Chapter 31 NPN

A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with hand washing. 2. Assist the client back to bed. 3. Change the clients bed. 4. Leave the clients room

1 Rationale 1: The client should utilize good hand washing after going to the bathroom. The unlicensed assistive personnel should assist the client with hand washing

A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room.

1 Rationale 1: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask.

The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the clients room. 3. Wash hands. 4. Wear a mask for all client care

3 Rationale 3: Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections.

The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only.

4 Rationale 4: Touching the mask by the strings is the appropriate intervention because the mask is considered contaminated

The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile object to a sterile field with a clean gloved hand

4 Rationale 4: Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile

The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy 3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy

Rationale 4: The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86-year-old client is also on steroid therapy, which compromises the immune system

The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? 1. Disinfecting an item before adding it to a sterile field 2. Allowing sterile gloved hands to fall below the waist 3. Suctioning the oral cavity of an unconscious client 4. Touching only the inside surface of the first glove while pulling it onto the hand

Rationale 4: Touching only the inside surface of the first glove while pulling it onto the hand is the correct technique when applying sterile gloves. This prevents contamination of the outside of the glove, which must remain sterile.

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications 2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment

Rationale 4: Using personal protective equipment demonstrates medical asepsis

The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the clients body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient

Rationale 4: Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus.

While irrigating a clients abdominal wound, the irrigate splashes into the nurses nose and eyes. What should the nurse do? 1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline. 2. Begin HIV high-risk exposure prophylaxis within 24 hours. 3. Wash the areas with soap and water. 4. Have blood drawn for hepatitis B antibodies.

1 Rationale 1: After an exposure to the mucous membranes, the area should be flushed for 5 to 10 minutes with saline or water

The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment (PPE) sparingly. 4. Wear gloves at all times

1 Rationale 1: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements

1 Rationale 1: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode.

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication. 5. Client is ambulating twice a day with assistance.

1, 2, 3 Rationale 1: Bacteremia can occur from an intravascular line. Rationale 2: The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter. Rationale 3: After surgery, the clients health status is compromised, lowering the clients defenses to fight infection

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention

1, 2, 3 Rationale 1: Intact skin is the bodys first line of defense against microorganisms. Rationale 2: Intact mucous membranes are the bodys first line of defense against microorganisms. Rationale 3: Peristalsis tends to move microbes out of the body

A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? Standard Text: Select all that apply. 1. Hand-washing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing 4. Increasing contact with others 5. Restricting rest period

1, 2, 3 Rationale 1: The nurse should instruct the client on the correct hand-washing technique to reduce the risk of infection. Rationale 2: The nurse should instruct the client on the importance of adequate nutrition to reduce the risk of infection. Rationale 3: The nurse should instruct the client to cover the mouth and nose when coughing or sneezing to reduce the risk of infection.

A client diagnosed with an infectious disease asks the nurse how the infection got inside her body. Which responses would be appropriate for the nurse to make? Standard Text: Select all that apply. 1. It depends on the number of organisms present to cause a disease. 2. It depends on how aggressive the organisms are to cause a disease. 3. It depends upon how the organisms get inside the body to cause a disease. 4. It depends upon where the person is at the time the disease is present. 5. It depends upon where the person works

1, 2, 3, 4 Rationale 1: It depends on the number of organisms present to cause a disease addresses the number of microorganisms present. Rationale 2: It depends on how aggressive the organisms are to cause a disease addresses the virulence and potency of the microorganisms. Rationale 3: It depends upon how the organisms get inside the body to cause a disease addresses the ability of the microorganisms to enter the body Rationale 4: It depends upon where the person is at the time the disease is present addresses the susceptibility of the host and the ability of the microorganisms to live in the hosts body.

The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? Standard Text: Select all that apply. 1. Triclosan 2. Chlorine (bleach) 3. Isopropyl alcohol 4. Hydrogen peroxide 5. Chlorhexidine gluconate

1, 3, 5 Rationale 1: Triclosan is an agent that can be used on the hands as a disinfectant. Rationale 3: Isopropyl alcohol is an agent that can be used on the hands as a disinfectant. Rationale 5: Chlorhexidine gluconate is an agent that can be used on the hands as a disinfectant.

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? 1. Cut the needle off a syringe after using it to give a client an injection. 2. Dispose of blood-contaminated materials in a biohazard container. 3. Gloves should not be worn for client care unless body fluids are seen. 4. Wear a mask when in direct contact with all clients.

2 Rationale 2: Disposal of blood-contaminated materials in a biohazard container is a standard precaution

The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a clients room. What action should the nurse take first for this puncture wound? 1. Complete an injury report. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water

2 Rationale 2: Encouraging bleeding is the first step

A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mothers breast milk with antibodies in it

2 Rationale 2: Receiving an immunization for rabies is an example of artificially acquired passive immunity.

The nurse is preparing to remove soiled gloves. What action should the nurse take first? 1. Drop the gloves into the appropriate waste receptacle. 2. Ease the fingers into the gloves. 3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove

3 Rationale 3: In order to remove gloves after use, one must grasp the outside of the nondominant glove

A client needs to be placed in contact isolation. What items should the nurse ensure are included in this clients room? 1. Cabinet stocked with gloves and gowns 2. Cards and records 3. Paper towels, sink, and blood pressure cuff 4. Sign on the door

3 Rationale 3: Paper towels and a sink for hand washing should be in the clients room so they can be used before the staff leaves the room. A blood pressure cuff needs to stay in the clients room to prevent cross contamination.

The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap

4 Rationale 4: Approximately 1 teaspoon of soap should be used when performing proper hand-washing technique

The nurse is preparing to leave a clients isolation room. Which action should the nurse take first when removing a grossly soiled gown? 1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first.

4 Rationale 4: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. After the neck ties are untied, the gown is allowed to fall forward

The nurse needs to apply personal protective equipment before entering a clients room. In which order should the nurse perform the following actions? Standard Text: Place the steps in the order in which they should be performed. 1. Apply gloves. 2. Apply eyewear. 3. Apply the gown. 4. Apply the face mask. 5. Perform hand hygiene

5, 3, 4, 2, 1 Rationale 1: Gloves are applied last. Rationale 2: Protective eyewear is applied after the face mask. Rationale 3: The gown is applied after hand hygiene. Rationale 4: The face mask is applied after the gown. Rationale 5: Before applying personal protective equipment, hand hygiene should be performed

The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound? 1. Adjust the diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify the physician of any edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide

Rationale 3: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection.

An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client

Rationale 4: How susceptible the client is for an infection is one of the factors that influences microorganism growth. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact.

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem

Rationale 1: Anxiety is appropriate because the client is discussing the impact of the communicable disease on work and home life

A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities

Rationale 2: Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection

The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin

Rationale 2: When the client has the disease, the body stimulates the process of acquired active immunity