Chapter 28: Infection Prevention and Control

36. The nurse is changing linens for a postoperative patient and feels a stick in her hand. A nonactivated safe needle is noted in the linens. This scenario would indicate that the nurse may be at risk for a. Hepatitis B. b. Clostridium difficile. c. Methicillin-resistant Staphylococcus aureus. d. Diphtheria.

ANS: A Bloodborne pathogens such as those associated with hepatitis B and C are most commonly transmitted by contaminated needles. Clostridium difficile is spread by contact with and ingestion of this microbe, and MRSA is spread by contact. Diphtheria is spread by droplets when one is within 3 feet of the patient.

35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of the following nursing actions would be appropriate given this organism? a. Instruct assistive personnel to use soap and water rather than sanitizer to clean hands. b. Place the patient on Droplet Precautions. c. Wear an N95 respirator when entering the patient room. d. Teach the patient cough etiquette.

ANS: A Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not transmitted via the droplet route; therefore Droplet Precautions are not needed. An N95 respirator is used primarily for patients with airborne illness. All patients should be taught cough etiquette; this action is not one to be take especially because the patient has Clostridium difficile.

1. The nurse is caring for a patient with pneumonia with a new nurse in orientation. Which of the following statements by the new nurse would indicate an understanding of the nature of this condition? a. "An infectious disease like pneumonia may not pose a risk to others." b. "We need to isolate the patient in a negative pressure room." c. "The patient will not be able to return home." d. "Clinical signs and symptoms are not present in pneumonia."

ANS: A Infections are infectious or communicable. Infectious diseases may not pose a risk for transmission to others, although they are serious for the patient. Pneumonia is not a communicable disease—a disease that is transmitted directly from one individual to the next; so there is no need for isolation. Clinical signs and symptoms are present in pneumonia and include but are not limited to elevated temperature, shortness of breath, fatigue, and coughing; in addition, the patient may have rhonchi and crackles upon auscultation. Frequently, patients with pneumonia do return home unless there are extenuating circumstances.

29. The nurse is caring for a patient on the medical-surgical unit. The nurse and the physician have completed an invasive procedure. What is the next step in handling the instruments used during the procedure? a. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and sterilization. b. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and disinfection. c. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and boiling. d. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning.

ANS: A Instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or in the vascular system present a high risk of infection if they become contaminated with bacteria.

16. The nurse is inserting a peripherally inserted central catheter (PICC) into the patient. Aware of the potential for health care-associated infection, the nurse is careful to a. Prepare the skin with 2% chlorhexidine gluconate. b. Select a catheter of appropriate size for the appropriate vein. c. Use nonallergenic tape and dressings on the patient. d. Utilize local anesthetic on the site as ordered.

ANS: A One of the sites for health care-associated infection is the bloodstream. Bloodstream infection can be caused by improper care of the needle insertion site. Two percent chlorhexidine gluconate is an antiseptic solution that when applied properly and allowed to dry reduces microbial counts at the insertion site. Selecting the correct catheter size, using nonallergenic tape and dressings, and utilizing local anesthetic are important steps for individualized patient care and are typically part of the procedure, but they do not affect the cause of a health care-associated infection by, for example, decreasing microbial counts at the insertion site.

9. Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response? a. Rest, ice, compression, and elevation b. Turn, cough, and deep breathe c. Orient to date, time, and place d. Passive range-of-motion exercises

ANS: A One sign of the inflammatory response, particularly after an injury, is swelling or edema. Resting the affected injured area, using ice as ordered, wrapping the area to provide support—particularly if it is an extremity—and elevating the injured area will help to decrease swelling or edema. Turn, cough, and deep breathe is utilized for postoperative patients and for immobilized patients to help prevent an infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many different types of patients who may be confused. Passive range of motion is utilized for individuals who need to improve movement of their extremities, including immobilized patients.

4. The nurse is admitting a patient with an infectious disease process. What question would be appropriate for a nurse to ask this patient? a. "Do you have a chronic disease, and how long have you had it?" b. "Do you have any children living in the home?" c. "What is your marital status—single, married, or divorced?" d. "Do you have any cultural or religious beliefs that will influence your care?"

ANS: A Some factors increase the susceptibility of an individual to acquire an infection. These include age, nutritional status, presence of chronic disease, trauma, and smoking. The other questions are part of an admission assessment process but are not pertinent to the infectious disease process.

15. Which of these interventions would take priority and should be included in a plan of care for a patient who presents with pneumonia? a. Observe the patient for decreased activity tolerance. b. Assume that the patient is in pain and treat accordingly. c. Maintain the temperature at 65° F. d. Provide the patient ice chips as requested.

ANS: A Systemic infection causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise. Be alert for changes in the patient's level of activity and responsiveness. Respiratory infection may result in a productive cough with purulent sputum, shortness of breath, and activity intolerance. Nurses do not assume but assess and communicate with the patient about pain, temperature, and ice chips. Asking these questions would not be a priority as much as assessing the patient and determining the effect that the systemic infection is having on the patient.

26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistant turning off the handle faucet with his hands. What professional practice supports the need for follow-up with the nursing assistant? a. The nurse is responsible for providing a safe environment for the patient. b. This is a key step in the procedure for washing hands. c. Allowing the water to run is a waste of resources and money. d. Different scopes of practice allow modification of procedures.

ANS: A The nurse is responsible for providing a safe environment for the patient. The effectiveness of infection control practices depends on conscientiousness and consistency in using effective aseptic technique. It is human nature to forget key procedural steps or to take shortcuts. However, failure to comply with basic procedures places the patient at risk for infection that can impair recovery or lead to death. After washing hands, turn off a handle faucet with a dry paper towel and avoid touching the handles with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer of pathogens from faucet to hands. The principles and procedures for washing hands are universal and apply to all members of health care teams. Being resourceful and aware of the cost of health care is important, but taking shortcuts that may endanger an individual's health is not a prudent practice.

21. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed her hands and has donned a sterile gown and gloves. Which action would indicate a break in sterile technique? a. Touching protective eyewear b. Standing with hands folded on chest c. Accepting sterile supplies from the surgeon d. Staying with the sterile table once it is open

ANS: A Touching nonsterile protective eyewear once gowned and gloved with sterile gown and gloves would indicate a break in sterile technique. Sterile objects remain sterile only when touched by another sterile object. Standing with hands folded on chest is common practice and prevents arms and hands from touching unsterile objects. Accepting sterile supplies from the surgeon who has opened them with the appropriate technique is acceptable. Staying with a sterile table once opened is a common practice to ascertain that no one or nothing has contaminated the table.

2. The nurse is assessing a new patient admitted to home health. To decrease the risk of infection, which of these questions would be most appropriate to ask? (Select all that apply.) a. "Will you demonstrate how to wash your hands?" b. "Do you have a working refrigerator?" c. "Can you explain the risk for infection in your home?" d. "What are the signs and symptoms of infection?" e. "Who runs errands for you?" f. "Are you able to walk to the mailbox?"

ANS: A, B, C, D In the home setting, the objective is that the patient and or family will utilize proper infection control techniques. Asking the patient and family about hand washing, risk of infection, and signs and symptoms of infection is important in evaluating the patient's knowledge base on infection control strategies. Refrigeration is essential in keeping perishables cold and in preventing foodborne illnesses and in allowing storage of enteral feedings or refrigerated medications. Activity assessment is important for evaluation of the overall status of the patient, and knowing who runs errands gives you information on who is helping to meet the needs of the patient, but neither of these relate to decreasing the risk of infection.

5. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. What items will the nurse need to care for this patient? (Select all that apply.) a. Private room b. Negative-pressure airflow in room c. Communication signs for Droplet Precautions d. Communication signs for Airborne Precautions e. Surgical mask, gown, gloves, eyewear f. N95 respirator, gown, gloves, eyewear

ANS: A, B, D, F Tuberculosis is a disease that is transmitted by droplets that remain in the air for long periods of time. Caring for this patient requires a private room, negative-pressure airflow in room, and wearing an N95 respirator that has been fit-tested, gloves, gown, and eyewear. This patient will not be in Droplet Precautions, and instead requires Airborne Precaution signs. This type of patient requires more than the average surgical mask for protection.

4. The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to don the sterile gloves. Which steps are included in this process? (Select all that apply.) a. Lay glove package on clean flat surface above waistline. b. Remove outer glove package by tearing the package open. c. Glove the dominant hand of the nurse first. d. While putting on the first glove, touch only the outside surface of the glove. e. With gloved dominant hand, slip fingers underneath second glove cuff. f. After second glove is on, interlock hands.

ANS: A, C, E, F Sterile objects held below the waist are considered contaminated. Gloving the dominant hand helps to improve dexterity. Slipping the fingers underneath the second glove cuff helps to protect the gloved fingers. Sterile touching sterile prevents glove contamination. Interlocking fingers ensures a smooth fit over the fingers. Sterile supplies are opened by carefully separating and peeling apart the sides of the package; this presents the sterile contents from accidentally opening and touching contaminated objects. Touching the outside of the glove surface will contaminate the sterile item; touch only the inside of the glove—the piece that will be against the skin.

6. The nurse is providing an education session to an adult community group about the effects of smoking. Which of the following is the most important point to be included in the educational session? a. Smoke from tobacco products clings to your clothing and hair. b. Smoking affects the cilia lining the upper airways in the lungs. c. Smoking tobacco products can be very expensive. d. Smoking can affect the color of the patient's fingernails.

ANS: B A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and increase the patient's potential for infection. Smoking can be expensive, the smell does cling to hair and clothing, and the tar within the smoke can alter the color of a patient's nails. This information can be included in the education but does not constitute the most important point.

37. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous infusion. The nurse's best next step is to a. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. b. Immediately wash the site with soap and running water, and seek guidance from the manager. c. Delay washing of the site until the nurse is finished providing care to the patient. d. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job.

ANS: B After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to cleanse the site immediately and thoroughly with soap and running water and notify the manager and employee health for guidance on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing because the splash was to intact skin could possibly spread the blood within the room and could spread the infection. Contain contamination immediately to prevent contact spread.

17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices a spike in postoperative infections on this unit and categorizes this type of health care-associated infection as _____ infections. a. Iatrogenic b. Exogenous c. Endogenous d. Nosocomial

ANS: B An exogenous organism is one that is present outside the patient. A postoperative infection is an exogenous infection because the organism that has caused the infection presents from outside the body. An example isStaphylococcus aureus. An endogenous organism is part of the normal flora of residing virulent organisms that could cause infection. An endogenous infection can occur when part of the patient's flora becomes altered, and overgrowth results. Iatrogenic infection results from a diagnostic or therapeutic procedure such as a colonoscopy. Nosocomial infection is the term formerly used for health care-acquired infection.

34. The nurse is caring for a patient on Contact Precautions. Which of the following actions would be appropriate to prevent the spread of disease? a. Wear a gown, gloves, face mask, and goggles for interactions with the patient. b. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. c. Place the patient in a room with negative airflow. d. Transport the patient quickly when going to the radiology department.

ANS: B Contact Precautions are a type of Isolation Precaution used for patients with illness that can be transmitted through direct or indirect contact. A patient is placed on Contact Precautions if a disease is present that can be transmitted through direct or indirect contact. Patients who are on Contact Precautions should have dedicated equipment wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay in the room with the patient and would be used for that patient only. A gown and gloves may be required for interactions with a patient who is on Contact Precautions. A face mask and goggles are not part of Contact Precautions. A room with negative airflow is needed for patients placed on Airborne Precautions; it is not necessary for a patient on Contact Precautions. When a patient on Contact Precautions needs to be transported, he should wear clean gowns, and wheelchairs or gurneys should be covered with an extra layer of sheets. Anyone who might come in contact with the patient needs to be protected, and equipment must be cleaned with an approved germicide after patient use and before another patient uses the shared equipment.

30. The nurse is observing a family member changing a dressing for a patient in the home health environment. Which of these observations would indicate that the family member has a correct understanding of how to manage contaminated dressings? a. The family member removes gloves and gathers items for disposal. b. The family member places the used dressings in a plastic bag. c. The family member saves part of the dressing because it is clean. d. The family member wraps the used dressing in toilet tissue before placing in the trash.

ANS: B Contaminated dressings and other infectious items should be placed in impervious plastic or brown paper bags and then disposed of properly in garbage containers. Gloves should be worn during this process. Parts of the dressing should not be saved, even though they may seem clean, because microbes may be present.

32. The home health nurse is teaching a patient and family about hand hygiene in the home. The nurse is sure to emphasize washing hands before a. And after shaking hands. b. And after treatments. c. Opening the refrigerator. d. And after using a computer.

ANS: B Patients should perform hand hygiene before and after treatments and when coming in contact with body fluids. Depending on the type of patient, holding hands does not require washing of hands before but is advisable before touching eyes, nose, or mouth—washing hands afterward would be a good practice. Washing hands before and after opening the refrigerator and using the computer is not required but during cold and flu season might be advisable.

11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access device. Which nursing intervention is priority in this procedure? a. Position the patient comfortably. b. Maintain aseptic technique. c. Gather available supplies. d. Review the procedure with the patient.

ANS: B Patients with disease processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious organism. It is priority that anytime an intravenous device is accessed, aseptic technique must be maintained with wearing of appropriate personal protective equipment, preparation of the skin, and use of sterile gloves, sterile supplies, appropriate flushing, and appropriate discontinuation. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the procedure but are not the priority in the procedure.

24. The nurse is caring for a patient with a nursing diagnosis of risk for infection. Aware of the need for Standard Precautions, the nurse is careful to a. Teach the patient about good nutrition. b. Wear eyewear when emptying a urinary drainage bag. c. Avoid contact with intact skin without wearing gloves. d. Don gloves when wearing artificial nails.

ANS: B Standard Precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter. Teaching the patient about good nutrition is positive but does not apply to Standard Precautions. The term Standard Precautions applies to all blood and body fluids except sweat, even if blood is not present. It also applies to nonintact skin and mucous membranes.

27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. The nurse's best next step is to a. Clean hands with wipes from the bedside table. b. Wash hands with an antimicrobial soap and water. c. Use an alcohol-based waterless hand gel. d. Instruct the patient to wash his face and hands.

ANS: B The Centers for Disease Control recommends that when hands are visibly soiled, one should wash with a non-antimicrobial soap or with antimicrobial soap. Cleaning hands with wipes or using waterless hand gel does not meet this standard. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. The patient may very well need to wash his face and hands, but this is not the best next step.

10. The nurse is caring for a group of medical-surgical patients. The patient most at risk for developing an infection is the patient who a. Is in observation for chest pain. b. Is recovering from a right total hip arthroplasty. c. Has been admitted with dehydration. d. Has been admitted for stabilization of atrial fibrillation.

ANS: B The patient who is recovering from a right total hip arthroplasty has had a surgical procedure wherein bone was removed from the body and an implant was placed within the patient. The patient has a large incision from surgery. The patient also has an intravenous infusion to provide fluids and medication. All these breaks in the skin increase the likelihood of infection. The patient has had anesthesia and medication for pain. Both of these depress the respiratory system and have the potential to decrease the expansion of alveoli and to increase the chance of infection in the respiratory system. The other patients may have one break in the skin when an intravenous infusion is used.

22. The nurse is caring for a patient with an incision. Which of the following actions would best indicate an understanding of medical and surgical asepsis? a. Donning sterile gown and gloves to remove the wound dressing b. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing c. Donning clean goggles, gown, and gloves to dress the wound d. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing

ANS: B Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies, including gloves and dressings (surgical asepsis-sterile technique) to reapply sterile dressings. Wearing sterile gowns and gloves is not necessary when removing soiled dressings. Donning clean gloves to dress a sterile wound would contaminate the sterile supplies. Utilizing clean supplies for a sterile dressing would not help in decreasing the number of microbes at the incision site.

13. The nurse is caring for a patient who is susceptible to infection. Which of the following nursing interventions will assist in decreasing the risk of infection? a. Teaching the patient about fall prevention b. Teaching the patient to select nutritious foods c. Teaching the patient to take a temperature d. Teaching the patient about the effects of alcohol

ANS: B When protein intake is inadequate as a result of poor diet, the rate of protein breakdown exceeds that of tissue synthesis. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces the body's defenses against infection and impairs wound healing. Teaching the patient about fall prevention, how to take a temperature, or about the effects of alcohol does not decrease the risk of infection.

1. The nurse is caring for a patient in Contact Precautions. The nurse includes hand hygiene as part of the plan of care to (Select all that apply). a. Provide an uninterrupted chain of infection. b. Decrease the incidence of health care-associated infection. c. Protect the nurse from transmission of the microbes. d. Decrease the transmission of microbes to other patients. e. Prevent contamination of clean supplies. f. Decrease the drying effects of soap.

ANS: B, C, D, E Handwashing is part of Contact Precautions and assists in interrupting the chain of infection. Washing hands can assist in decreasing the incidence of health care-associated infection, protect the nurse from the transfer of microorganisms, decrease the transmission of microbes to other patients, and prevent contamination of clean supplies. Hands are a common means of transmission of bacteria from one place to another. Proper hand hygiene does not decrease the drying effects of soap—in fact, it increases the drying effects of soap.

6. The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in Airborne Precautions, and one is in Contact Precautions. The nurse explains to the student different interventions for care. What should the nurse include in her teaching? (Select all that apply). a. Be consistent in nursing interventions; there is only one difference in the precautions. b. Wash hands before entering and leaving both of the patients' rooms. c. Dispose of supplies to prevent the spread of microorganisms. d. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. e. Patients in Airborne Precautions wear a mask during transportation to departments. f. Checking the working order of the negative-pressure room is done on admission and at the time of discharge.

ANS: B, C, D, E Washing hands, properly disposing of supplies, applying knowledge of the disease process, and having patients in Airborne Precautions wear a mask during transfer are all principles to follow when caring for patients in isolation. Multiple differences are evident between these types of isolation, including the type of room used for the patient and what the nurse wears while caring for the patient. It is important to check the working order of a negative-pressure room before admitting a patient to the room, each shift the patient is in the room, and if and when the device alarms. Even when no patient is in this type of room, regular and routine checks are important to ensure the working order.

33. The nurse has been caring for a patient in the perioperative area for several hours. The surgical mask the nurse is wearing has become moist. The nurse's best next step is to a. Change the mask when relieved. b. Air-dry the mask while at lunch, and reapply. c. Ask for relief, step out of the surgical area, and apply a new mask. d. Not change the mask, if the nurse is comfortable.

ANS: C A mask should fit snugly around the face and nose. After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture encourages the growth of microorganisms. Waiting to change the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection control.

18. The patient has contracted a urinary tract infection while in the hospital. Which of these actions would most likely increase the risk of a patient contracting a urinary tract infection (UTI)? a. Emptying the urinary drainage bag once a shift b. Reusing the patient's graduated receptacle to empty the drainage bag c. Allowing the drainage bag port to touch the graduated receptacle d. Providing perineal hygiene at least once a shift

ANS: C Allowing the urinary drainage bag port to touch contaminated items may introduce bacteria into the system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once every 8 hours. Each patient should have his own receptacle for measurement to prevent cross-contamination. Perineal hygiene should be provided every 8 hours and after bowel movements to assist in preventing a UTI.

2. The patient and the nurse are discussing Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission of this disease? a. "When I go camping, I will be sure to wear sunscreen." b. "When I go camping, I will drink bottled water." c. "When I go camping, I will be sure to wear insect repellent." d. "When I go camping, I will be sure to use hand gel on my hands."

ANS: C Each infectious disease has a specific mode of transmission—a component of the chain of infection. Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks. Wearing a repellent that is designed for repelling ticks, mosquitoes, and other insects can help in preventing transmission of this disease. Drinking plenty of uncontaminated water, wearing sunscreen, and using alcohol-based hand gels for cleaning hands are all important activities to participate in while camping, but they do not contribute to or prevent transmission of this disease.

38. What would be required after exposure of a nurse to blood by a cut from a scalpel in the perioperative area? a. Removing sterile gloves and disposing of in kick bucket b. Placing the scalpel in a needle safe container c. Testing the patient and offering treatment to the nurse d. Providing a medical evaluation of the nurse to the manager

ANS: C Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Syphilis may be indicated if the patient is HIV positive. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process. A confidential medical evaluation is provided to the nurse.

31. The nurse is caring for a home health patient. After completing an assessment, the nurse has diagnosed the patient as being at risk for infection. Which of the following orders would the nurse question? a. Urinary catheter to bedside drainage bag. May change to leg bag during the day. b. May reuse nebulizer equipment. Clean with mild soap and warm water, and allow to dry. c. Prepare enough enteral feedings for 12 hours. Rinse feeding bag and tubing daily. d. Call for temperature greater than 100.5, heart rate greater than 100, and respiratory rate greater than 24.

ANS: C For patients who receive tube feedings in the home, to decrease the risk of bacterial contamination it is important to prepare enough commercially prepared formula for only 8 hours and home-prepared formula for 4 hours. Sometimes the urinary drainage system is disrupted in the home to place the patient on a leg bag system when up and about. Nebulizer equipment is cleaned and reused in the home health environment. Notifying the physician about potential signs and symptoms of infection would be common practice in the home health environment.

14. A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which of these interventions would be most appropriate for the nurse to provide? a. Position the patient comfortably on the stretcher. b. Explain the procedure for dressing change to the patient. c. Don gloves and other appropriate personal protective equipment. d. Review the medication list that the patient brought from home.

ANS: C Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and other personal protective equipment as appropriate when examining or providing treatment to localized infected areas. Positioning the patient, explaining the procedure, and reviewing the medication list are all tasks that need to be completed, but preventing the spread of infection takes precedence.

20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient for dilatation and effacement, the electronic infusion device being used on the intravenous infusion alarms. Which of these actions is most appropriate for the nurse to take? a. Complete the assessment, remove gloves, and silence the alarm. b. Discontinue the assessment, and assess the intravenous infusion. c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion.

ANS: C Medical asepsis or clean technique includes procedures to decrease the number of organisms present and to prevent the transfer of organisms. Wearing gloves while assessing the dilatation and effacement of a labor and delivery patient, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate.

23. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which of these observations would require the nurse to intervene? a. Washing hands after removing gloves b. Placing the endoscope in a container for transfer c. Removing gloves to transfer the endoscope d. Disinfecting endoscopes in the workroom

ANS: C Standard Precautions are used to prevent and control the spread of infection. Transferring contaminated equipment without the protection of gloves can assist in the spread of microbes to inanimate objects and to the person doing the transfer. Utilizing gloves, washing hands, covering contaminated supplies during transfer, and disinfecting equipment in the appropriate way in the appropriate places utilize principles of basic medical asepsis and Standard Precautions and can break the chain of infection.

7. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. During the health history, which of these questions should the nurse prioritize? a. "When was the last time you visited the physician?" b. "Has this condition affected your eating habits?" c. "What medications are you currently taking?" d. "Are you able to sleep at night?"

ANS: C The body contains normal flora (microorganisms) that live on the surface of skin, saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal secretions to achieve a low pH. This inhibits the growth of many microorganisms. Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida albicans in that area. It is important to ask the patient about current medications to obtain information that may assist with diagnosis. Visiting the physician is important for the patient's health maintenance. Learning about the patient's eating and sleeping habits will assist in the plan of care.

12. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The patient presents with signs and symptoms of a urinary tract infection. Along with needed education surrounding this diagnosis, the nurse teaches the patient about rest, exercise, eating properly, and how to utilize deep breathing and visualization. Which of these explanations would best support these nursing interventions? a. Urinary tract infections are painful, and these techniques would help with managing the pain. b. Interventions listed are standard topics taught during health care visits. c. Stress for long periods of time can lead to exhaustion and decreased resistance to infection. d. The patient requested this information to teach to extended family at home.

ANS: C The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with pain, but the interventions listed are not all standard interventions taught at every health care visit.

28. The nurse is performing hand hygiene before assisting a physician with insertion of a chest tube. While washing hands, the nurse touches the sink. What is the next action the nurse should take? a. Inform the physician and recruit another nurse to assist. b. Rinse and dry hands, and begin assisting the physician. c. Repeat handwashing using antiseptic soap, d. Extend the handwashing procedure to 5 minutes.

ANS: C The inside of the sink and the counter at the edges of the sink, faucet, and handles are considered contaminated areas. If the hands touch any of these areas during handwashing, repeat the handwashing procedure utilizing antiseptic soap. There is no need to inform the physician or be relieved of this assignment. If the hands are contaminated when touching the sink, drying hands and proceeding with the procedure could possibly contaminate and contribute to increased microbial counts during the procedure, resulting in infection for the patient. Extending the time for washing the hands (although this is what will happen when the procedure is repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap.

19. Which of the following nursing actions would most increase a patient's risk for developing a health care-associated infection? a. Use of surgical aseptic technique to suction an airway b. Urinary catheter drainage bag placed below the level of the bladder c. Clean technique for inserting a urinary catheter d. Use of a sterile bottled solution more than once within a 24-hour period

ANS: C Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care-associated infection. Urinary catheters need to be inserted using sterile technique, also referred to as surgical asepsis. This involves eliminating all microorganisms, including pathogens and spores, from an object or area. Placing a catheter into a sterile body cavity such as the bladder requires sterile technique. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Keeping the urinary catheter drainage bag below the bladder helps decrease the risk of developing a health care-associated infection because it prevents reflux of urine from the bag back into the bladder. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded.

3. The circulating nurse in the perioperative area is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which of the following behaviors indicate to the nurse that the procedure has been done correctly? (Select all that apply.) a. Surgical cap and face mask are in place. b. Surgical technologist ties the back of the gown. c. Surgical technologist touches only inside of gown. d. Surgical technologist slips arms into arm holes simultaneously. e. Surgical technologist uses hands covered by sleeves to open gloves. f. Fingers are extended fully into both gloves.

ANS: C, D, E, F To maintain sterility, the surgical technologist (ST) touches the inside of the gown that will be against the body. Arms are slipped simultaneously into the gown to prevent contamination. Using the sleeves covering the hands maintains the principle of sterile only touching sterile. Extending the fingers fully into both gloves ensures that the ST has full dexterity while using the sterile gloved hand. Surgical cap, face mask, and eye wear are applied before entering the surgical area and completing the surgical scrub. Reaching behind to tie the back of the gown will contaminate the sterile area of the gown.

5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5° F and the WBC is 10,500/mm3. Which nursing action should the nurse take? a. Plan to change the surgical dressing during the shift. b. Check to see what solution was used for skin preparation in surgery. c. Collect supplies to culture the surgical incision. d. Utilize SBAR to call and communicate the patient's needs to the physician.

ANS: D Organisms enter the body in several different ways. Proper skin preparation for surgery is essential to decrease the chance of infection. The nursing assessment indicates signs and symptoms of infection. The physician needs to be called and notified of the patient's needs. SBAR—Situation, Background, Assessment, and Recommendation—can be utilized to organize thoughts and data and to provide a through explanation of the patient's current status. Changing the dressing may be a need during the shift but is not a first priority. Checking to see about the skin prep used 2 days ago may or may not be useful information at this time. Collecting supplies for culture may be necessary after talking with the physician.

25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. It is important for the nurse to utilize _____ Precautions. a. Contact b. Protective c. Droplet d. Standard

ANS: D Standard Precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes of all patients. Contact Precautions apply to individuals with colonization of infection such as MRSA. Protective Precautions apply to individuals who have undergone transplantations. Droplet Precautions focus on diseases that are transmitted by large droplets.

8. The nurse is caring for a school-aged child who has injured his leg after a bicycle accident. To determine whether the child is experiencing a localized inflammatory response, the nurse should assess for which of these signs and symptoms? a. Fever, malaise, anorexia, and nausea and vomiting b. Chest pain, shortness of breath, and nausea and vomiting c. Dizziness and disorientation to time, date, and place d. Edema, redness, tenderness, and loss of function

ANS: D The body's cellular response to an injury is seen as inflammation. Inflammation can be triggered by physical agents, chemical agents, or microorganisms. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as nausea and vomiting. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.

3. The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group that the most important thing to do to prevent the spread of infection is to a. Encourage preschool children to eat a nutritious diet. b. Encourage parents to provide a multivitamin to the children. c. Clean the toys every afternoon before putting them away. d. Wash their hands between each interaction with children.

ANS: D The single most important thing that individuals can do to prevent the spread of infection is to wash their hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose, as well as after cleaning toys or tables, after picking up after the children, and between touching each individual child. It is important for preschool children to have a nutritious diet; a healthy individual can fight infection more effectively. A physician, along with the parent, makes decisions about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most important thing to do in this scenario.

2. The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the chain of infection for possible solutions. Arrange these items in the proper order. (All answers are utilized.) a. A mode of transmission b. An infectious agent or pathogen c. A susceptible host d. A reservoir or source for pathogen growth e. A portal of entry to a host f. A portal of exit from the reservoir

B, D, F, A, E, C The nurse manager is evaluating the chain of infection to determine actions that could be implemented to influence the spread of infection in the intensive care unit. Understanding the spread of infection and directing actions toward those steps have the potential to decrease infection in the setting. For spread of infection, the chain has to be uninterrupted with an infectious agent, a reservoir and portal of exit, a mode of transmission, a portal of entry, and a susceptible host.

1. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. Select the correct order for removal of the personal protective equipment and associated tasks. (All answers are utilized.) a. Remove eyewear/face shield and goggles. b. Perform hand hygiene. c. Remove gloves. d. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. e. Remove mask by strings; do not touch outside of mask. f. Dispose of all contaminated supplies and equipment in designated receptacles. g. Leave room and close the door.

C, A, D, E, B, G, F The correct order for removing personal protective equipment for a patient in a protective environment and for performing associated tasks is to remove gloves, remove eyewear, remove gown, remove mask, perform hand hygiene, leave room and close doors, and dispose of all contaminated supplies and equipment in a manner that prevents the spread of microorganisms.