Chapter 24: Asepsis and Infection Control

A nurse is explaining the process of infection to a nursing student. Place the process in the most appropriate order. 1 a reservoir 2 susceptible host 3 an exit route 4 transmission mode 5 entry portal 6 infectious agent

infectious agent a reservoir an exit route transmission mode entry portal susceptible host

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? A.) "Wearing an N95 respirator is critical when I care for clients in droplet precautions." B.) "Masks, gloves, and gowns should be used to protect from infectious agents." C.) "It is important to refrain from recapping needles." D.) "I will always wash my hands thoroughly and often."

A.) "Wearing an N95 respirator is critical when I care for clients in droplet precautions" p. 613

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform? A.) Hold sterile objects above waist level to prevent accidental contamination. B.) Consider the outer 3-in edge of a sterile field to be contaminated. C.) Open sterile packages so that the first edge of the wrapper is directed toward you. D.) Consider the outside of the sterile package to be partially sterile.

A.) Hold sterile objects above waist level to prevent accidemtal contamination. p. 1392-1393

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? A.) Surgical asepsis B.) Medical asepsis C.) Universal precautions D.) Contact precautions

A.) Surgical asepsis p. 603

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? A.) into a private room B.) with a client with pneumonia C.) with a client with a myocardial infarction D.) with another client with a draining wound

A.) into a private room p. 615

Standard precautions apply to blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes. A.) true B.) false

A.) true p. 614

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: A.) reverse precautions. B.) universal precautions. C.) body-substance isolation. D.) droplet precautions.

B.) Universal precautions p. 617

Which client would the nurse consider the most infectious? A.) A client who is in the full stage of illness B.) A client who is in the incubation period C.) A client who is in the prodromal stage D.) A client who is in the convalescent period

C.) A client who is in the prodromal stage p. 600

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? A.) No action is needed. B.) Complete a sentinel event report. C.) Don another pair of sterile gloves. D.) Notify the primary care provider.

C.) Don another pair of sterile gloves. p. 633

A nurse is performing a venipuncture on a client and notices that there is a hole in one of the sterile gloves. What would be the appropriate action to take to maintain a sterile field? A.) Finish the procedure and perform handwashing immediately afterward. B.) Stop the procedure, remove damaged gloves, and open new sterile gloves. C.) Stop the procedure, remove damaged gloves, perform handwashing, and open new sterile gloves. D.) Finish the procedure, remove damaged gloves, and open new sterile gloves.

C.) Stop the procedure, remove damaged gloves, perform handwashing, and open new sterile gloves. p. 637 If a hole or tear is noticed in one of the gloves during the procedure, the nurse should stop the procedure, remove damaged gloves, wash hands or perform hand hygiene (depending on whether soiled or not), and put on new sterile gloves. Finishing the procedure after a break in sterility could cause an infection in the client. Handwashing is critical after removal of the damaged gloves to protect the nurse for blood and/or body fluids.

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? A.) Gowns B.) Pillows C.) Surgical masks D.) Goggles

C.) Surgical masks. p. 613 Surgical masks may contain latex. Pillows, goggles, and gowns likely do not contain latex. The nurse can order latex-free medical supplies, although most items in the acute care setting are latex-free including googles, pillows, and gowns.

What is the most common client site for development of healthcare-associated infections (HAI)? A.) Respiratory tract B.) Surgical wound C.) Urinary tract D.) Bloodstream

C.) Urinary tract p. 608

In which situation is an alcohol-based rub an inappropriate option for hand hygiene? A.) When the nurse leaves the room of an immunocompromised client B.) When the nurse is caring for a client with an active infection C.) When the nurse's hands are visibly soiled D.) When the nurse anticipates contact with the client's skin

C.) When the nurse's hands are visibly soiled p. 607

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. A.) 5, 2, 7, 1, 3, 4, 6 B.) 5, 1, 2, 7, 3, 4, 6 C.) 5, 3, 4, 7, 2, 1, 6 D.) 5, 7, 2, 1, 3, 4, 6

D.) 5, 7, 2, 1, 3, 4, 6 p. 633-637

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? A.) Human resources department B.) The emergency room charge nurse C.) The infectious disease nurse D.) Policy for clients with latex sensitivity

D.) Policy for clients with latex sensitivity p. 612

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? A.) make contact between two clean surfaces B.) make contact between two contaminated surfaces C.) remove the garments that are most contaminated D.) handwashing before leaving the client's room

D.) handwashing before leaving the client's room p. 604

Which piece of personal protective equipment (PPE) should be removed first? A.) Gloves B.) Respirator C.) Gown D.) Goggles

A.) Gloves p. 604

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? A.) contact B.) airborne C.) droplet D.) vehicle

A.) contact p. 599

An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate? A.) Contact B.) Standard C.) Airborne D.) Droplet

B) Standard p. 615 The nurse should implement standard precautions, as these precautions are appropriate for all hospitalized clients. There is no indication that additional precautions such as airborne, droplet, or contact precautions are needed at this time.

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? A.) wearing a face mask when entering and staying at a distance from the client B.) placing the client in a regular, private room C.) wearing a particulate respirator for all client care and interaction D.) wearing protective eye wear for all client contact

C.) wearing a particulate respirator for all client care and interaction p. 615

which piece of personal protective equipment should be removed first? A.) Gown B.) Respirator C.) Goggles D.) Gloves

D.) Gloves p. 604

A nurse is caring for four clients. Which client has the highest risk of infection? A.) young woman with a history of scoliosis B.) woman in second trimester of pregnancy C.) toddler with a benign heart murmur D.) older male with an enlarged prostate

D.) older man with an enlarged prostate p. 601

convalescent period

The convalescent period involves the recovery from the infection. The signs and symptoms disappear, and the person returns to a healthy state. However, there may be a temporary or permanent change in the patient's previous health state even after the convalescent period.

incubation period

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.

Full stage of illness

The presence of infection-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 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)? A.) remove gloves, wash hands, remove gown B.) remove gown, wash hands, remove gloves C.) remove gloves, remove gown, wash hands D.) remove gown, remove gloves, wash hands

D.) remove gown, remove gloves, wash hands p. 639

prodromal stage

A person is most infectious during the prodromal stage. Early signs and symptoms of disease are present, but these are often vague and nonspecific. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection spreads to other hosts.

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? A.) "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." B.) "We only wash our hands when they are visibly soiled." C.) "Washing the hands with soap and water is not necessary." D.) "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene."

A.) "Alcohok-based hand rub provides the greatest reduction in microbial counts on the skin." p. 605

The nurse observes a colleague putting on a gown and mask while preparing to care for a client with bacterial meningitis. What is the nurse's most appropriate statement to the colleague? A.) "Don't forget to put on your gloves." B.) "We don't actually need to wear a mask." C.) "We'll need to wear N95 masks, not surgical masks." D.) "You also need to wear goggles and gloves."

A.) "Don't forget to put on your gloves p. 615 Bacterial meningitis is a diagnosis that requires droplet precautions. That is, nurses must wear a gown and gloves as well as a mask. In most cases, a surgical mask is sufficient and an N95 mask is not necessary. Goggles are not required.

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. A.) "The virus enters the host cell's metabolism and replicates itself" B.) "I can take an antibiotic to eradicate a viral infection ". C.) "Viruses are not as harmful as bacteria." D.) "There are some Immunizations that are available for select viruses. E.) "There are some viruses that may be associated with cancers."

A.) "The virus enters the host cell's metabolism and replicates itself" D.) "There are some Immunizations that are available for select viruses." E.) "There are some viruses that may be associated with cancers." p. 597, 598 A virus invades a living cell many times its size, uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup. Viruses cause AIDS, chickenpox, colds, cold sores, encephalitis, hepatitis, herpes, HPV, influenza, measles, mononucleosis, mumps, polio, rabies, shingles, pneumonia, and many other diseases. They have been associated with some cancers and leukemias and with many autoimmune diseases. Viruses may be just as harmful as bacteria since there is not an effective treatment for a virus.

The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response? A.) "When your sputum culture is negative." B.) "Until you leave the hospital." C.) "Only until you begin to feel better." D.) "For 2 days as you get settled onto the unit."

A.) "When your sputum culture is negative." p. 615

Which client would require a negative flow room? A.) an 81-year-old man with active tuberculosis and a productive cough B.) a 21-year-old man with latent tuberculosis who is postoperative following repair of a femoral fracture C.) a 3-year-old with influenza A and a productive cough D.) a 4-year-old boy with meningitis

A.) An 81-year-old man with active tuberculosis and a productive cough p. 615 Active tuberculosis always requires a negative flow room.

A nurse at health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action is appropriate by the nurse when using masks? Select all that apply. A.) Avoid touching the mask once it is in place. B.) Discard used masks into a regular wastebasket. C.) Touch only the strings of the mask during removal. D.) Change the mask every 20 or 30 minutes. E.) Position the mask so that it covers the nose and mouth.

A.) Avoid touching the mask once it is in place C.) Touch only the strings of the mask during removal.. D.) Change the mask every 20 or 30 minutes. E.) Position the mask so that it covers the nose and mouth. p. 612 The nurse should avoid touching the mask once it is in place because touching the mask transfers microorganisms to the hands. The mask should be changed every 20 or 30 minutes or when it becomes damp, to preserve its effectiveness. The nurse should touch only the strings of the mask during removal to prevent transfer of microorganisms to the hands. The mask should be positioned over the nose and the mouth to provide a barrier to nasal and oral ports of entry. The nurse should discard used masks into a lined or waterproof waste container and not a regular wastebasket.

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? A.) Blood and body fluids are major reservoirs for microorganisms. B.) All nonsterilized surfaces are considered to be equally contaminated. C.) It is impossible to completely eliminate microorganisms from an object. D.) Visibly clean objects are considered to be sterile.

A.) Blood and body fluids are major reservoirs for microorganisms. p. 615 Blood, body fluids, cells, and tissues are considered major reservoirs of microorganisms. Visible cleanliness is not synonymous with sterility, though it is possible to sterilize (eliminate microorganisms from) certain objects. Nonsterilized objects are considered contaminated, but some objects and areas are considered to be more contaminated than others.

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse? A.) Discard the supplies and field and prepare a new sterile field. B.) Educate the client on sterile fields and continue preparing for the procedure. C.) Give the client the water pitcher and continue preparation. D.) Remove the supplies from the field and replace with new supplies.

A.) Discard the supplies and field and prepare a new sterile field. p. 633

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? A.) Escherichia coli in the intestinal tract B.) Shigella in the intestinal tract C.) Shigella in the urinary tract D.) Escherichia coli in the urinary tract

A.) Escherichia coli in the intestinal tract p. 598

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. A.) HIV B.) Hepatitis B C.) Hepatitis C D.) Tuberculosis

A.) HIV B.) Hepatitis B C.) Hepatitis C p. 616

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? A.) Perform surgical hand scrub using detergent. B.) Apply alcohol-based handrub up to the mid-forearm C.) Perform hand antisepsis using a designated bleach solution. D.) Wash hands with soap or detergent.

A.) Perform surgical hand scrub using detergent p. 607 The nurse should perform a surgical hand scrub using detergent when caring for a client undergoing surgery. Bleach solutions are not used and a basic handwash is not sufficient. Alcohol-based rubs may be used in many situations that do not involve surgery.

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? A.) Pour the liquid into a sterile container within the sterile field. B.) Pour the liquid into the cap of the bottle and dip the gauze as needed. C.) Pour the liquid into the palm of a sterile gloved hand for use. D.) Pour the liquid onto gauze on the sterile field until the gauze is moist.

A.) Pour the liquid into a sterile container within the sterile field. p. 629-633

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. A.) Protective eyewear B.) Gowns C.) Sterile gloves D.) Nonsterile gloves E.) Masks

A.) Protective eyewear B.) Gowns D.) Nonsterile gloves E.) Masks p. 611 The nurse should assess the levels of the nonsterile gloves, gowns, masks, and protective eyewear, as these are all part of the PPE. Sterile gloves are not part of the PPE.

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? A.) Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) B.) Clostridium difficile and diabetic ketoacidosis C.) Tuberculosis and pneumonia D.) Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

A.) Reactive airway disease and exacerbation of chronic obstructive pulmonary disease (COPD) p. 615

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? A.) the client placed in contact isolation who was admitted with a draining abdominal wound B.) the client admitted with a rash who reports recent exposure to measles C.) the client who is 48-hours postsurgical procedure D.) the client admitted with diarrhea who tested positive for Escherichia coli (E. coli)

A.) The client who is 48-hours postsrugical procedure p. 609 The nurse should see clients from "clean" to "dirty"

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? A.) The client's immune system became further weakened B.) The resident microorganisms mutated and became virulent C.) The client's normal flora began producing spores D.) The client's normal flora proliferated because of a nutritional deficit

A.) The client's immune system became further weakened p. 600

A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply. A.) The nurse moves soiled equipment away from the body when cleaning it. B.) The nurse carries soiled items away from the body. C.) The nurse pours discarded liquids into a basin then pours them into the drain. D.) The nurse places soiled bed linen on the floor. E.) The nurse cleans least soiled areas first and then moves to more soiled ones. F.) The nurse opens a window and dusts the room in the direction of the window.

A.) The nurse moves soiled equipment away from the body when cleaning it. B.) The nurse carries soiled items away from the body E.) The nurse cleans least soiled areas first and then moves to more soiled ones. p. 614 The nurse would be following medical asepsis when the nurse carries soiled items away from the body, moves soiled equipment away from the body when cleaning it, and cleans least soiled areas first—then moves to more soiled areas. The nurse would not place soiled bed linen on the floor. The nurse would not open a window and dust the room in the direction of the window. The nurse would not pour discarded liquids into a basin before pouring them into the drain.

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? A.) The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. B.) The nurse rinses thoroughly with water flowing away from the fingertips. C.) The nurse uses soap and cold water to wash hands. D.) The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands.

A.) The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. p. 629

Personal protective equipment (PPE) is used in health care facilities for primarily which reason? A.) To protect both the staff and clients from becoming infected by one another B.) To protect clients from becoming infected by staff members C.) To protect staff members from becoming infected by clients D.) To protect the hospital from legal liability

A.) To protect both the staff and clients from becoming infected by one another p. 624-627

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. A.) Use personal grooming habits, such as shampooing hair often, to prevent spreading microorganisms. B.) Place soiled bed linen on the floor, instead of the bed or furniture. C.) Move equipment close to the body when brushing, dusting, or scrubbing articles. D.) Clean the least soiled areas first and then move to the more soiled ones. E.) Shake out linens and client clothing before placing them back on the bed. F.) Carry soiled items close to the body to prevent transfer of pathogens into the environment.

A.) Use personal grooming habits, such as shampooing hair often, to prevent spreading microorganisms. C.) Clean the least soiled areas first and then move to the more soiled ones. p. 603, 604 Carry soiled items, including linens, equipment, and other used articles, away from the body to prevent them from touching the clothing. Do not place soiled bed linen or any other items on the floor, which is grossly contaminated; it increases contamination of both surfaces. Move equipment away from you when brushing, dusting, or scrubbing articles. Clean the least soiled areas first and then move to the more soiled ones. Use personal grooming habits that help prevent spreading microorganisms; shampoo your hair regularly. Do not shake linens; dust and lint particles constitute a vehicle by which organisms may be transported from one area to another.

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? A.) Wear gloves whenever entering the client's room. B.) Use respiratory protection when entering the room. C.) Keep visitors 3 feet (1 m) from the client. D.) Place the client in a private room that has monitored negative air pressure.

A.) Wear gloves whenever entering the client's room. p. 614

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? A.) an 80-year-old woman B.) a 2-year-old toddler C.) a 12-year-old girl D.) an 18-month-old infant

A.) an 80-year-old woman p 608

Personal protective equipment for use with standard precautions includes which items? Select all that apply. A.) eye protection B.) disposable gloves C.) fluid-repellent gown D.) disposable shoe covers E.) face mask F.) disposable head cover

A.) eye protection B.) disposable gloves C.) fluid-repellent gown E.) face mask p. 615 For standard precautions, wear personal protective equipment, such as mask, eye protection, face shield, or fluid-repellent gown during procedures and care activities that are likely to generate splashes or sprays of blood or body fluids. Use gown to protect skin and prevent soiling of clothing. Disposable shoe and head covers are not required under standard 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. A.) gloves B.) respirator C.) mask with face shield D.) gown

A.) gloves C.) mask with face shield D.) gown p. 613

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile? A.) gown and gloves B.) mask and shoe covers C.) goggles and gloves D.) respirator mask and gown

A.) gown and gloves p. 610

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? A.) hand washing B.) sterile technique C.) putting on gloves D.) signs of healing

A.) hand washing p. 602

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? A.) holding the container off to the side B.) placing the cap upside down on the table C.) pouring the solution slowly D.) pouring out a small amount of the solution and discarding

A.) holding the container off to the side p. 618 The client should hold the bottle in front of them for the most control and to see what they are pouring. Pouring out a small amount of the solution is appropriate; this is called lipping. Holding the lid or placing it upside down prevents contamination when the lid is reapplied to the sterile solution. Splashing can contaminate the area around the client. Pouring slowly will avoid splashing.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? A.) keeping sterile field above waist level B.) putting on sterile gloves before opening sterile package C.) maintaining a 3-in. (7.5-cm) border around the sterile field D.) opening the sterile package toward the nurse to prevent reaching over

A.) keeping the sterile field about waist level p. 618

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition? A.) contagious disease B.) health care-associated infection (HCAI) C.) community-acquired infection D.) infectious disease

B.) health care-associate infection (HCAI) p. 608 HCAI, the most common adverse event in hospitals, are acquired within healthcare facilities. Community-acquired infections occur in the community. Infectious and contagious can be acquired in any setting.

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? A.) infectious disease B.) noncommunicable disease C.) communicable disease D.) contagious disease

B.) noncommunicable disease p. 595

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? A.) Wear a mask with face shield during invasive procedures. B.) Apply a nonparticulate (N-95) respirator when entering the room. C.) Wear a protective gown and gloves with any direct contact. D.) Have the client wear a mask during care.

B.) Apply a nonparticulate (N-95) respirator when entering the room p. 613

A client has tested positive for colonization with a multidrug-resistant organism (MDRO) and has been placed on contact precautions. Which actions should be included in this client's care? Select all that apply. A.) Appoint one specific nurse to provide all of the client's care for the duration of a shift. B.) Arrange for the client to be housed in a single room. C.) Change the client's linens and gown at least twice daily. D.) Ensure that all care providers have current immunizations against the microorganism. E.) Use appropriate PPE.

B.) Arrange for the client to be housed in a single room. E.) Use appropriate PPE. p. 624 -627

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? A.) remind others to use a mask when caring for this client B.) be sure that there are gloves of various sizes and gowns for use C.) include a N95 respirator mask for health care staff entering the room D.) recognize that this type of infection requires droplet precautions

B.) Be sure that there are gloves of various sizes and gowns for use p. 610

Which client should the nurse determine to be at the greatest risk for hospital acquired infection (HAI)? A.) Client with an IV catheter B.) Client with a urinary catheter C.) Client with a surgical wound D.) Client with a diabetic foot ulcer

B.) Client with a urinary catheter p. 608

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? A.) Proceed with the procedure since it was only touched by the client. B.) Discard the sterile field and the supplies and start over. C.) Call for help and ask for new supplies. D.) Change the sterile field, but reuse the sterile equipment.

B.) Discard the sterile field and the supplies and start over. p. 640

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? A.) Discard it in the waste can. B.) Disinfect it with alcohol swabs. C.) Sterilize it by placing it in the autoclave. D.) Do nothing; it can be used again immediately.

B.) Disinfect it with alcohol swabs. p. 610

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? A.) Lay the item in an open package on the 1-in (2.5-cm) border. B.) Drop the item from 6 in (15 cm) above the sterile field. C.) Extend the sterile field by laying the open package beside it. D.) Remove the gauze from the package with one sterile hand.

B.) Drop the item from 6 in (15 cm) above the sterile field. p. 628-633

Which nursing action causes the greatest likelihood of spreading VRE? A.) Sending a VRE-positive client to the radiology department for a chest X-ray with a face mask B.) 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 C.) Removing the staples from VRE-positive postoperative client's incision without prior hand washing D.) Delivering a meal tray to a VRE-positive client without first donning gloves and a gown

B.) Emptying the Foley cather bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. p. 6

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. A.) Mask B.) Nonsterile gloves C.) Gown D.) Sterile gloves E.) Hand hygiene

B.) Nonsterile gloves E.) Hand hygiene p. 615

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. A.) Coolness B.) Redness C.) Swelling D.) Exudate E.) Pain

B.) Redness C.) Swelling D.) Exudate E.) Pain p. 600

The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply. A.) Secure the second glove inside the first glove while keeping the contaminated area on the outside. B.) Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside. C.) Slide the fingers of the ungloved hand between the remaining glove and the wrist. D.) Removing the second glove by pulling the cuff up, inverting it as it is pulled, and keeping the contaminated area on the outside. E.) Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area. F.) Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene.

B.) Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside C.) Slide the fingers of the ungloved hand between the remaining glove and the wrist E.) Use the dominant hand to grasp the opposite glove near the cuff end on the outside exposed area. F.) Discard the gloves in the appropriate container, removing additional PPE, if used, and performing hand hygiene p. 636-637 The recommended actions for removing soiled gloves are numerous. The nurse would use the dominant hand to grasp the opposite glove near the cuff end on the outside exposed area. Next, the nurse would remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside. The nurse would then slide the fingers of the ungloved hand between the remaining glove and the wrist. The nurse would discard the gloves in an appropriate container, removing additional PPE, if used, and performing hand hygiene. The nurse would also remove the second glove by pulling the cuff up, inverting it as it is pulled, and keeping the contaminated area on the inside, not the outside. Next, the nurse would secure the second glove inside the first glove while keeping the contaminated area on the inside.

Which action is the best example of a nurse donning/removing protective equipment properly? A.) Donning gown after entering client's room B.) Removing respirator after leaving client's room C.) Removing gown after leaving client's room D.) Donning respirator inside of client's room

B.) Removing respirator after leaving client's room p. 615 The best example of proper utilization of protective equipment is the removal of a respirator after leaving the client's room, as doing so prevents contact with airborne microorganisms. Gowns should be removed before leaving the client's room. Gowns and respirators should be donned prior to entering the client's room.

What is an accurate guideline for the use of PPE? A.) Substitute personal glasses for protective eyewear, if desired. B.) Replace gloves if they are visibly soiled. C.) When wearing gloves, work from "dirty" areas to "clean" ones. D.) Put on PPE after entering the client's room.

B.) Replace gloves if they are visibly soiled. p. 624-628

The nurse is preparing a sterile field for a dressing change. How would the nurse add paper-wrapped sterile items to the sterile field? A.) While wearing sterile gloves, unwrap the package and add to the field. B.) Separate the sealed flaps and drop contents onto field. C.) Set up another sterile field for the additional items. D.) Open the package away from the field.

B.) Separate the sealed flaps and drop contents onto field. p. 634

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? A.) The resident microorganisms mutated and became virulent B.) The client's immune system became further weakened C.) The client's normal flora proliferated because of a nutritional deficit D.) The client's normal flora began producing spores

B.) The client's immune system became further weakened p. 600

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take? A.) Apply a 1-in (2.5-cm) layer of the ointment to the site using the index finger B.) Use a sterile cotton-tipped applicator to apply the prescription to the site C.) Place sterile 4 × 4 gauze on the wound and secure the dressing with dressing with paper tape D.) Put soiled dressing change supplies in the client's bathroom garbage and double bag

B.) Use a sterile cotton-tipped applicator to apply the prescriptiom to the site p. 604; 618

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? A.) Use a private room with the door closed at all times. B.) Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. C.) Place client in a private room that has monitored negative air pressure. D.) Ensure that hard surfaces in the room are disinfected at least once per day.

B.) Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client p. 624

The nurse is caring for a 7-year-old client with varicella. Which precautions will the nurse initiate? A.) reverse isolation B.) airborne C.) droplet D.) contact

B.) airborne p. 615 Varicella is transmitted via airborne mechanisms; therefore, airborne precautions are appropriate.

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? A.) contact B.) airborne C.) none D.) droplet

B.) airborne p. 615 Pulmonary tuberculosis is transmitted via airborne mechanisms; therefore airborne contact precautions are appropriate.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. A.) body fluid precautions B.) airborne precautions C.) respiratory precautions D.) droplet precautions E.) contact precautions F.) microbial precautions

B.) airborne precautions D.) droplet precautions E.) contact precautions p. 615

When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission? A.) vehicle B.) contact C.) vector D.) airborne

B.) contact p. 599

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. A.) contact with sweat B.) contact with wound openings C.) contact with blood via mucous membranes D.) via syringes shared between the client and others E.) via sexual contact

B.) contact with wound openings C.) contact via mucous membranes D.) via syringes shared between the client and others E.) via sexual contact p. 599

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? A.) constant use of gloves when on the unit B.) diligent handwashing practices C.) prophylactic antibiotic therapy for MRSA-negative clients D.) reduced length of stay for MRSA-positive clients

B.) diligent handwashing practices p. 605

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? A.) swab the outside of each specimen container with alcohol prior to transport B.) place the specimens into plastic biohazard bags C.) wear gloves and a gown when transporting the specimen D.) place each of the three sealed specimens in a separate paper bag

B.) place the specimen into plastic biohazard bags p. 614

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse? A.) touching the tip of the bottle to the sterile container to avoid splashing B.) pouring the sterile solution from a height of 5 in. (13 cm) C.) discarding any unused sterile solution D.) placing the cap on the table with edges down

B.) pouring the sterile solution from a height of 5 in. (13 cm) p. 632 Sterile solutions can be poured onto a sterile field from a height of 4 to 6 in. (10 to 15 cm). The tip of the bottle should not touch the sterile container on the field. The cap should always be placed with edges up to maintain sterility. Unused solution can be labeled with date and time and stored for up to 24 hours.

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. A.) nails that are cut to ½ inch (1.25 cm) beyond the nail bed B.) red nail polish C.) nails that are down to the nail bed D.) rings on finger E.) artificial nails with intact clear nail polish

B.) red nail polish D.) rings on finger E.) Artificial nails with intact clear nail polish p. 604 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 who has been diagnosed with a cold is upset that antibiotic therapy was not prescribed. Which nursing response is most appropriate? A.) "Sometimes antibiotics work for colds and sometimes they do not." B.) "We can ask the PCP for an antiviral medication." C.) "The common cold is a virus and will not respond to antibiotics." D.) "Antibiotics have too many side effects anyway."

C.) "The common cold is a virus and will not respond to antibiotics". p. 597

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? A.) Remove the gown before removing gloves. B.) Perform hand hygiene before removing the gown. C.) Avoid touching the outer surfaces of the gown. D.) Remove the gown immediately after exiting the room.

C.) Avoid touching the outer surfaces of the gown. p. 624-627

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? A.) Release of histamine B.) Production of antibodies C.) Migration of leukocytes to the area of the wound D.) Constriction of the small blood vessels near the wound

C.) Migration of leukocytes to the area of the wound p. 600

The nurse prepares for a sterile procedure. What action does the nurse perform first? A.) Put on personal protective equipment, if required. B.) Place all the necessary supplies in the room. C.) Perform hand hygiene with alcohol-based hand rub. D.) Identify the client the procedure is prescribed for.

C.) Perform hand hygiene with alcohol-based hand rub. p. 628-633

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? A.) applies a mask with face shield B.) performs hand hygiene before donning gloves C.) removes gloves and walks out of the room D.) asks the client to state name and date of birth

C.) Removes gloves and walks out of the room p. 608

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement? A.) All new residents are prescribed antibiotics. B.) Culture all residents and staff. C.) Review the current infection control protocols. D.) Restrict visitors to public places.

C.) Review the current infection control protocols. p. 608-610 The nurse manager that notes an increase in infection rates should first review the current infection control protocols. Reviewing the protocols can identify if the protocols are appropriate and being implemented by the staff. Prescribing antibiotics to all new residents will not decrease infections rates, but may increase the rate of antibiotic resistant bacteria. Culturing all residents and staff would identify infection, but not decrease the rates. Restricting visitors would not decrease rates.

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. A.) The nurse drops a sterile item on a sterile field from the height of 12 inches (30 cm). B.) The nurse places the cap of an opened solution on the table with edges down. C.) The nurse calls for help when realizing a supply is missing. D.) The nurse discards a sterile field when a portion of it becomes contaminated. E.) The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. F.) The nurse holds an agency-wrapped item with the top flap opening toward the body.

C.) The nurse calls for help when realizing a supply is missing D.) The nurse discards a sterile field when a portion of it becomes contaminated E.) The nurse considers the outer 1-inch edge of the sterile field to be contaminated p. 618 The nurse practitioner would follow several recommended guidelines when performing a biopsy on a client. First, the nurse would consider the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. The nurse would discard a sterile field when a portion of it became contaminated. The nurse would call for help when realizing a supply is missing. The nurse would not place the cap of an opened solution on the table with edges down. The nurse would not drop a sterile item on a sterile field from the height of 12 in (30 cm), rather 6 in (15 cm). The nurse would hold a wrapped item with the top flap opening away from the body.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? A.) The nurse performs hand hygiene after touching the client's surroundings B.) The nurse applies non-medical hand cream after performing hand hygiene C.) The nurse removes her gown and then removes her gloves D.) The nurse performs hand hygiene before putting on gloves

C.) The nurse removes her gown and then removes her gloves p. 624-627 Gloves should be removed prior to a gown. Hand hygiene is necessary before applying gloves and after touching a client's surroundings. The use of moisturizers is acceptable.

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism? A.) Airborne B.) Direct contact C.) Vehicle D.) Droplet

C.) Vehicle p. 598 Vehicle transmission involves the transfer of microorganisms by way of vehicles or contaminated items that transmit pathogens; for example, food can carry Salmonella. Direct contact transmission involves body surface-to-body surface contact causing the physical transfer of organisms between an infected or colonized person and an infected host. Droplet transmission occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. Airborne transmission occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens.

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? A.) wearing a face mask when entering and staying at a distance from the client B.) wearing protective eye wear for all client contact C.) wearing a particulate respirator for all client care and interaction D.) placing the client in a regular, private room

C.) Wearing a particulate respirator for all client care and interaction p. 615

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? A.) prophylactic antibiotic therapy for MRSA-negative clients B.) reduced length of stay for MRSA-positive clients C.) diligent handwashing practices D.) constant use of gloves when on the unit

C.) diligent handwashing practices p. 605

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response? A.) teach the colleague why the gloves should be removed outside the room B.) maintain a distance of at least 5 ft (1.5 m) from the colleague C.) encourage the colleague to remove the glove by grasping the cuff D.) take no action at this time

C.) encourage the colleague to remove the glove by grasping the cuff p. 626

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)? A.) fold soiled side to the inside and roll with outer surface exposed B.) fold soiled side to the outside and roll with inner surface exposed C.) fold soiled side to the inside and roll with inner surface exposed D.) fold soiled side to the outside and roll with outer surface exposed

C.) fold soiled side to the inside and roll with inner surface exposed p. 627

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene? A.) has wedding band on ring finger B.) drains hands lower than the wrist C.) has manicured nails that are 1-in. (2.5-cm) long D.) washes hands for 15 seconds

C.) has manicured nails that are 1-in. (2.5 cm) long p. 604

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from: A.) needles left in the client's linen. B.) full needle boxes. C.) recapping a needle. D.) faulty needles and syringes.

C.) recapping the needle p. 616

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter? A.) Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. B.) Use an alcohol-based hand rub to decontaminate the hands. C.) Remove all jewelry, including wedding bands, before hand washing. D.) Keep hands lower than elbows to allow water to flow toward fingertips.

D.) Keep hands lower than elbows to allow water to flow toward fingertips. p. 622

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: A.) "You will likely have an outbreak due to the stress of labor and delivery." B.) "A cesarean section will prevent a herpes outbreak." C.) "Have you discussed this with your physician?" D.) "You may have infection in your birth canal that you are unaware of."

D.) "You may have infection in your birth canal that you are unaware of." p. 598

When providing care to a incontinent client with a history of methicillin-resistant Staphylococcus aureus (MRSA), what is the priority goal for the nurse's observable intervention? A.) Providing a clean enviroment while providing client care B.) Maintaining the cleanliness of the nurse's uniform C.) Preventing the introduction of microorganisms to the client D.) Avoiding the introduction of microorganisms to the nurse's uniform

D.) Avoiding the introduction of microorganisms to the nurse's uniform p. 624

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? A.) "Lip" a new or old bottle of solution before pouring it and hold the solution with the label facing out from a height of 4 to 6 in (10 to 15 cm). B.) Touch the tip of the bottle to the sterile container to start the flow of the solution and pour it into the container directly from the top of the container edge. C.) Hold the bottle inside the 1-inch edges of the sterile field with the label side facing the palm of the hand, then pour from a height of 2 to 4 in (5 to 10 cm). D.) 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).

D.) 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). p. 632 Holding the bottle outside the edge of the sterile field with the label side facing the palm of the hand and preparing to pour from a height of 4 to 6 in (10 to 15 cm) is the correct step for adding a sterile solution. The tip of the solutions should never touch the container or dressing, and the label should face the palm when pouring the solution. Only a used bottle of solution needs to be lipped. The bottle should be held outside the edge of the sterile field.

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? A.) Request that the examination be done at the bedside. B.) Question the need for the examination, because the client must remain under airborne precautions. C.) Notify the CT department in advance so other clients and staff can be removed from the area. D.) Place a surgical mask on the client and transport to the CT department at the specified time.

D.) Place a surgical mask on the client and transport to the CT department at the specified time. p. 615

Which should be documented by the nurse? A.) The specific items that the nurse transferred into a sterile field B.) The fact that the nurse donned gloves two different times during a procedure C.) The fact that the nurse washed her hands before a procedure D.) The fact that sterile technique was used for a given procedure

D.) The fact that sterile technique was used for a given procedure p. 628 - 633

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? A.) The nurse keeps visitors 3 feet away from the infected person. B.) The nurse uses droplet precautions when providing care for the client. C.) The nurse places the client in a private room with the door open. D.) The nurse places the client in a private room with monitored negative air pressure.

D.) The nurse places the client in a private room with monitored negative air pressure. p. 615

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct? A.) Slide one gloved hand under the other glove for removal. B.) Remove the goggles before removing other equipment. C.) Remove respirator at the doorway of the client's room. D.) Touch the inside of the gown and pull it away from the torso.

D.) Touch the inside of the gown and pull it away from the torso. p. 624-627 The outside of the equipment is considered contaminated. Removal follows a prescriptive sequence. Most personal equipment is removed at the door of the client's room. The contaminated glove grasps the other contaminated glove for removal. The nurse's clean hand reaches under the other glove for removal. Goggles are removed by holding the earpieces. Clean hands touch the inside of the gown for removal, pulling away from the torso. Roll these items up, inside out, for disposal. Grasp ties on mask on respirator for removal after leaving the room.

Surgical asepsis is defined as: A.) slowed growth of microorganisms. B.) use of hand washing, gowning, and gloving. C.) absence of all virulent microorganisms. D.) absence of all microorganisms.

D.) absence of all microorganisms p. 603

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection? A.) describing each step verbally to the client while performing the dressing change B.) checking that the sterile dressing packages are intact before opening C.) ensuring that the surface where the sterile field will be set up is dry D.) applying a new dressing with the gloves that were used to remove the old dressing

D.) applying a new dressing with the gloves that were used to remove the old dressing p. 617

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin? A.) none B.) droplet C.) airborne D.) contact

D.) contact p. 615

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? A.) contact B.) airborne C.) none D.) droplet

D.) droplet p. 615

The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin? A.) contact B.) airborne C.) none D.) droplet

D.) droplet p. 615 Meningococcal meningitis is transmitted through droplets; therefore droplet precautions are appropriate.

Health care professionals are required to follow certain principles to ensure that healthcare-associated infections (HAI) do not occur in the health care facility. What contributes to infections during health care? A.) health professionals with earrings B.) health professionals with short hair C.) health professionals with leather footwear D.) health professionals donning artificial nails

D.) health professionals donning artificial nails p. 605

A nurse has put on personal protective equipment (PPE) to perform the dressing change of a client's surgical wound. While the nurse is cleansing the incision, the client begins bleeding and blood hits the nurse's wrist, running down under the cuff of her glove. What is the nurse's best action? A.) Rinse the infected hand with hydrogen peroxide after applying a sterile bandage to the client's wound. B.) Remove the contaminated gloves and apply a clean pair of gloves. C.) Perform thorough hand hygiene immediately after completing the dressing change. D.) Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol.

D.) interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol. p. 624-627 If the nurse is accidentally exposed to blood, it is necessary to stop the task and immediately follow facility protocol for exposure, including reporting the exposure. It would be unsafe to proceed with the dressing change before addressing the exposure. Applying new gloves does not eliminate the exposure.

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? A.) wear a mask and gown in the client's room B.) avoid direct contact with the client C.) wear gloves when touching the client D.) perform hand hygiene before and after entering the client's room

D.) perform hand hygiene before and after entering the client's room p. 639

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? A.) offer the student a mask B.) teach that a gown and shoe coverings must be worn in addition to gloves C.) do nothing, as the precautions observed are appropriate D.) remind the student that a fitted N95 respirator is required

D.) remind the student that a fitted N95 respirator is required p. 613