. The mother states that her older child has just been diagnosed with chickenpox. She is concerned that her newborn will develop the disease. What is the best response by the nurse?
"Have you had chickenpox?"
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 on droplet precautions should only leave the room when necessary and wear a mask. The nurse should limit the client's movement outside the room. Visitors should remain 3 feet (1 meter) from the client. Anything that enters the isolation room should remain until discharge. Any staff who enters the room will wear PPE.
A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful?
"I will obtain a mask from the staff and wash my hands before touching my family member."
The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.
"If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus to my child during pregnancy and childbirth." "I may transmit the virus if I share needles with another person."
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 nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?
place the specimens into plastic biohazard bags
A nurse assessing a client with an injured ankle observes edema and pus formation around the injury. Which of the following are systemic responses to inflammation? Select all that apply.
presence of fever and fatigue loss of appetite presence of aches in muscles
A woman has moved from the east coast to the west coast. She is a single parent of four children who is having difficulty finding employment due to a lack of a car and primarily speaking an uncommon language for the area. Which factor is a barrier to health care?
primary language other than the dominant one
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
Which piece of personal protective equipment (PPE) should be removed first?
Gloves
The nurse is caring for a client that is suspected of having a latex allergy. What item of personal protective equipment should the nurse use with caution?
Surgical masks
A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:
Survival adaptation
A nursing instructor is preparing a class about the different types of white blood cells. Which of the following would the instructor include as agranulocytes? Select all that apply.
T lymphocytes Monocytes
A client is in the fever phase. His temperature remains significantly elevated. The nurse is preparing to implement sponge bathing. Which type of water would the nurse most likely use?
Tepid water Tepid baths or sponging are used for febrile clients when temperature reaches elevated levels. Tepid water is used to prevent chilling, which would trigger the shivering mechanism.
The charge nurse observes the licensed practical nurse (LPN) removing personal protective equipment (PPE). Which action by the LPN warrants intervention from the charge nurse?
The LPN removes the mask by untying the top of the mask first. The face mask should be untied at the bottom first. This helps to prevent the top of the mask from flopping forward and potentially exposing the nurses face to the dirty side of the mask. To remove PPE goggles appropriately, the nurse should handle them by the earpieces to lift away from the face. Gloves should be removed without touching the hand to prevent contaminating the skin. Gowns should be rolled into an inside out ball when removed to prevent exposure from contaminated surfaces of the gown.
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 is assigned to four clients who report elevated temperature. Based on their admitting diagnoses, the clients are at risk for developing infection. Which client should the nurse see first?
cancer client undergoing chemotherapy
The nurse is supervising a nursing student who will be performing wound care. During preparation of the sterile field, the nurse observes the student performing the action picture above. What is the nurse's best response?
commend the student's appropriate technique
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."
The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?
Assess client's pain level and manage pain accordingly.
The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct?
Touch the inside of the gown and pull it away from the torso.
The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?
Use a sterile intravenous catheter.
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
A nurse instructs a new mother on immunizations. An immunization produces:
active immunity
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
When describing the inflammatory response to a group of nursing students, what would the instructor most likely include as a local effect? Select all that apply.
Erythema Edema Pain
A 9-year-old client admitted for flulike symptoms has a high-grade fever of 104.2°F (40°C). Which intervention should the nurse perform first?
Give tepid sponge bath. Tepid baths and sponging are used for febrile clients when their temperature reaches seriously elevated levels. Do not give aspirin to children with flulike illnesses. The use of aspirin in such cases has been associated with Reye syndrome, a potentially fatal condition involving liver damage and encephalopathy. Hypothermia blankets are special blankets that can be used to reduce the temperature of the hyperpyrexic client. When cooling is desired, the blanket is usually set slightly lower than normal body temperature. A rectal probe is inserted to continuously monitor core body temperature so that excessive cooling does not occur.
The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?
Perform hand hygiene.
Which factor has contributed to resistant microbial strains?
use of antibiotics in clients with viral infections
A nurse is reviewing the laboratory test results of a client who is at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis?
3.2 mmol/L
The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing intervention(s)? Select all that apply.
facilitating interdepartmental coordination about the transport placing a clean sheet on the stretcher that the client will be transported upon ensuring that the client has a mask on reminding transporter to utilize droplet precautions
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? Select all that apply.
gloves gown mask with face shield
Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?
gown and gloves
The nurse is providing care to a client who is hospitalized for uncontrolled diabetes and performs the following activities. Which activity(ies) would it be recommended for the nurse to wear clean gloves? Select all that apply.
performing a fingerstick to check the blood glucose level administering subcutaneous insulin based on the glucose level
Nursing students are reviewing the different types of bacteria. The students demonstrate understanding of the information when they identify which of the following as Gram-positive bacteria? Select all that apply.
streptococci staphylococci
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.
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?
Surgical asepsis
A 70-year-old client with chronic obstructive pulmonary disease (COPD) has a respiratory infection being treated with antibiotics. He is also taking oral corticosteroids to assist in decreasing the inflammation in the lungs. The client is prone to:
superinfection. Drug therapy can cause defects in the host's response to infection. Steroids, chemotherapy, antimetabolites, and inappropriate or prolonged use of antibiotics can increase the risk of infection.
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
When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is:
universal precautions.
The most lethal infection in an older adult client is:
urinary. Urinary tract infections and respiratory infections are most common and most lethal for older adult clients.
Nursing students are reviewing information about healthcare-associated infections (HAI). What would the students expect to find as a possible risk factor? Select all that apply.
use of antibiotic therapy use of steroid therapy insertion of invasive devices multiple wounds
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift
An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate?
Standard
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 finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?
Disinfect it with alcohol swabs.
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.
A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter?
Keep hands lower than elbows to allow water to flow toward fingertips.
A nurse is reviewing the medical record of a client with a systemic infection. What would the nurse expect to find?
Loss of appetite Systemic responses include fever, fatigue, muscle aches, and loss of appetite. Erythema, edema, and warmth indicate a localized infection.
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 in the wound In many situations, clients with like infections can be placed together. The presence of similar causative microorganisms negates the risks of cross-contamination. Each of the other listed clients would encounter a risk for MRSA.
A client with an infection is experiencing prolonged, severe, shaking chills with a high fever. What may the nurse expect to administer to alleviate the shaking chills?
Meperidine Intravenous meperidine may be used in severe cases of prolonged shaking chills. Morphine sulfate, atropine and amiodarone are not used for this purpose.
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
The student nurse observes another nurse wash her hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium Difficile (C diff). Why is this behavior incorrect?
The bathroom is highly contaminated with the Clostridium difficile bacteria.
The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.
Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.
A nursing student comes to the university health center reporting a sore throat, malaise, and loss of appetite. The nurse assesses the student and determines she has large, white-yellow exudates in the back of the throat and a fever. The student is presenting with:
an infectious disease.
When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:
an older adult can have an infection without a fever.
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?
an older adult client with a history of heart failure
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 measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?
diligent handwashing practices
The nurse is admitting a client to the unit who needs frequent airway suctioning. Which precautions will the nurse select for the client?
droplet
The nurse is reviewing the urine analysis results for the client who is confused and agitated. Which lab result clearly indicates urinary tract infection.
pH of 8.5
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 preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply.
place a mask on the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet
When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do?
Obtain a new bottle of sterile saline.
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
The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?
handwashing
A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?
wash the area with soap and water
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.
A nurse is caring for a client, age 7 months, following surgical repair of a tracheoesophageal fistula. When collecting the client's vital signs, the nurse notes her rectal temperature to be 103.1°F (39.5°C). The nurse knows what to be true of fever in young children?
Young children often have a vigorous immune response to infection and thus high fevers.
The nurse in the health center is conducting assessment related to risk for infection on different age clients. Which clients are at higher risk of acquiring infection? Select all that apply.
a 45-year-old female who is allergic to flu vaccine a 5-month-old infant with low grade fever due to teething the 65-year-old male suffering from diabetic foot ulcer
The nurse is providing education to a senior circle group during an active flu season about the differences between viruses and bacteria. What statements made by the attendees indicates that the education has been effective? Select all that apply.
"There are some Immunizations that are available for select viruses. "There are some viruses that may be associated with cancers." "The virus enters the host cell's metabolism and replicates itself"
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
After assessing a client's temperature, the nurse documents that the client has a fever that is categorized as being high-grade. Which reading would the nurse most likely have obtained in this client?
39.2 degrees C A temperature elevation above 38.2C is considered a high-grade fever. A temperature greater than 40.5C is referred to as hyperpyrexia. A low-grade fever is a temperature that is slightly elevated, 37.1C to approximately 38.2C. A temperature between 35C and 36.8C is a subnormal temperature.
The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?
A= Assessment
A nurse's gloves became soiled while providing morning care for a client. Which action best demonstrates that the nurse applied principles of infection control?
After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.
What is an accurate guideline for removing soiled gloves after client care?
After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.
The nurse instructor is discussing the relation of early ambulation and infection control. Which response from the student indicates the need for further explanation?
All clients must ambulate as early as possible to avoid infection.
A nurse is preparing to obtain blood cultures from a client with an infection. Which action would be important for the nurse to do? Select all that apply.
Allow the tops of the culture bottles to dry after cleaning. Change the needle on the syringe containing the specimen before inoculating the culture bottles. Use two different venipuncture sites for the specimen collection.
A nurse is working with an 82-year-old man following gallbladder surgery. He is NPO. and has IV access in his hand. He also has a Foley catheter in place. He is able to ambulate with the aid of a walker. What does not lower this client's immunity?
Ambulation
The nurse is assigned to change the client's abdominal dressing after hernia repair. Which action will the nurse perform?
Change the dressing using sterile technique. The use of sterile technique during wound care prevents contamination of the wound and spread of infection. The nurse would not use aseptic technique to change a surgical dressing.
The nurse is caring for a client with human immunodeficiency virus (HIV) who currently has no signs or symptoms of the disease. Which important information about being an HIV carrier does the nurse teach the client?
HIV can be transmitted from an infected person to another person through blood, semen, vaginal fluids and breast milk.
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 nurse is adding a sterile solution to a sterile field and has just opened the bottle according to 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).
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.
Most healthcare-associated infections (HAI) involve which of the following systems?
Intravascular line
Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process? Select all that apply.
Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection
The nurse is performing wound care on a wound that tested positive for methicillin-resistant Staphylococcus aureus (MRSA). What is the most effective way for the nurse to apply the principles of infection control?
Perform hand hygiene after removing gloves
The nurse is preparing to provide wound care for a client who is on droplet precautions. Place the following steps in the correct order that the nurse should take. All options must be used.
Perform hand hygiene. Put on gown, with the opening in the back and tie gown securely at neck and waist. Apply mask with face shield, secure ties at the middle of the head and neck. Put on clean disposable gloves.
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.
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? Select all that apply.
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.
A client is having an open cholecystectomy and requires a saline irrigation. What action will reduce the spread of pathogens to the client and other clients?
Pour a small amount of solution out of the container prior to pouring it into the sterile basin.
The nurse is preparing to enter a client's room who is on airborne precautions. Which technique should the nurse use when wearing a nonparticulate respirator (N-95) mask? Select all that apply.
The mask covers the nose and mouth. Replace the mask after 20-30 minutes. Tie the upper strings of mask snugly against back head.
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 is creating a care plan for a client. Risk for Infection is the identified problem. Which situation supports this problem?
the client with a urinary catheter inserted at the emergency department
The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?
"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."
The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?
"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."
Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?
"These barriers help prevent the transmission of infection to you or other people."
On a preoperative surgical unit, as a standard of care, all clients are swabbed for methicillin-resistant Staphylococcus aureus (MRSA). Prior to his surgery, a nurse notes that a specific client's results have come back positive. the client ask the nurse what this means. What is the nurse's best response?
"These results indicate that you are colonized with MRSA."
A nurse is working with a 50-year-old woman status post liver transplant. She is on multiple immunosuppressive drug therapies, is intubated, and is NPO. with parenteral nutrition running through a central line. What would raise the nurse's suspicions that the client is developing septicemia? Select all that apply.
A WBC count of 15,000 with 12% bands temperature of 103.1°F (39.5°C) A temperature greater than 100.4°F (38°C) and a WBC count greater than 12,000 or less than 4,000 are signs of septicemia. Other signs include a heart rate greater than 90 bpm and a RR greater than 20 bpm, chills, confusion, lethargy, mottling, and decreased urine output.
Which client would the nurse consider the most infectious?
A client who is in the prodromal stage The client is most infectious during the prodromal stage of the illness. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the client often is unaware of being contagious. As a result, the infection spreads. The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the client's general condition. The signs and symptoms disappear, and the person returns to a healthy state.
Which term describes foreign particles that enter a host and stimulate the body's immune response?
Antigen
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.
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room
The nurse is caring for a client that requires a dressing change. When applying the principles of asepsis, what aspect of care should the nurse include?
Blood and body fluids are major reservoirs for microorganisms.
The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.
Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.
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 providing care for a client with varicella. What action should the nurse perform?
Ensure the client is housed in a negative pressure room. Varicella is an airborne disease requiring a negative air flow room. Airborne diseases such as varicella require an N95 mask to protect noninfected persons; a surgical mask is insufficient. Staff and visitors must use personal protective equipment but do not need to maintain a rigid buffer zone. Unless visibly soiled, hand hygiene can safely be performed with alcohol-based handrubs.
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
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
A nurse is applying the principles of standard precautions on a hospital unit. In which instances should the nurse perform hand hygiene? Select all that apply.
Immediately after touching a client After touching a client's surroundings Before performing a clean procedure
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
Infection control is foremost for all health care providers. Which example best interferes with the chain of infection?
Inform the family to avoid visiting the client while they are sick
The nurse is caring for a client who has an intravenous (IV) catheter in place with a saline lock. The nurse is preparing to change the dressing to the IV site. After reviewing the image, what should the nurse do next?
Obtain a new intravenous dressing change kit Once the dressing is contaminated, a new sterile dressing change kit must be obtained to avoid the transmission of infectious organisms to the intravenous site. Maintaining the effectiveness of clean technique (medical asepsis) and sterile contents depends on the effectiveness of both conscientious adherence to these guidelines by health care professionals. The other options do not adhere to medical asepsis. Harm to the client can result, due to an increase in the client's risk for an IV site infection.
A client is scheduled to receive an immune globulin. When explaining this to the client, the nurse integrates knowledge that this action results in which type of immunity?
Passive
The nurse assessing a client who had an elevated temperature 1 hour ago determines that the client is in the crisis phase of fever. What would lead the nurse to this conclusion?
Profuse diaphoresis The client will have profuse diaphoresis during the crisis phase of fever. Gooseflesh and shivering are evident during the chill phase. During the fever phase, the skin is warm and flushed, and the client feels general malaise.
The nurse is asked to check the unit's supply of personal protective equipment (PPE) to see if additional equipment needs to be ordered from central supply. The nurse should assess the level of which type of equipment? Select all that apply.
Protective eyewear Gowns Masks Nonsterile gloves
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. Only the outer 1 in (2.5 cm) of the sterile package is safe to touch. In this case, the nurse touches 1.5 in (4 cm), which is inside the sterile field. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body.
The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection?
Urine culture is positive for vancomycin-resistant enterococci (VRE).
The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply.
Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside. Slide the fingers of the ungloved hand between the remaining glove and the wrist. Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene.
After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply.
Used syringe with attached needle Used fingerstick lancet Injurious wastes include needles, scalpel blades, lancets, broken glass, pipettes and aerosol cans. Blood-soiled dressings or contaminated cotton-tipped applicators would be considered infectious waste. Chemotherapy solution containers would be considered hazardous waste.
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 admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?
contact precautions
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 a client who developed pneumonia while hospitalized. How will the nurse document this condition?
health care-associated infection (HAI)
The nurse is teaching a client the correct procedure for pouring a sterile solution. Which client action indicates the need for further education from the nurse?
holding the container off to the side
A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as:
iatrogenic.
To eliminate needlesticks as potential hazards to nurses, the nurse should:
immediately deposit uncapped needles into a puncture-proof plastic container.
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
The nurse is caring for a client who has been hospitalized and placed in airborne precautions for a week. Which nursing intervention is appropriate to provide sensory stimulation?
move the bed and furnishings to a different place in the room To promote sensory stimulation, move the bed and furnishings around in the room. The client cannot be transported outside without risking infecting others. Family and friends may not be able to visit more without exposing themselves to infection or bringing further infection to the client. Communicating only through the intercom is not appropriate, as the client will still need hands-on care as well.
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on infection.
The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as:
parasite.
A group of students is reviewing information about cellular and humoral immunity. The group demonstrates understanding of these concepts when they identify what as a function of cellular immunity?
reactivate if the same antigen reappears
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
A student nurse is attending a clinical rotation in the perioperative department and will be allowed to scrub in to observe. What observation made by the clinical instructor requires intervention before the student is allowed to attend the rotation? Select all that apply.
rings on finger artificial nails with intact clear nail polish red nail polish Artificial nails and nail polish are never appropriate and may introduce infection into a surgical wound. Nail polish may chip and enter into surgical wounds. Rings should be removed because they are a source of contamination from bacteria and other pathogens. Nail length of 1/2 inch (1.25 cm) beyond the nail bed or down to the nail bed is an appropriate length and is acceptable.
A client comes to the clinic for a visit. During the assessment, the client says that he felt terrible last week, and this week is a bit achy. Blood studies reveal evidence of antigens. The nurse interprets this as:
subclinical infection. When the body successfully resists being overwhelmed by infection, the condition is called "subclinical infection." Symptoms may be few, and the host may be unaware of exposure. Nevertheless, antigens form that can be recovered from the person's blood. Clinical disease refers to an obvious complex of symptoms. Colonization is the introduction of microorganisms onto a body surface, where they grow and multiply but do not invade the body or cause an immune response or symptoms. Secondary infection occurs when an infection develops in a weakened client.
A nurse is reviewing the white blood cell (WBC) count and differential of a client and notes that there is a significant shift to the left. The nurse interprets this as indicating:
the client has developed a bacterial infection. A shift to the left, or leftward shift in the granulocytic differential count, is considered a strong indicator of bacterial infection, not a viral infection. This shift occurs when an infection is severe or prolonged and the body cannot manufacture neutrophils quickly enough, resulting in the release of immature granulocytes into the blood. The greater the shift, the more worrisome the infection appears. When the proportion of neutrophils increases, the client's resistance is good and the body is considered to be fighting the infection well.
The charge nurse is working on client assignments for the incoming shift. A client with methicillin-resistant Staphylococcus aureus (MRSA) is assigned to a nurse. Which type of client should the charge nurse avoid assigning to the incoming nurse?
the client with cancer and with neutropenic precaution
A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the priority nursing action the nurse must perform before leaving the client's room?
thorough handwashing
The patient 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.
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 baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."
The nurse determines that which client is at greatest risk for a wound infection?
A two-day postoperative client he client at greatest risk for a wound infection is the two-day postoperative client, as the surgery disrupted the integrity of the skin, thereby increasing the risk for wound infection. Although older adult clients are at greater risk for infection, this client's skin is dry (versus having an open or surgical wound); thus, this client is at less risk than the postoperative client. An infant with intact skin is not at risk for a wound infection. A client with a urinary catheter is at risk for a urinary tract infection versus a wound infection.
A nurse has implemented numerous practices with the goal of reducing the number and transfer of pathogens. Which actions are consistent with this goal? Select all that apply.
Clean the least soiled areas first and then move to the more soiled ones. Use personal grooming habits, such as shampooing hair often, to prevent spreading microorganisms.
When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?
Cleanse and disinfect the sphygmomanometer.
A nurse is preparing to obtain an aerobic wound culture from a client's surgical site. What would be most important for the nurse to do to ensure that the results are accurate?
Clear exudate from around the wound. To ensure the most accurate results, it is important to remove any old drainage and microorganisms from the wound which could interfere with the report. Clean gloves are necessary. Irrigating with hydrogen peroxide would interfere with the results of the report. The culture medium ampule is crushed after the swab is reinserted into the culture tube, after obtaining the specimen.
Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?
Client receiving chemotherapy The nurse should determine that the client receiving chemotherapy is the client at greatest risk for VRE infection due to having a compromised immune system from the chemotherapy. Other risk factors for VRE include recent abdominal or chest surgery, presence of urinary or central IV catheter, prolonged antibiotic use (especially with vancomycin), and lengthy hospital stays (especially in an ICU).
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.
Which statement about neonatal development is accurate?
Neonates may have an infection without fever.
A nurse is preparing a class for a group of new parents about infections and infants. When reviewing the development of the infant's immune system, what would the nurse be least likely to include?
Newborns have little difficulty localizing infections.\ The immune system does not become fully operational until a baby reaches about 6 months of age (Shaw, Thalapial, Shaw, & Malla, 2007). Before then, the infant's resistance to infection comes from the antibodies passed by way of the placenta and breast milk. Newborns have difficulty localizing infections (preventing the spread of organisms from the site of contact). Their phagocytes have difficulty trapping microbes, and they do not produce enough antibodies. At this time viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.
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.
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 slides the item from the wrapper into the side of the sterile field. The nurse should hold the wrapped sterile item in the dominant hand and use the non-dominant hand to first open the top flap away from the body, then open both sides, and finally pull the remaining flap back toward the wrist and gather all corners of the wrapper back toward the wrist to cover the hand and wrist. The nurse should take care not to touch the inner surface of the wrapper or the sterile item. The sterile item should be held 6 inches above the surface of the sterile field and dropped onto the field. The nurse should be careful to avoid touching the surface or other items, or dropping any item onto the 1-inch border. This prevents contamination of the field and inadvertent dropping of the sterile item too close to the edge of or off the field. Any items landing on the 1-inch border are considered contaminated.
A nurse is preparing a sterile field for the health care provider to perform a biopsy on a client. Which actions follow recommended guidelines for maintaining the sterile field for this procedure? Select all that apply.
The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. The nurse discards a sterile field when a portion of it becomes contaminated. The nurse calls for help when realizing a supply is missing.
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
When explaining the inflammatory response to nursing students, the instructor describes a series of events. Place the events in the order in which the instructor would describe them.
tissue injury dilation of blood vessels plasma flow out of capillaries white blood cell migration to the area phagocytosis
Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.
airborne precautions droplet precautions contact precautions
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 caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client?
wearing a mask when working within 3 feet (1 m) of the client
The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin?
droplet
The client sustained a large skin tear to his arm while getting out of bed. He is concerned that it is now infected. Which manifestation shows infection?
enlarged axillary lymph nodes
Otitis media occurs in children because the:
eustachian tube is shorter and straighter.
A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts?
exit route
A client develops a fever. When assessing the client, the nurse determines that the client is in the crisis phase based on assessment of:
flushed skin
A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.
increased respiratory rate lymph node enlargement fever
A nurse is explaining the process of infection to a nursing student. Place the process in the most appropriate order.
infectious agent a reservoir an exit route transmission mode entry portal susceptible host
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
When developing a plan of care for a client who has developed neutropenia secondary to chemotherapy, which of the following would the nurse most likely include? Select all that apply.
placing the client in a private room having the client wear a mask when outside the room removing fresh flowers from the room
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
A client is receiving prescribed antibiotic therapy to treat an infection. On the fourth day of therapy, the client comes to the clinic and tells the nurse that she has developed a really sore mouth. After inspection, the nurse suspects that the client has developed a fungal oral infection. The nurse identifies this as:
superinfection. A superinfection is a secondary infection that occurs when antibiotics, immunosuppression, or cancer treatment destroy normal flora. Usually, superinfection appears 4 to 5 days after antimicrobial therapy begins. Superinfections commonly are fungal infections of the mouth or vagina. Bacteremia refers to the spread of bacteria through the bloodstream; endotoxins are potent poisons released by bacteria that can cause hemorrhagic shock when large amounts are released into the blood; healthcare-associated infection (HAI) refers to a hospital-acquired infection.
