Foundations Exam 1 // CH 24

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

A. Exudate B. Pain C. Redness E. Swelling

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin? A. droplet B. contact C. none D. airborne

B. contact

Any microorganism capable of disrupting normal physiologic body processes is a: A. bacterium. B. pathogen. C. fomite. D. virus.

B. pathogen

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? A. Protozoans B. Helminths C. Rickettsiae D. Fungi

D. Fungi

A client with HIV is the: A. virulence. B. pathogen. C. specificity. D. carrier.

D. carrier.

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: a. droplet precautions. b. reverse precautions. c. universal precautions. d. body-substance isolation.

c. universal precautions.

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens? a. place each of the three sealed specimens in a separate paper bag b. swab the outside of each specimen container with alcohol prior to transport c. wear gloves and a gown when transporting the specimen d. place the specimens into plastic biohazard bags

d. place the specimens into plastic biohazard bags

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood? a. 2000 b. Wait until day 5 of treatment. c. 1500 d. 1200

1500

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response? A. "Help me understand your thoughts about vaccinations." B. "Transmission of certain diseases is halted with vaccination." C. "Has your child received any previous vaccinations?" D. "Vaccinations prevent disease."

A. "Help me understand your thoughts about vaccinations."

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? A. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." B. "I received a blood transfusion in 1989, which could be a factor in contracting the disease." C. "I may have gotten the virus when I got a tattoo while I was in prison." D. "I can't transmit the virus other people if I shake their hands."

A. "I probably got the virus when I sat on the toilet seat in a dirty bathroom."

Following insertion of a foley catheter, the nurse instructs the unlicensed assistive personnel (UAP) to remove the sterile gloves by inverting one glove into the other. The UAP asks, "Why is that important?" Which response by the nurse is most appropriate? A. "Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms." B. "Inverting the gloves makes it easier to remove the gloves and throw them away." C. "Inverting the gloves after inserting a foley prevents the potential for client infection." D. "Inverting the gloves prevents any soil on the outside from getting on your uniform."

A. "Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms."

Which practice is a correct application of infection control practices? A. A nurse performs hand washing each time the nurse removes a pair of gloves. B. A nurse rinses hands thoroughly after the application of an alcohol-based hand rub. C. A nurse dons a pair of gloves prior to any client contact. D. A nurse uses an alcohol-based hand rub each time that the nurse's hands are visibly soiled.

A. A nurse performs hand washing each time the nurse removes a pair of gloves.

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? A. Decontaminate hands using an alcohol-based hand rub. B. Wash hands with soap and hot water. C. Wash hands with soap and water, followed by an alcohol-based hand rub. D. Do not wash hands; apply clean gloves.

A. Decontaminate hands using an alcohol-based hand rub.

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

A. Discard the supplies and field and prepare a new sterile field.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? A. Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. B. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing C. delivering a meal tray to a VRE-positive client without first donning gloves and a gown D. sending a VRE-positive client to the radiology department for a chest X-ray without a face mask

A. Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student? A. Hand hygiene is needed after contact with objects near the client. B. Hand lotions should not be used after hand hygiene. C. The use of gloves eliminates the need for hand hygiene. D. The use of hand hygiene eliminates the need for gloves.

A. Hand hygiene is needed after contact with objects near the client.

A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply. A. Hepatitis B B. Hepatitis C C. Tuberculosis D. HIV

A. Hepatitis B B. Hepatitis C D. HIV

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

A. Hold sterile objects above waist level to prevent accidental contamination.

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply. A. Nonsterile gloves B. Hand hygiene C. Gown D. Mask E. Sterile gloves

A. Nonsterile gloves B. Hand hygiene

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

A. Replace gloves if they are visibly soiled.

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms? A. The client's immune system became further weakened B. The client's normal flora began producing spores C. The resident microorganisms mutated and became virulent D. The client's normal flora proliferated because of a nutritional deficit

A. The client's immune system became further weakened

The charge nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction? A. The new nurse drops the item from the wrapper into the side of the sterile field. B. The new nurse holds wrapped item in dominant hand to open, opening top flap away from body. C. The new nurse grasps the remaining flap of the wrapper and pulls back toward wrist. D. The new nurse keeps hands and wrists on the outside of the wrapped sterile item.

A. The new nurse drops the item from the wrapper into the side of the sterile field.

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

A. The nurse carries soiled items away from the body. C. The nurse moves soiled equipment away from the body when cleaning it. E. The nurse cleans least soiled areas first and then moves to more soiled ones.

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

A. To protect both the staff and clients from becoming infected by one another

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply. A. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. B. Nurses may use a waterproof gown more than one time. C. During some care activities for an individual client, nurses may need to change gloves more than once. D. Nurses need only apply clean gloves when performing or assisting with invasive client procedures. E. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. F. Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse.

A. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. C. During some care activities for an individual client, nurses may need to change gloves more than once. E. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator.

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client? A. Wear gloves whenever entering the client's room. B. Keep visitors 3 feet (1 m) from the client. C. Use respiratory protection when entering the room. D. Place the client in a private room that has monitored negative air pressure.

A. Wear gloves whenever entering the client's room.

For which client would the use of standard precautions alone be appropriate? A. an incontinent client in a nursing home who has diarrhea B. a client with diphtheria who needs p.m. care C. a client with TB who needs medications administered D. a child with chickenpox who is treated in the emergency room

A. an incontinent client in a nursing home who has diarrhea

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

A. contact

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? A. contact precautions B. airborne precautions C. standard precautions D. droplet precautions

A. contact precautions

A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to don PPE. Which would be appropriate? Select all that apply. A. gloves B. respirator C. mask with face shield D. gown

A. gloves C. mask with face shield D. gown

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

A. handwashing before leaving the client's room

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

A. keeping sterile field above waist level

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition? A. noncommunicable disease B. infectious disease C. contagious disease D. communicable disease

A. noncommunicable disease

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

A. removes gloves and walks out of the room

The nurse is teaching a community group about transmission of HIV. Which client statement by a community member demonstrates that further teaching is needed? A. "I should not share razors or toothbrushes with others." B. "I can catch HIV by swimming in pools." C. "HIV is transmitted through sexual contact." D. "Someone can be exposed to this virus by sharing needles."

B. "I can catch HIV by swimming in pools."

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? A. "My personal belongings should remain in the room until I am discharged." B. "I can leave my room any time I want as long as I wear a mask." C. "Any staff who enters my room will be wearing personal protective equipment (PPE)." D. "I will tell my visitors to keep their distance from me."

B. "I can leave my room any time I want as long as I wear a mask."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? A. "Drug resistance can develop when the wrong antibiotic is used for pneumonia." B. "This antibiotic is the best choice since the causative organism is not known." C. "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." D. "Pneumonia is usually caused by multiple organisms."

B. "This antibiotic is the best choice since the causative organism is not known."

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds: A. "A cesarean section will prevent a herpes outbreak." B. "You may have infection in your birth canal that you are unaware of." C. "Have you discussed this with your physician?" D. "You will likely have an outbreak due to the stress of labor and delivery."

B. "You may have infection in your birth canal that you are unaware of."

Which client presents the most significant risk factors for the development of Clostridium difficile infection? A. A client with renal failure who receives hemodialysis three times weekly B. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis C. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior D. A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft

B. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

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

B. Client with a urinary catheter

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

B. Don another pair of sterile gloves.

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

B. Escherichia coli in the intestinal tract

An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client? A. Perform hand antisepsis using a designated bleach solution. B. Perform surgical hand scrub using detergent. C. Wash hands with soap or detergent. D. Apply alcohol-based handrub up to the mid-forearm

B. Perform surgical hand scrub using detergent.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? A. Pour the liquid into the cap of the bottle and dip the gauze as needed. B. Pour the liquid into a sterile container within the sterile field. C. Pour the liquid into the palm of a sterile gloved hand for use. D. Pour the liquid onto gauze on the sterile field until the gauze is moist.

B. Pour the liquid into a sterile container within the sterile field.

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

B. Surgical asepsis

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

B. The fact that sterile technique was used for a given procedure

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety? A. The nurse keeps visitors 3 feet away from the infected person. B. The nurse places the client in a private room with monitored negative air pressure. C. The nurse places the client in a private room with the door open. D. The nurse uses droplet precautions when providing care for the client.

B. The nurse places the client in a private room with monitored negative air pressure.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply. A. The nurse disposes of an opened container of sterile saline after half is used. B. The nurse touches an unsterile object to the instrument tray. C. The nurse keeps hands above waist level while donning sterile gloves. D. The nurse is talking with the scrub nurse over the sterile field. E. The nurse's back is facing the sterile field.

B. The nurse touches an unsterile object to the instrument tray. D. The nurse is talking with the scrub nurse over the sterile field. E. The nurse's back is facing the sterile field.

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

B. Use a sterile cotton-tipped applicator to apply the prescription to the site

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation? A. After direct contact with clients B. When hands are visibly soiled C. After completing a wound dressing D. Before direct contact with clients

B. When hands are visibly soiled

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

B. When the nurse's hands are visibly soiled

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? A. an adolescent who has a right radial fracture B. an older adult client with a history of heart failure C. a middle-aged adult who takes prescribed medication to control blood pressure D. a school-age child who is current with immunizations

B. an older adult client with a history of heart failure

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply. A. health care-associated infection (HCAI) B. contagious disease C. noncommunicable disease D. infectious disease E. communicable disease

B. contagious disease D. infectious disease E. communicable disease

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

B. encourage the colleague to remove the glove by grasping the cuff

To eliminate needlesticks as potential hazards to nurses, the nurse should: A. slide the needle into the cap and deposit it in a puncture-proof plastic container. B. immediately deposit uncapped needles into a puncture-proof plastic container. C. stick the uncapped needle into a Styrofoam block and deposit it in a plastic container. D. place the uncapped needle on a tray and carry it to the medicine room for disposal.

B. immediately deposit uncapped needles into a puncture-proof plastic container.

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

B. noncommunicable disease

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

B. older male with an enlarged prostate

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds? A. one that the client has personally purchased for use B. one that remains in the client's room C. one that remains directly outside the client's room D. one that is the nurse's personal stethoscope

B. one that remains in the client's room

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? A. avoid direct contact with the client B. perform hand hygiene before and after entering the client's room C. wear gloves when touching the client D. wear a mask and gown in the client's room

B. perform hand hygiene before and after entering the client's room

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action? A. to protect the integrity of the nurse's immune system B. to eliminate disease-producing organisms from the nurse's skin C. to prevent the nurse from developing disease D. to sterilize the nurse's hands to prevent infection

B. to eliminate disease-producing organisms from the nurse's skin

A team of nurses is caring for a client with tuberculosis. They have not been fitted for N95 respirators. How will the team proceed with care? A. enter the room as normal but maintain a 3-foot (1-meter) distance from the client B. utilize a powered air purifying respirator (PAPR) c. use a regular mask and continue to provide care as usual d. refrain from providing care until a nurse who has been fitted arrives

B. utilize a powered air purifying respirator (PAPR)

Before and after doing aseptic techniques with a client, the nurse should: A. sterilize equipment. B. wash hands. C. apply clean gloves. D replace equipment.

B. wash hands.

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? A. "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." B. "We only wash our hands when they are visibly soiled." C. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." D. "Washing the hands with soap and water is not necessary."

C. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

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

C. Apply a nonparticulate (N-95) respirator when entering the room.

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? A. Remove the gown immediately after exiting the room. B. Perform hand hygiene before removing the gown. C. Avoid touching the outer surfaces of the gown. D. Remove the gown before removing gloves.

C. Avoid touching the outer surfaces of the gown.

A client is admitted to the hospital with pneumonia. The nurse is preparing to enter the client's room. Which action would the nurse perform first? A. Auscultate the client's breath sounds B. Explain the steps to use incentive spirometry C. Compete hand hygiene and don gloves D. Assess the client's oxygen saturation

C. Compete hand hygiene and don gloves

A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take? A. Ask the parent to take the child home. B. Ask the child to stay at least 2 feet (0.6 meters) away from all other clients. C. Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes. D. Have all clients in the waiting room don face masks.

C. Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique? A. Consider the outside of the sterile package to be sterile. B. Open sterile packages so that the first edge of the wrapper is directed toward the nurse. C. Hold sterile objects above waist level to prevent inadvertent contamination. D. Consider the outer 3-in. (8-cm) edge of a sterile field to be contaminated.

C. Hold sterile objects above waist level to prevent inadvertent contamination.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? A. Revising the facility's infection control protocols B. Encouraging visitors to adhere to isolation precautions C. Incentivizing health care workers to utilize hand hygiene D. Limiting visitors to family members over the age of 18

C. Incentivizing health care workers to utilize hand hygiene

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

C. Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? A. Production of antibodies B. Constriction of the small blood vessels near the wound C. Migration of leukocytes to the area of the wound D. Release of histamine

C. Migration of leukocytes to the area of the wound

The nurse is caring for an older adult client in a long-term care facility who has been previously alert and oriented. The client has become agitated and disoriented to time and place. The client is afebrile. What action by the nurse may assist with the determination of a causative factor in the client's condition? A. Obtain a psychiatric consultation, because the client may be psychotic B. Give the client a meal, because the client may be hungry C. Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection D. Obtain a blood pressure reading, because the client may be hypertensive

C. Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? A. Direct visualization of the sterile field is maintained. B. The top flap of the package is opened away from the new nurse's body. C. The new nurse touches 1.5 in. (4 cm) from the outer edges. D. The sterile field is set up at waist level.

C. The new nurse touches 1.5 in. (4 cm) from the outer edges.

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

C. The nurse removes her gown and then removes her gloves.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection? A. The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C) B. The client reports nausea and vomiting. C. Urine culture is positive for vancomycin-resistant enterococci (VRE). D. The nurse notes the client's urine is dark yellow with sediment.

C. Urine culture is positive for vancomycin-resistant enterococci (VRE).

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

C. Vehicle

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? A. wearing clean unsterile gloves when changing the dressing B. applying a face mask with shield C. changing the soiled dressing D. isolating the client's belongings

C. changing the soiled dressing

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? A. droplet B. airborne C. contact D. vehicle

C. contact

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? A. fold soiled side to the outside and roll with outer surface exposed B. fold soiled side to the outside and roll with inner surface exposed C. fold soiled side to the inside and roll with inner surface exposed D. fold soiled side to the inside and roll with outer surface exposed

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

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

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

A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as: A. endogenous. B. antibiotic resistant. C. iatrogenic. D. exogenous.

C. iatrogenic.

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? A. bath blanket B. face shields C. indwelling catheter D. specimen containers

C. indwelling catheter

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

C. keeping sterile field above waist level

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor? A. stretches the glove over the hand without touching the unsterile area B. washes hands for 20 seconds with soap and water C. reaches down to the bed to pick up a sterile drape D. picks up the glove at the folded edge with the thumb and forefinger

C. reaches down to the bed to pick up a sterile drape

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? A. PICC line B. Salem sump nasogastric tube C. urinary catheter D. endotracheal tube

C. urinary catheter

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

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

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others? A. "Everyone who enters the room must wear a gown and gloves." B. "Under no circumstances should you touch the client." C. "No visitors are allowed in the room to decrease the spread of disease." D. "All visitors who enter the room must wear special masks."

D. "All visitors who enter the room must wear special masks."

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure? A. "I use my whole hand to touch the non-waterproof surface before placing the sterile equipment on it." B. "It is okay to turn the drape on the other side." C. "Using either side of the drape is okay, as long as you do not contaminate the sterile supplies on the field." D. "The way you are doing it helps to minimize contamination of the non-waterproof side."

D. "The way you are doing it helps to minimize contamination of the non-waterproof side."

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator? A. "It is important to refrain from recapping needles." B. "Masks, gloves, and gowns should be used to protect from infectious agents." C. "I will always wash my hands thoroughly and often." D. "Wearing an N95 respirator is critical when I care for clients in droplet precautions."

D. "Wearing an N95 respirator is critical when I care for clients in droplet precautions."

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it. A. 5, 3, 4, 7, 2, 1, 6 B. 5, 2, 7, 1, 3, 4, 6 C. 5, 1, 2, 7, 3, 4, 6 D. 5, 7, 2, 1, 3, 4, 6

D. 5, 7, 2, 1, 3, 4, 6

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

D. A client who is in the prodromal stage

The nurse determines that which client is at greatest risk for a wound infection? A. An infant with intact skin B. A client with a urinary catheter D. A two-day postoperative client C. An older adult client with dry skin

D. A two-day postoperative client

What is an accurate guideline for removing soiled gloves after client care? A. After removing the first glove, slide the fingers of the ungloved hand between the remaining glove and the wrist and pull the glove straight off, with the contaminated area on the outside. B. Remove the glove on the nondominant hand by pulling it straight off, keeping the contaminated area on the outside. C. Use the nondominant hand to grasp the opposite glove, near the cuffed end on the outside exposed area. D. After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.

D. After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown? A. After taking the client's pulse B. Before taking the client's pulse C. After entering the client's room D. Before entering the client's room

D. Before entering the client's room

A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply. A. Candida albicans B. E. coli C. Staphylococcus aureas D. Clostridium difficile E. Norovirus

D. Clostridium difficile E. Norovirus

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate? A. Sterilize it by placing it in the autoclave. B. Discard it in the waste can. C. Do nothing; it can be used again immediately. D. Disinfect it with alcohol swabs.

D. Disinfect it with alcohol swabs.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection? A. Iatrogenic B. Endogenous healthcare-associated C. Antibiotic-resistant D. Exogenous healthcare-associated

D. Exogenous healthcare-associated

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate? A. Notify the CT department in advance so other clients and staff can be removed from the area. B. Request that the examination be done at the bedside. C. Question the need for the examination, because the client must remain under airborne precautions. D. Place a surgical mask on the client and transport to the CT department at the specified time.

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

An operating room (OR) nurse on the facility's infection control team notices that a coworker in the OR is wearing artificial nails. What is the appropriate action/response by the nurse? A. No action is needed at this time B. Remind coworker to wash hands for 2 minutes C. Remind coworker of the need to wear gloves D. Remind coworker that artificial nails increase infections

D. Remind coworker that artificial nails increase infections

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

D. Urinary tract

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

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

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

D. an 81-year-old man with active tuberculosis and a productive cough

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

D. contact

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

D. droplet precautions E. contact precautions F. airborne precautions

The nurse is monitoring a student who is performing surgical hand asepsis. Which student actions indicate the need for further education from the nurse? Select all that apply. A. washing the nails and all surfaces of each finger B. dropping the soapy sponge in the sink to discard C. cleaning beneath each fingernail with a file D. dropping hands to side when the wash is complete E. wearing a gold wedding band F. using at least five strokes for cleansing in each area

D. dropping hands to side when the wash is complete E. wearing a gold wedding band F. using at least five strokes for cleansing in each area

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? A. sterile technique B. signs of healing C. putting on gloves D. hand washing

D. hand washing

A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection? A. pregnant woman B. adult C. child D. older adult

D. older adult

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention? A. teach that a gown and shoe coverings must be worn in addition to gloves B. offer the student a mask C. do nothing, as the precautions observed are appropriate D. remind the student that a fitted N95 respirator is required

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

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)? A. remove gown, remove gloves, wash hands B. remove gloves, wash hands, remove gown C. remove gown, wash hands, remove gloves D. remove gloves, remove gown, wash hands

D. remove gloves, remove gown, wash hands

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

D. the client who is 48-hours postsurgical procedure

Which factor has contributed to resistant microbial strains? A. antibiotic use for bacterial infections B. use of topical antibiotics on skin abrasions C. mutation of common disease-causing viruses D. use of antibiotics in clients with viral infections

D. use of antibiotics in clients with viral infections

A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client? A. washing hands with an antimicrobial agent or waterless antiseptic agent B. using a special high-filtration particulate respirator C. changing gloves after contact with the client's infective material D. wearing a mask when working within 3 feet (1 m) of the client

D. wearing a mask when working within 3 feet (1 m) of the client

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense? A. staying home when sick B. early intervention with antibiotics C. low levels of flora D. the cell-mediated immune response E. intact skin and mucous membranes

E. intact skin and mucous membranes

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

True

Which client presents the most significant risk factors for the development of Clostridium difficile infection? a. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis b. A client with renal failure who receives hemodialysis three times weekly c. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior d. A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft

a. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

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

a. Arrange for the client to be housed in a single room. e. Use appropriate PPE.

The nurse is asked to check the unit's supply of personal protective equipment (PPE) to see if additional equipment needs to be ordered from central supply. The nurse should assess the level of which type of equipment? Select all that apply. a. Masks b. Protective eyewear c. Sterile gloves d. Nonsterile gloves e. Gowns

a. Masks b. Protective eyewear d. Nonsterile gloves e. Gowns

The community nurse is educating a family about infection control measures. What teaching will the nurse include? Select all that apply. a. Standard precautions should be used when family members have active infections. b. Do not share drinking glasses with family members who are ill. c. Wear personal protective equipment (PPE) when appropriate. d. Keep the entire living environment as clean as possible. e. Hand hygiene is not needed in the home environment.

a. Standard precautions should be used when family members have active infections. b. Do not share drinking glasses with family members who are ill. c. Wear personal protective equipment (PPE) when appropriate. d. Keep the entire living environment as clean as possible.

The nurse is caring for an older adult with influenza. Which precautions will the nurse begin? a. droplet b. none c. contact d. airborne

a. droplet

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

b. "When your sputum culture is negative."

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

b. Avoiding the introduction of microorganisms to the nurse's uniform

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: a. decreased b. within normal limits c. stable d. elevated

b. within normal limits

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

c. Separate the sealed flaps and drop contents onto field.

The nurse is caring for a client who has been hospitalized and placed in airborne precautions for a week. Which nursing intervention is appropriate to provide sensory stimulation? a.take the client outside for fresh air d. communicate with the client only through the intercom b. encourage family and friends to visit more often c. move the bed and furnishings to a different place in the room

c. move the bed and furnishings to a different place in the room

The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin? a. airborne b. none c. contact d. droplet

d. droplet

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? a. sterile drape hanging off the work surface b. sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field c. sterile gloves, removed from the outer wrapping, 4 in (10 cm) away from the edge of the sterile field d. sterile drape positioned with the moisture-proof side facing up

d. sterile drape positioned with the moisture-proof side facing up

Personal protective equipment (PPE) is used in health care facilities to protect the staff from potentially infected clients. false true

true