Concept Week 1 :CH24
Which client presents the most significant risk factors for the development of Clostridium difficile infection? 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis 30-year-old client who has recently contracted human immunodeficiency virus (HIV) 44-year-old client who is paralyzed and whose pressure injury on the coccyx required a skin graft 56-year-old client with acute kidney injury who receives hemodialysis three times weekly
)81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis (Two common factors that increase a client's risk of becoming infected with Clostridium difficile are age greater than 65 and current or recent use of antibiotics. The client who is 81 years of age and received recent, long-term antibiotic therapy is at significant risk C. difficile infection. These risk factors supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.
An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate? Fomite Airborne Droplet Contact
Airborne ( The nurse should implement airborne precautions for clients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). Droplet precautions should be used for clients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Contact precautions should be used for clients who are infected or colonized by a multidrug-resistant organism (MDRO). )
After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter? Alcohol-based hand rub Soap and water hand washing technique Scrubbing hands with soap, water, and brush Mixture of soap and alcohol-based hand rub techniques
Alcohol-based hand rub (Alcohol-based hand rubs may be used if hands are not visibly soiled, or have not come in contact with blood or body fluids. They should be used before and after each client contact, or when in contact with surfaces in the client's environment. Indications for washing hands with soap and water include visibly dirty hands, hands visibly soiled with body fluids, or after using the toilet. Concomitant alcohol-based hand rub and soap and water use is not recommended. Surgical hand hygiene is reserved for sterile procedures.)
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action? change to contact precautions change to airborne precautions change to standard precautions continue with droplet precautions
change to airborne precautions (Tuberculosis is transmitted via the air, so airborne precautions are required. The other answers are incorrect.)
When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? fold soiled side to the inside and roll with inner surface exposed fold soiled side to the outside and roll with outer surface exposed fold soiled side to the inside and roll with outer surface exposed fold soiled side to the outside and roll with inner surface exposed
fold soiled side to the inside and roll with inner surface exposed (To dispose of the gown, the nurse will fold the soiled side to the inside and roll with the inner surface exposed. The other answers are incorrect.)
The nurse is preparing to help mobilize a client with an abdominal wound that is colonized by methicillin-resistant Staphylococcus aureus (MRSA). Which of the shown actions should the nurse perform before assisting the client?
gloves (Drug-resistant wounds normally require contact precautions. This necessitates the use of gloves and a gown but not a mask, goggles, or face shield.)
Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? wearing a particulate respirator for all care and interaction with this client wearing a face mask when entering and staying at a distance from the client wearing protective eye wear for contact with this client placing the client in a regular, private room
wearing a particulate respirator for all care and interaction with this client (To prevent the transmission of TB, the National Institute for Occupational Safety and Health recommends the use of a particulate air filter respirator that fits snugly to the face for all client care and interaction. A face mask does not block small TB particles effectively. Protective eyewear is only needed if contact with bodily fluids is expected. The client would be placed in a negative pressure room to prevent the potential spread of TB.)
A client is being screened for a parasitic infection and the health care provider orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: 2 days. 3 days. 4 days. 5 days.
3 days. (Usually when a client is being screened for a parasitic infection, stool specimens are collected daily for 3 days. Parasites lay eggs in the GI tract that can be detected on examination. Moving organisms can easily be detected in fresh specimens.)
The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.
Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? Escherichia coli in the intestinal tract Escherichia coli in the urinary tract Shigella in the intestinal tract Shigella in the urinary tract
Escherichia coli in the intestinal tract (Escherichia coli resides in the intestinal tract, is normal flora, and does not cause harm or infection in the client. Shigellosis is an infectious disease caused by a group of bacteria called Shigella, closely related to E. coli. Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria.)
The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection? Hand hygiene Good nutrition and getting enough rest Avoid crowded areas and people who have the flu How to properly wear a mask during flu season
Hand hygiene (Hand hygiene is the most effective way to control the spread of microorganisms. While it is true that the client may be less susceptible to illness when well rested, exposure to a pathogen can still result in influenza. Avoiding those with the flu is also appropriate; however, hand washing remains the best answer for prevention. Wearing a mask all season may or may not prevent the flu and is not the most reasonable choice.)
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client? Vancomycin-resistant enterococci and urinary tract infection Clostridium difficile and colitis Coronary artery bypass grafting MRSA in the wound
MRSA in the wound (In many situations, clients with like infections can be placed together. The presence of similar causative microorganisms negates the risks of cross-contamination. Each of the other listed clients would encounter a risk for MRSA.)
The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first? Put on personal protective equipment, if required. Perform hand hygiene. Check that the packaged kit is dry and unopened. Set up a work area at waist level.
Perform hand hygiene. (When preparing for a sterile procedure, the nurse will perform hand hygiene followed by any personal protection equipment, if required. Next, the nurse confirm the client's identity with the order and explains the procedure to the client. Then, the nurse the will check that the sterile package or kit is dry and unopened as well as the expiration date. Next, the nurse will set up a work area at waist level or higher followed by opening the outside package and remove the kit.)
The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? Allow many family members to visit at once. Deliver flowers and balloons to the room. Remove fresh fruit from the room. No special precautions are required.
Remove fresh fruit from the room. (Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.)
What is an accurate guideline for the use of PPE? Put on PPE after entering the client's room. Substitute personal glasses for protective eyewear, if desired. Replace gloves if they are visibly soiled. When wearing gloves, work from "dirty" areas to "clean" ones.
Replace gloves if they are visibly soiled. (If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas.)
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? Surgical asepsis Medical asepsis Universal precautions Contact precautions
Surgical asepsis (Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter. Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.)
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene? The nurse uses gloves in place of hand hygiene. The nurse keeps fingernails less than 1/4 in (0.63 cm) long. The nurse uses hand hygiene instead of gloves when in contact with blood. The nurse refrains from using hand moisturizer following hand hygiene.
The nurse keeps fingernails less than 1/4 in (0.63 cm) long. (The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood. The nurse could use a hospital sanctioned hand moisturizer after hand hygiene, but this is not the best answer.)
Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup? Bacteria Fungi Virus Parasites
Virus (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.)
For which clients would the nurse be required to use droplet precautions? Select all that apply.
a client with rubella a client with mumps a client with diphtheria prioritization (Droplet precautions would be used for clients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. For tuberculosis and SARS, airborne precautions would be used. Contact precautions would be the primary method of precautions with MRSA.)
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client? standard airborne droplet contact
airborne (Tuberculosis is transmitted via the air. Therefore, airborne precautions are required. Standard, droplet, and contact precautions will not be selected by the nurse for a client who has tuberculosis.)
A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess? clear mucus productive cough dyspnea abnormal breath sounds
clear mucus (Assessment findings associated with a respiratory infection include productive cough, dyspnea, and abnormal breath sounds. Sputum changes in color from clear to possibly yellow, brown, or green.)
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin? airborne droplet contact none
contact (Fluids from a draining abscess can transmit infection through contact; therefore contact precautions are appropriate.)
Which nursing action is a component of medical asepsis? handwashing after removing gloves insertion of an indwelling urinary catheter insertion of an intravenous catheter drawing blood from a central line
handwashing after removing gloves (Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood).)
A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is: it is an antiviral vaccine used to eradicate wound infection. it is a vaccine given to booster antibodies towards the tetanus pathogen. it induces humoral immunity in the client's blood. It counteracts the effects of the inflammatory process.
it is a vaccine given to booster antibodies towards the tetanus pathogen. (Active immunity is produced when the immune system is stimulated, either naturally or artificially, to produce antibodies. Natural immunity occurs after an infection has run its course.)
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? contagious disease infectious disease communicable disease noncommunicable disease
noncommunicable disease (A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe an illness that is contracted after eating food.)
The most common infection in children is: respiratory. gastrointestinal. neurologic. urinary.
respiratory
The most lethal infection in an older adult client is: skin. optic. otic. urinary.
urinary (Urinary tract infections and respiratory infections are most common and most lethal for older adult clients.)
Which factor has contributed to resistant microbial strains? antibiotic use for bacterial infections use of antibiotics in clients with viral infections use of topical antibiotics on skin abrasions mutation of common disease-causing viruses
use of antibiotics in clients with viral infections (The overprescribing of antibiotics for viral infections has contributed to the evolution of resistant microbial strains. Antibiotics are intended for bacterial infections and topical use has not been linked to the development of resistance. Viral mutation does not cause resistance, since viruses are never susceptible to antibiotics.
A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client? changing gloves after contact with the client's infective material using a special high-filtration particulate respirator wearing a mask when working within 3 feet (1 m) of the client washing hands with an antimicrobial agent or waterless antiseptic agent
wearing a mask when working within 3 feet (1 m) of the client (Rubella spreads through droplet transmission; therefore, the nurse should wear a mask when working within 3 feet of the rubella client as a precaution against droplet transmission. Changing gloves after contact with the client's infective material and washing hands with an antimicrobial agent or waterless antiseptic agent are contact precautions used for clients with diseases that spread through contact transmission. Using a special high-filtration particulate respirator is an airborne precaution followed in cases of clients with active tuberculosis.)
The nurse is caring for a client admitted with tuberculosis. The client asks why the nurse wears a respirator, gown, and gloves whenever they are in the room. How should the nurse respond? "Because of the tuberculosis, I need to follow airborne precautions for protection." "The droplet precautions are to protect me from the tuberculosis." "I wear the equipment to protect you from anything I could give you." "This equipment is just standard precautions for all clients."
"Because of the tuberculosis, I need to follow airborne precautions for protection." (The client has tuberculosis, which requires airborne precautions as described by the respirator, gloves, and gown. Droplet precautions are insufficient for clients with tuberculosis. Equipment to protect the client describes neutropenic precautions, which would only be a mask and proper hand hygiene when entering the room. Standard precautions do not include respiratory, gown, and gloves.)
A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? "I will not visit my family member in the first 3 days of my cold." "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." "I will obtain a mask from the staff and wash my hands before touching my family member." "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."
"I will obtain a mask from the staff and wash my hands before touching my family member." (Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is an older adult or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.)
A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse? "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." "You cannot be admitted to the hospital with pneumonia without receiving some sort of antibiotics." "We give antibiotics to treat the virus that are causing your the pneumonia." "The antibiotics we are giving you will boost your immune system and help fight off whatever pathogen is present."
"We are giving you broad spectrum antibiotics because they are active for many types of bacteria." (Many bacteria are susceptible to broad-spectrum antibiotics and prior to the diagnosis of a specific bacteria, a broad-spectrum antibiotic will be prescribed to help eradicate the present bacteria until a culture result is returned. A client may be admitted to the hospital with pneumonia without receiving antibiotics, although it is likely that an antibiotic will be given at some point during hospitalization. Antibiotics do not boost the immune system and may destroy normal healthy flora. Antibiotics are used to treat bacterial infections, not viral infections; antibiotics do not kill viruses.)
The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first? Educate the client of the importance of infection prevention. Assess client's pain level and manage pain accordingly. Inform the client that these exercises must be done at regular intervals. Inform the health care provider of the client's noncompliance
Assess client's pain level and manage pain accordingly. (Encouraging clients to cough, breathe deeply, blow the nose, and move the body promotes clearance of respiratory secretions, which may become infected if allowed to pool in the lower respiratory tract. Retained secretions prevent adequate gas exchange at the alveolar level and reduce oxygen available to the tissues to combat infection, heal injured tissues, and meet metabolic needs. Secondary infections are commonly associated with impaired respiratory tract function. Timing is an important consideration when administering analgesics. To time analgesics appropriately, know the average duration of action for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense. For example, an analgesic would be offered before ambulating a client postoperatively.
About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? Avoid contact with mosquitoes Use hand sanitizer after touching any public surface Self-quarantine yourself for 2 weeks if you feel ill Use a face mask when in crowds
Avoid contact with mosquitoes ( Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate. )
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene? Decontaminate hands using an alcohol-based hand rub. Do not wash hands; apply clean gloves. Wash hands with soap and hot water. Wash hands with soap and water, followed by an alcohol-based hand rub.
Decontaminate hands using an alcohol-based hand rub. (Alcohol-based hand rubs can be used if hands are not visibly soiled. If the hands are visibly soiled, the nurse should wash hands with soap and hot water. The nurse should wash their hands. The nurse does not need to wash their hands AND use an alcohol-based hand rub.)
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? Change the sterile field, but reuse the sterile equipment. Proceed with the procedure since it was only touched by the client. Discard the sterile field and the supplies and start over. Call for help and ask for new supplies.
Discard the sterile field and the supplies and start over. (The nurse's next appropriate action would be to discard the sterile field and the supplies and start over. The client touching the end of the sterile field contaminated the field and the items on the field. The nurse cannot reuse the sterile equipment because the items are no longer sterile. The nurse cannot proceed with the procedure since the items have been contaminated. Calling for help and asking for new supplies is not the best answer. The field has been contaminated also.)
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? Discard it in the waste can. Do nothing; it can be used again immediately. Disinfect it with alcohol swabs. Sterilize it by placing it in the autoclave.
Disinfect it with alcohol swabs. (Equipment such as stethoscopes, sphygmomanometers, and other assessment tools that are used for clients on contact precautions should be cleaned and disinfected before use on other clients. The other answers are incorrect.)
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? Fungi Rickettsiae Protozoans Helminths
Fungi (Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes.)
A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of: Means of transmission Spore production Aerobic activity Survival adaptation
Survival adaptation ( An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae. Bacterial resistance is not demonstrated by aerobic activity. Spore production is another form of adaptation. Means of transmission is a component of the chain of infection, not an example of bacterial resistance. )
The client is to be discharged home with the wife providing some wound care. Which interventions can the wife perform at home? Select all that apply.
Take vital signs before giving medications. Monitor the wound for signs of infection. Provide basic hygiene care. Properly dispose of contaminated supplies. (Clients and their caregivers must learn how to evaluate vital signs, give medications, and observe for signs of infection. Stress the importance of basic hygiene measures such as bathing, toileting, and oral care as well as basic aseptic practices. Educate clients and caregivers about the importance of proper hand hygiene and proper disposal of contaminated supplies. Instruction in sterile technique is necessary for managing IV devices and IV medications.)
A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate? The client will state how to safely take the prescribed antibiotic. The client will identify signs and symptoms of worsening infection. The client will verbalize measures appropriate to minimize infection transmission. The client demonstrates the proper technique for hand hygiene.
The client will state how to safely take the prescribed antibiotic. (The client's knowledge deficit is related to antibiotic therapy. Therefore, the most appropriate outcome would be that the client states how to take the prescribed antibiotic. Identifying signs and symptoms of infection would relate to a nursing diagnosis of Deficient Knowledge related to infection. Verbalizing measures to minimize risk and demonstrating proper hand hygiene would be appropriate for a nursing diagnosis of Knowledge Deficit related to infection control or transmission, or possibly a nursing diagnosis of Risk for Infection.)
The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply.
The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room. (Alcohol-based handrub is preferred in situations when hands are not visibly soiled; before and after touching a client; before handling an invasive device for client care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; and after removing sterile or nonsterile gloves. Use of an alcohol-based handrub does not replace the need for gloves or for handwashing, however. After performing catheter care and assisting with changing a colostomy, gloves are worn and handwashing should take place.)
The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.
Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.
The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding confirms the client has developed an infection? Urine culture is positive for vancomycin-resistant enterococci (VRE). The client reports nausea and vomiting. The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C). The nurse notes the client's urine is dark yellow with sediment.
Urine culture is positive for vancomycin-resistant enterococci (VRE). (Infections result from pathogens that produce illness after invading body tissues and organs. The client with the indwelling urethral catheter is at risk for developing an infection. The finding that confirms an infection would be a positive result on culture. Nausea and vomiting, a fever, and dark yellow urine with sediment are possible signs of an infection, but each of these findings alone does not confirm an infection.)
The community nurse is educating a family about infection control measures. What teaching will the nurse include? Select all that apply. Hand hygiene is not needed in the home environment. Wear personal protective equipment (PPE) when appropriate. Standard precautions should be used when family members have active infections. Do not share drinking glasses with family members who are ill. Keep the entire living environment as clean as possible.
Wear personal protective equipment (PPE) when appropriate. Standard precautions should be used when family members have active infections. Do not share drinking glasses with family members who are ill. Keep the entire living environment as clean as possible. (Wearing PPE when appropriate, practicing good hand hygiene, and keeping the living environment clean interfere with the chain of infection. Drinking glasses should be cleaned or sterilized (depending on type of infection present) between uses. Standard precautions should be used if a family member has an active infection.)
A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients? indwelling catheter bath blanket face shields specimen containers
indwelling catheter (Infections are often transmitted to older adult clients through equipment reservoirs (e.g., indwelling urinary catheters, humidifiers, and oxygen equipment) or through incisional sites, such as those for intravenous tubing, parenteral nutrition, or tube feedings. Use of proper aseptic techniques is essential to prevent the introduction of microorganisms. Bath blankets, face shields, and specimen containers are not part of the equipment reservoir that transmits infection easily, because they are disposed of immediately after one-time use. )
What is the second line of defense in microbial invasion? Inflammation Infection Disease Disability
inflammation
The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? into a private room with a client with pneumonia with a client with a myocardial infarction with another client with a draining wound
into a private room ( The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate. )
Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care? redness size over sacral area is with minimal increase blanching over elbow area noted skin is dry and intact slight bleeding noted while old dressing is removed
skin is dry and intact (The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare.)
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first? urinary catheter PICC line Salem sump nasogastric tube endotracheal tube
urinary catheter (Urinary catheters account for the highest percentage (26%) of hospital-associated infections. The four most common types of HAIs are related to invasive devices or surgical procedures: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated events (VAEs). A peripherally inserted catheter is an invasive line. Nasogastric tubes and endotracheal tubes are not associated with HAIs.)