HESI CONCEPT- Infection

Which advantage does enteral feeding offer a patient? Select all that apply. (i) Reducing sepsis (ii) Decreasing hospital mortality (iii) Maintaining intestinal structure and function (iv) Maximizing the hypermetabolic response to trauma (v) Decreasing the risk of aspiration

(i), (ii), (iii) Rationale: Early introduction of enteral feeding decreases the risk of sepsis by preventing the shift of the microorganisms from the lumen to the cells. It decreases hospital mortality by decreasing complications. It maintains the intestinal structure and function by protecting it from gastric enzymes. Enteral feeding minimizes the hypermetabolic response of trauma by providing adequate nutrition and calories. Enteral feeding increases the risk of aspiration pneumonia because of the placement of a nasogastric tube.

Which statement is true regarding postoperative hyperglycemia? Select all that apply. (i) It is associated with surgical wound infection. (ii) It refers to blood glucose levels greater than 180 mg/dL. (iii) It can result in longer hospital stays for surgical patients. (iv) It is now recommended as an evidence-based practice. (v) It is considered both safe and effective for patient management.

(i), (ii), (iii) Rationale: Postoperative hyperglycemia is associated with surgical wound infection. It refers to blood glucose levels greater than 180 mg/dL and results in longer hospital stays in surgical patients. Normoglycemia, or glucose levels less than 150 mg/dL, are recommended as an evidence-based practice; this is considered both safe and effective for patient management.

Which statement is true regarding the hemostasis phase of blood clotting? Select all that apply. (i) Clots form a fibrin matrix. (ii) Blood vessels constrict, and platelets gather. (iii) Blood loss is controlled, establishing bacterial control. (iv) Epithelial cells migrate from a wound's edges to resurface. (v) Collagen fibers go through remodeling before assuming a normal appearance.

(i), (ii), (iii) Rationale; In the hemostasis phase, clots form a fibrin matrix that offers a structure for cellular repair in a later stage. During this phase, blood vessels constrict and platelets gather to stop bleeding. Blood loss is controlled, and bacterial control is established in this phase. In the proliferative phase, the epithelial cells migrate from the wound edges to resurface. In the maturation phase, the collagen fibers go through remodeling before assuming a normal appearance.

Which reduction of incidence is considered a nursing-sensitive outcome? Select all that apply. (i) Severe pressure injuries (ii) Vascular catheter-associated infections (iii) Catheter-associated infections (iv) Falls (v) Hospital readmissions

(i), (ii), (iii), (iv) Rationale: Reduction in severe pressure injuries, vascular catheter-associated infections, catheter-associated infections, and falls are nursing-sensitive quality outcomes. A nursing-sensitive outcome is a measurable state, behavior, or perception that can be affected by nursing interventions. These outcomes are within the scope of nursing practice and not medical interventions. Reduction in hospital readmissions is classified as a medical outcome, not a nursing-sensitive quality outcome since nurses do not admit patients to the hospital.

When discussing cough etiquette during an education session, which information would the nurse include? Select all that apply. (i) Cover the nose and mouth with a tissue when coughing. (ii) Dispose of any contaminated tissue promptly. (iii) Perform hand hygiene after contact with respiratory secretions and contaminated objects. (iv) Maintain a distance of greater than 2 feet from persons with respiratory infections. (v) Place a surgical mask on the patient if it does not compromise respiratory function.

(i), (ii), (iii), (v) Rationale: Cough etiquette involves covering the nose and mouth with a tissue when coughing, which helps prevent the spread of infections. Disposing of contaminated tissue promptly helps contain the microbes. Hand hygiene should be performed after contact with respiratory secretions and contaminated objects or materials. Placing a surgical mask on a patient if it does not compromise respiratory function helps prevent the transmission of infection to other people. Spatial separation of greater than 3 feet from persons with respiratory infections helps avoid contracting the infection through droplets. A distance of 2 feet is too close and promotes the spread of infection through droplets.

For which disease would the nurse screen all blood donors? Select all that apply. (i) Human immunodeficiency virus (HIV) (ii) Syphilis (iii) Hepatitis C (iv) Gonorrhea (v) Cytomegalovirus

(i), (ii), (iii), (v) Rationale: HIV, syphilis, hepatitis C, and cytomegalovirus are bloodborne infections and may spread from the donor blood to the recipient. Therefore the donor blood must be screened for these infections to reduce transmission. Gonorrhea is not routinely screened because it is not transmitted through blood and blood products.

The nurse expects which assessment finding in a patient with an abscess on the arm and a suspected systemic infection? Select all that apply. (i) Anorexia (ii) Malaise (iii) Enlarged lymph nodes (iv) Decreased white blood cells (WBCs) (v) Elevated body temperature

(i), (ii), (iii), (v) Rationale: When inflammation becomes systemic, other signs and symptoms develop, including anorexia, malaise, lymph node enlargement, or fever. When inflammation becomes systemic, symptoms include increased (not decreased) WBCs.

To reduce transmission of disease, which step would the nurse take when administering medication to a patient with Clostridium difficile infection? Select all that apply. (i) Give oral medication using a disposable cup (ii) Wash hands with antimicrobial soap and water. (iii) Wear a respirator mask while in the room. (iv) Discard safety needles into the sharps container. (v) Wear gloves when administering an injection.

(i), (ii), (iv), (v) Rationale: Using a paper (disposable) cup, hand hygiene, wearing gloves for an injection, and discarding needles into a sharps container are all procedural guidelines for a patient with an infectious disease. If care is being provided to a patient with a spore-borne infection, such as anthrax (Bacillus anthracis) or C difficile, washing with soap and water is the preferred practice (CDC, 202lc). A respirator is needed for diseases with airborne precautions, such as tuberculosis, not C difficile.

Which piece of equipment is considered a noncritical item that should be disinfected? Select all that apply. (i) Bedsheet (ii) Implant (iii) Stethoscope (iv) Blood pressure cuff (v) Intravascular catheter

(i), (iii), (iv) Rationale: Linens, stethoscopes, and blood pressure cuffs are considered noncritical items that should be disinfected. Implants and intravascular catheters are critical items that should be sterilized.

Which action may increase the risk of amputation in a patient who has diabetes mellitus? select all that apply. (i) Wearing garters (ii) Wearing dry socks (iii) Wearing tight shoes (iv) Wearing knee-high nylons (v) Wearing cotton socks

(i), (iii), (iv) Rationale: Patients with diabetes should avoid wearing tight shoes, because the patient may develop poor circulation in the feet and be at a higher risk of amputation. Wearing restrictive garters may also result in amputation. The use of knee-high nylons should also be avoided. Dry socks should be worn to prevent the risk of infection. Wearing cotton socks does not increase the risk of amputation.

The nurse applies an elastic bandage to a patient who has a sprained ankle. Which purpose would the bandage serve? Select all that apply. (i) Reduces edema (ii) Prevents infection (iii) Provides support (iv) Supports stretching (v) Provides immobilization

(i), (iii), (v) Rationale: An elastic bandage on a sprained ankle will reduce edema, provide support, and provide immobilization. The bandage will not prevent infection, and this is not a concern for a sprain unless open wounds are also present. Because the elastic bandage helps immobilize the ankle, it prevents stretching

Which element is part of the chain of infection? Select all that apply. (i) An infectious agent (ii) A vaccine schedule (iii) The source of pathogen growth (iv) Normal flora (v) A susceptible host

(i), (iii), (v) Rationale: An infectious agent is the main pathogen or infection-causing organism that spreads through the chain of infection. The source for pathogen growth is the reservoir where the pathogens can multiply, survive, and wait until they are transferred to a susceptible host. A susceptible host is the element in the chain of infection that receives the pathogens and is in a favorable condition for their growth and transmission. A vaccine schedule is the plan of immunization and is not an element in the chain of infection. Normal flora is defined as resident organisms that are permanent residents of the skin and within the body, where they survive and multiply without causing illness; therefore, normal flora is not part of the chain of infection.

Which is a cause of eye infections in patients who wear contact lenses? Select all that apply. (i) The use of homemade saline (ii) Wearing lenses while driving (iii) Wearing lenses while swimming (iv) The use of lenses with reduced visual acuity (v) Contamination of the lens' storage cases

(i), (iii), (v) Rationale: The use of homemade saline, wearing lenses while swimming, and contamination of the lens' storage cases cause eye infections. Homemade saline creates a high risk of contamination and may cause an eye infection. The lens may absorb chemicals from the pool water while swimming, which may cause irritation or infection of the eye. Lenses that are stored in a contaminated case may become contaminated and cause an eye infection. Wearing lenses while driving and the use of lenses for strengthening reduced visual acuity do not cause an eye infection.

A systemic infection causes which symptom? Select all that apply. (i) Fatigue (ii) Redness (iii) Swelling (iv) Warmth (v) Malaise

(i), (v) Rationale: Fatigue, malaise, fever, and vomiting are the generalized symptoms of systemic infections. Redness, swelling, and warmth are symptoms of localized inflammation.

Which equipment is required for the preparation of a sterile field? Select all that apply. (i) Sterile drape (ii) Paper face mask (iii) Countertop surface (iv) Protective eyewear (v) Surgical scrub (with sponge)

(i),(iii) Rationale: Sterile drapes and countertop surfaces are required to prepare a sterile field. Paper face masks, protective eyewear, and surgical scrub sponges are required for surgical asepsis.

To reduce the risk of infectious diseases, which vaccine is recommended in older adults? Select all that apply. (i) Influenza (ii) DTaP (iii) Rubella (iv) Varicella (v) Pneumonia

(i),(v) Rationale: Influenza and pneumonia vaccines are recommended for older adults to reduce the risk of infectious diseases. TaP (diphtheria, tetanus, and acellular pertussis) vaccinations are effective for preventing whooping cough in children. Children are vaccinated for rubella infections. Varicella vaccinations are used to prevent chickenpox in children.

Which assessment would the nurse perform on a patient who is suspected to have a localized inflammation based on reports of itching and irritation of the arm? Select all that apply. (i) Examine for paleness of skin. (ii) Palpate the area for tenderness. (iii) Inquire about pain and tightness. (iv) Inspect the area for redness and swelling. (v) Inquire about gastrointestinal disturbances.

(ii), (iii), (iv) Rationale: Gentle palpation of the infected area may reveal some degree of local tenderness caused by inflammation. Inquiring about pain and tightness is important because they may be caused by edema. Infected areas generally appear red and swollen, which are caused by inflammation. Redness (not paleness) of the skin is a manifestation of infection. Gastrointestinal disturbances are not related to localized infection and mav sometimes be found in systemic infections.

Which equipment is required for surgical hand asepsis? Select all that apply. (i) Sterile gloves (ii) Paper face mask (iii) Protective eyewear (iv) Clean countertop surface (v) Surgical scrub (with sponge)

(ii), (iii), (v) Rationale: A paper face mask, protective eyewear, and surgical hand scrub (with sponge) are required during surgical hand asepsis. Sterile gloves and a clean countertop surface are required for the preparation of a sterile field

The health care provider instructs the nurse to irrigate an infected wound that has a high concentration of bacteria. Which type of irrigating fluid will the nurse most likely use? Select all that apply. (i) Plain water (ii) Normal saline (iii) Dakin's solution (iv) Hydrogen peroxide (v) Povidone-iodine solution

(iii), (iv), (v) Rationale: Dakin's solution contains sodium hydrochloride, which is a cytotoxic fluid that helps kill bacteria in the wound. Hydrogen peroxide solution and povidone-iodine solution are also used for colonized wounds. Plain water is used for the irrigation of granulating wound and draining wound. Normal saline can also be used for irrigation of granulating wound

Which source is an example of the vehicle mode of transmission for infection? Select all that apply. (i) Mosquitoes (ii) Flies (iii) Intravenous (IV) fluid (iv) Food (v) Water

(iii), (iv), (v) Rationale: Examples of the vehicle mode of transmission include IV solutions, drugs, and water. Mosquitoes and flies are vector modes of transmission.

The nurse determines that a patient has glossitis based on which assessment finding? Select all that apply. (i) Missing teeth (ii) Tongue scraping (iii) Yellow teeth (iv) Change in color of tongue (v) Increased tongue thickness

(iv), (v) Rationale; Any change in the color and thickness of the tongue may indicate glossitis, an inflammation of the tongue. Missing teeth, yellowish color of teeth, and tongue scraping do not indicate glossitis.

Mycobacterium tuberculosis is spread through which method of transmission? Select all that apply. (i) Indirect contact (ii) Vectors (iii) Direct contact (iv) Vehicles (v) Airborne

(v) Rationale: A patient with Mycobacterium tuberculosis can spread the infection through airborne particles. Airborne Precautions are put into place; these include a private room, negative-pressure airflow of at least 6-12 exchanges per hour via HEPA filtration, mask or respiratory protection device, and a N95 respirator. Infections such as human immunodeficiency virus are transmitted through indirect contact, such as contaminated needles. Examples of transmission through vectors include mosquitoes, fleas, and lice. Infections that are transmitted through direct contact are spread through patient or envinromental contact. Examples of transmission through vehicles include blood, water, and contaminated items.

When assessing local inflammation of a patient's ankle, which clinical manifestation would the nurse expect? Select all that apply. (i) Swelling (ii) Redness (iii) Pain (iv) Loss of function (v) Heat

ALL

In which order do the stages of infection for mumps occur? Invasion of the pathogen into the body Incubation period Occurrence of symptoms such as malaise and fatigue Occurrence of a high fever and parotid swelling Convalescence

Invasion of the pathogen into the body Incubation period Occurrence of symptoms such as malaise and fatigue Occurrence of a high fever and parotid swelling Convalescence

Which statement made by the nursing student indicates the need for further teaching regarding phlebitis? a) "I should assess for Homans' signs." b) "I should assess for unilateral edema." c) "I should inspect the calves for localized redness." d) "I should gently palpate the calf muscle to reveal warmth."

a) "I should assess for Homans' signs." Rationale; Homans' sign is no longer a reliable indicator of phlebitis because it is present in other conditions. The nurse should assess for unilateral edema because it is one of the manifestations for phlebitis. The nurse should inspect the calves for localized redness and swelling of the veins because it is an indication for phlebitis. The nurse should gently palpate the calf muscle to reveal warmth.

Which statement made by the nursing student indicates effective learning regarding the handling of sterile instruments? a) "I will apply sterile gloves to handle sterile forceps." b) "I will place the syringe on a clean disposable glove." c) "I will place the sterile scissors in a tray after performing hand hygiene." d) "I can use the package contents even if the pack has a small tear near the base as long as the contents look undisturbed."

a) "I will apply sterile gloves to handle sterile forceps." Rationale: The nurse should apply sterile gloves to handle sterile forceps to keep the equipment sterile. Placing a syringe on a clean disposable glove may contaminate the syringe. Hand hygiene indicates cleanliness of hands. Clean hands touching sterile scissors may still cause contamination. A sterile object should be discarded (even if it is untouched or appears undisturbed) when a tear or small break of the covering is observed.

Which statement made by the student nurse indicates the need for additional teaching regarding the stages of infection? a) "The incubation period for mumps is 1 to 5 days.' b) "The acute symptoms of malaria will disappear during the convalescence stage." c) "Group A beta-hemolytic Streptococcus causes a sore throat, pain, and swelling at the illness stage." d) "Herpes simplex at the prodromal stage begins with itching at the site before the lesion appears."

a) "The incubation period for mumps is 1 to 5 days.' Rationale: The average incubation period for mumps is 16 to 18 days but can range from 12 to 25 days. The recovery of the patient is noticed during the convalescence stage of malaria. Acute infections are noticed during the illness stage. Group A beta-hemolytic Streptococcus causes strep throat manifested by a sore throat, pain, and swelling. Herpetic whitlow is the infection caused by the herpes simplex virus. The nonspecific signs and symptoms, such

When discussing the tiers of transmission-based precautions at an education session, the nurse would state that Standard Precautions apply to which patient population? a) All patients receiving care b) Patients with bloodborne infections c) Patients with draining wounds d) Patients suspected of having an infectious disease

a) All patients receiving care Rationale: Standard Precautions are designed to be used for the care of all patients, in all settings, regardless of risk or presumed infection status. The answer choices concerning the use of Standard Precautions only for patients with bloodborne infections, those patients with infected or draining wounds, or patients suspected of having an infectious disease are incorrect. Standard Precautions are not limited to certain patient populations.

A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. Which condition is the probable cause of these symptoms and findings? a) Cystitis b) Hematuria c) Pyelonephritis d) Dysuria

a) Cystitis Rationale: Urine is cloudy in cystitis because of bacteria and white cells. Hematuria is blood in the urine. Pyelonephritis is a serious upper urinary tract infection. Dysuria is painful urination.

Which method is most effective to break the chain of infection? a) Hand hygiene b) Wearing gloves c) Placing patients in isolation d) Providing private rooms for patients

a) Hand hygiene Rationale: The most effective basic technique in preventing and controlling the transmission of infection is hand hygiene. Hand hygiene is a general term that applies to four techniques: handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. Wearing gloves, placing patients in isolation, and providing private rooms can also help break the chain of infection, but hand hygiene is the most effective method.

The nurse identifies that a patient with assessment findings of sore throat and pain while swallowing and the presence of group A beta-hemolytic Streptococcus is in which stage of infection? a) Illness stage b) Convalescence c) Prodromal stage d) Incubation period

a) Illness stage Rationale: The interval when a patient manifests signs and symptoms (such as a sore throat and pain while swallowing) that are specific to a type of infection is the illness stage. Convalescence is the interval when acute symptoms of infection disappear. The prodromal stage is the interval from the onset of nonspecific signs and symptoms to more specific symptoms. The incubation period is the first stage of the infection process. It is the interval between the entrance of a pathogen into the body and the appearance of the first symptoms.

Which option is an example of a nurse managing indirect care activities? a) Infection control b) Patient counseling c) Medication administration d) Lifesaving measures

a) Infection control Rationale: Infection control is an example of indirect care. Indirect care activities are those that the nurse performs without coming into direct contact with the patient. These activities are not necessarily performed on patients but are meant for the betterment of patients. Counseling the patient, administering medication, and performing lifesaving measures involve direct contact between the nurse and the patient. These are examples of direct care, not indirect care, activities.

Regarding surgical hand asepsis, the nurse would intervene when which action by a nursing student is observed? a) Keeping the hands below waist level b) Turning off the faucet using the knees c) Using a continuous motion to rinse from the fingertips to the elbows d) Using a rotary motion to move the towel from the fingers to the elbows

a) Keeping the hands below waist level Rationale: Because the area below waist level is considered unsterile, the nurse should keep his or her hands above the waist. The faucet should be closed by using the knees to prevent contamination of the hands. The nurse should use a continuous motion to rinse from the fingertips to the elbows, allowing water to run off at the elbows. The nurse should use a rotary motion to move the towel from the fingers to the elbows during drying to dry the skin from the hands to the elbows.

Which policy regarding the fingernails of health care workers reduces the harboring of microorganisms? a) Natural tips should be no longer than 0.625-cm (¼-inch) long. b) Artificial nails are permitted if the fingers are meticulously cleaned. c) Only clear nail polish may be used. d) Nail polish should be removed every 7 days.

a) Natural tips should be no longer than 0.625-cm (¼-inch) long. Rationale: Natural nails should be less than ¼-inch long from the fingertip. Artificial nails are known to harbor gram- negative microorganisms and fungus (AORN, 2020; CDC, 2021c). The Centers for Disease Control and Prevention's hand-hygiene guidelines recommend that artificial nails should not be worn by health care providers when working with high-risk patients. There is no differentiation within the research between clear and colored nail polish. The nurse should remove nail polish if chipped or worn longer than 4 days because it is likely to harbor microorganisms (AORN, 2020).

During assessment, the nurse notes a break in the skin due to the patient's abscess and identifies that this finding represents which element of the chain of infection? a) Portal of exit b) Reservoir c) Susceptible host d) Infectious agent

a) Portal of exit Rationale: The skin is considered a portal of exit because any break in the skin can allow pathogens, such as in purulent drainage, to exit the body. Organisms exit from wounds, venipuncture sites, hematemesis, and bloody stool. A reservoir is a place inside the body or in the environment where pathogens can grow. A susceptible host is a patient who is at risk of infection. Infectious agents are microorganisms that include bacteria, viruses, fungi, and protozoans.

The nurse identifies that which action by the assistive personnel (AP) who is wearing a mask indicates a need for correction? a) Removes the mask before the gown when leaving an isolation room b) Changes an unused mask because of a moist feeling c) Ties the two top ties at the back of the head and above the ears d) Wears the mask so that the top of the mask fits below the glasses

a) Removes the mask before the gown when leaving an isolation room Rationale: The AP should remove the mask after the gown is removed when leaving an isolation room. A mask that has become moist does not provide a barrier to microorganisms and should be discarded. While wearing a mask the two top ties should be tied at the back of the head and above the ears. The top of the mask should fit below the glasses.

Which action by the nurse may cause contamination of a sterile field? a) Selecting a clean dry work surface below waist level b) Assembling necessary equipment before preparation c) Completing all priority care tasks before beginning the procedure d) Asking visitors to step out of the room briefly during the procedure

a) Selecting a clean dry work surface below waist level Rationale: While preparing a sterile field, a clean dry work surface should be located above waist level because a sterile object held below the waist is considered contaminated. The equipment should be assembled before preparation to prevent a break in technique. Visitors should be asked to step out of the room briefly during the procedure because traffic and movement increase the potential for spreading microorganisms through air currents. Priority care tasks should be completed before beginning the procedure, and the sterile field should be prepared as close as possible to the time of use.

The nurse observes an altered gait while ambulating a patient. Which condition is likely to be associated with this assessment finding? a) Stroke b) Heart failure c) Renal disease d) Diabetes mellitus

a) Stroke Rationale: A stroke frequently causes leg weakness or paralysis. This commonly results in altered walking patterns. Heart failure and renal diseases increase the risk of tissue edema, particularly in dependent areas such as the feet, but do not typically result in a significantly altered gait. Neuropathic changes associated with diabetes mellitus may cause altered sensation in the feet, but the gait is most likely unaffected until the late stage of the disease.

Which nursing intervention requires surgical asepsis? a) Suctioning the tracheobronchial airway b) Emptying and disposing of drainage suction bottles c) Keeping drainage tubes and collection bags patent d) Placing needleless systems into puncture-proof containers

a) Suctioning the tracheobronchial airway Rationale: Surgical asepsis maintains a sterile field for surgery or procedural intervention. Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area. The nurse would use surgical aseptic techniques at a patient's bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and sterile dressing changes). Emptying and disposing of drainage suction bottles, keeping drainage tubes and collection bags patent, and placing needleless systems into puncture-proof containers indicate that the nurse is reducing reservoirs of infection; sterile technique is not needed.

Which method would the nurse use for hand hygiene after the nurse's ungloved hands come into contact with drainage from a patient's wound? a) Wash them with soap and water. b) Use an alcohol-based hand cleaner. c) First rinse them with warm water, then clean using an alcohol-based hand cleaner. d) Wipe them with a paper towel

a) Wash them with soap and water. Rationale: According to the Centers for Disease Control and Prevention, when hands are visibly soiled or contaminated with blood or body fluids, the nurse should wash them with either a nonantimicrobial soap or antimicrobial soap and water. When hands are not visibly soiled or contaminated with blood or body fluids, the nurse could use an alcohol-based hand rub to perform hand hygiene. Wiping the hands with a paper towel is insufficient.

Which action by the nurse may cause an infection? a) Wearing rings on both hands b) Maintaining nail tips no longer than 0.25 inch (0.625 cm) c) Rubbing both hands together after applying the antiseptic d) Pushing long uniform sleeves above the wrists

a) Wearing rings on both hands Rationale: The skin underneath jewelry may carry a higher bacterial count (AORN, 2020). The nurse should avoid wearing rings. The nail tips should be less than 0.25 (0.625 cm) long. Antiseptic should be applied on the palm, and both hands should be rubbed together. Long uniform sleeves should be pushed above the wrist to provide complete access to the fingers, hands, and wrists.

When teaching wellness for a group of females, which information would the nurse include related to perineal care? a) Wipe from the urinary meatus toward the rectum b) Use stool softeners regularly to prevent pressure on the perineal area while defacating. c) Clean the perineal region once a day. d) Cleaning the perineal area is more important for young women than for older women who are postmenopausal.

a) Wipe from the urinary meatus toward the rectum Rationale: The nurse should instruct the patient about cleaning the perineal region correctly to reduce the incidence of genitourinary infections. The rectum is a highly contaminated area compared to the urinary meatus. It is necessary to wipe the perineal area from the urinary meatus toward the rectum, as cleaning should be done from least to most contaminated regions to reduce infections. Stool softeners should only be used as needed. Cleaning the perineal area only once a day increases the risk of contracting infection; the perineal region should be cleaned after every voiding and bowel movement. Keeping the perineal region meticulously clean is important for women of all ages, especially for older women who may wear incontinence pads.

The nurse questions which item that has been chosen by a nursing student to perform mouth care for a patient with an endotracheal tube in place? a) Oral swabs b) 5% hydrogen peroxide c) Oropharyngeal suction equipment d) 0.12% chlorhexidine mouthwash

b) 5% hydrogen peroxide Rationale: A solution of 1.5% hydrogen peroxide (not 5%) is used to clean the mouth. Oral swabs and a 0.12% chlorhexidine mouthwash can also be used. Oropharyngeal secretions should be suctioned as necessary.

Which technique would the nurse use when gloving during the suctioning procedure? a) Picking up the connecting tubing with the dominant hand b) Applying clean gloves to both hands for oropharyngeal suctioning c) Applying a sterile glove to the nondominant hand for artificial airway suctioning d) Picking up the suction catheter with the nondominant hand and not letting the catheter touch nonsterile surfaces

b) Applying clean gloves to both hands for oropharyngeal suctioning Rationale: For oropharyngeal suctioning, clean technique using clean gloves is appropriate. Connecting tubing is picked up with the nondominant hand, not the dominant hand. The glove on the dominant hand must remain sterile; the glove on the nondominant hand becomes contaminated when attaching the suction tubing to the catheter. The suction catheter is picked up with the dominant hand (not the nondominant), and the catheter should not be allowed to touch nonsterile surfaces.

Which action would the nurse perform immediately after administering a nasal decongestant? a) Observe the patient for side effects. b) Ask if the patient is experiencing any difficulty in breathing. c) Position the patient's head tilted slightly forward in the supine position. d) Compare the name of the medication on the label with the medication administration record

b) Ask if the patient is experiencing any difficulty in breathing. Rationale: Difficulty in breathing is an adverse effect of decongestants; therefore it is important to immediately ask a patient if he or she has difficulty breathing after the administration of decongestants. After 15 to 30 minutes of decongestant administration, the nurse should observe the patient for any signs of side effects. Before the administration of nasal sprays, the patient is positioned in the supine position and the head is tilted forward Before administering the medication, the name of the medication on the label is compared with the medication administration record.

The nurse reviews the plan for foot care of a patient with peripheral vascular disease and questions which intervention? a) Filing the fingernails b) Clipping the toenails c) Using a soft cuticle brush d) Applying lotion to the feet

b) Clipping the toenails Rationale; The nurse should teach patients with loss of sensation to file nails instead of clipping. Clipping the toenails is contraindicated in patients with peripheral vascular disease. Using a soft cuticle brush reduces the incidence of inflamed cuticles. Applying lotion prevents the skin from becoming too dry.

Which condition does nonblanchable erythema indicate about the skin tissue? a) Infection b) Damage c) Hypoxia d) Pressure

b) Damage Rationale: Nonblanchable erythema indicates that the tissue was under pressure that caused inflammation, leading to tissue damage. The tissue is infected when there is drainage from the wound or sutures at the surgical site. The tissue appears mottled or exhibits pallor when it is under hypoxia. Tissue with erythema is an early indication of pressure to the tissue.

The nurse is managing wound care for a patient with a stage 3 pressure injury on the elbow. The nurse cleans the area and removes all the dead, nonviable tissue from the wound. Which term is used to describe this process? a) Irrigation b) Debridement c) Hemostasis d) Cleansing

b) Debridement Rationale: Removal of nonviable necrotic tissue from the wound is called debridement, which can be accomplished chemically, mechanically, autolytically, or surgically. Debridement rids the wound of dead tissues, which are ideal for bacterial growth, and minimizes the risk of infection. Irrigation involves cleaning the wound with a cleaning solution under pressure to remove bacteria and exudates from the wound bed and maintain moisture. Hemostasis is the control of bleeding from a wound. Cleansing is not used to describe the removal process of dead tissue from the wound.

How would the nurse respond to a patient with an infection who states, "I am anxious and feeling depressed that I need to stay in this room with isolation precautions"? a) Provide a dark, quiet room to calm the patient. b) Explain each item used for infection control and isolation procedures. c) Limit visitors to reduce the spread of infection. d) Provide the patient with an antianxiety medication.

b) Explain each item used for infection control and isolation procedures. Rationale: When a patient requires isolation precautions, the nurse should explain the infection control and isolation procedures that are used to maintain infection prevention and control practices. Darkening the room can increase the patient's sense of isolation and depression. The nurse should allow visitors as long as they follow infection precautions. The nurse would need to obtain an order for an antianxiety medication from the health care provider.

Which nursing action may contaminate the surface of a sterile item? a) Disposing of the outer wrapper b) Holding the arm over the sterile field c) Peeling the wrapper onto the nondominant hand d) Allowing the drape to unfold on a surface above waist level

b) Holding the arm over the sterile field Rationale: While adding sterile items, the nurse should not hold the arm over the sterile field because it may contaminate the surface of the sterile item. The nurse should keep the arm outstretched and away from the sterile field. Disposing of the outer wrapper prevents accidental contamination of the sterile field. The nurse should carefully peel the wrapper onto the nondominant hand. The nurse should allow the drape to unfold on a surface above the waist and work surface to prevent contamination.

Which nursing intervention would be appropriate for a patient who is at risk of infection because of a surgical incision at the right hip? a) Applying moisture barrier cream b) Obtaining a wound culture as needed c) Providing analgesics before wound care d) Using correct repositioning techniques

b) Obtaining a wound culture as needed Rationale: Whereas all of these interventions are appropriate for a patient with impaired skin integrity, the intervention that is specific to a patient at risk of infection is obtaining a wound cultures needed. Applying a moisture barrier is appropriate when the patient's skin integrity is compromised because of limited mobility. Providing analgesics and using correct repositioning techniques are appropriate interventions for impaired physical mobility related to incisional pain.

Which condition would the nurse suspect in a patient receiving intravenous (IV) fluids who develops tenderness, warmth, erythema, and pain at the site? a) Sepsis b) Phlebitis c) Infiltration d) Fluid overload

b) Phlebitis Rationale: Redness, warmth, and tenderness at the IV site are signs of phlebitis. Swelling and coolness at the site are indicative of infiltration. Signs of sepsis include tachypnea, chills, fever, hypotension, confusion, and tachycardia. Dyspnea, swelling, and neck vein distension are signs of fluid overload.

Which priority postoperative nursing diagnosis does the nurse include in the care plan of a patient who states, "I am diabetic, and I haven't been allowed to eat or drink anything. Also, I am worried about having anesthesia while my open leg fracture is being repaired"? a) Anxiety b) Risk for infection c) Social isolation d) Impaired nutritional status

b) Risk for infection Rationale: A postoperative nursing diagnosis would include risk for infection related to the diabetes, which can impair the healing process and the open wound. Postoperatively, it is unlikely that the patient will continue to have anxiety about anesthesia. There is no indication of social isolation or impaired nutritional status. The patient was placed on nothing-by-mouth (NPO) status preoperatively but will be offered liquid intake soon after the anesthesia wears off and the recovery process begins.

Which defect would be considered congenital? a) Arthritis b) Scoliosis c) Osteoporosis d) Osteomalacia

b) Scoliosis Rationale: Scoliosis is a structural curvature of the spine associated with vertebral rotation; it is a congenital defect. Arthritis is an inflammatory joint disease that causes systemic signs of inflammation and destruction of the synovial membrane and articular cartilage. Osteoporosis is an aging disorder that results in the reduction of bone density or mass. Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bones.

The nurse reviews the oral and foot care being provided to a patient who is receiving anticoagulant therapy and questions which intervention? a) Flossing gently near the gum line b) Shaping the corners of the toenails c) Brushing the teeth with a soft brush d) Rinsing the dentures after every meal

b) Shaping the corners of the toenails Rationale: Shaping corners of toenails damages tissues, which increases the risk of bleeding and infection. It is especially important that the nurse reduces the risk of trauma (e.g., bleeding) when providing care for a patient who is receiving anticoagulant therapy. Brushing the teeth with a soft brush prevents the gums from bleeding. Flossing is done very gently near the gum line to prevent bleeding. Rinsing the dentures after every meal prevents stomatitis.

Which statement is true regarding the donning and removing of caps, masks, and eyewear during a medical or surgical procedure? a) The nurse should remove the mask before removing the gown. b) The nurse should wear eyewear only for procedures that create the risk of body fluids splashing into the eyes. c) A surgical mask should be applied first and then a clean cap to cover all of the nurse's hair. d) Even if the procedure is lengthy, the surgical mask should not be removed until after the completion of the procedure.

b) The nurse should wear eyewear only for procedures that create the risk of body fluids splashing into the eyes. Rationale: The nurse should wear eyewear only for procedures that create the risk of body fluids splashing into the eyes. The nurse should remove personal protective equipment in the following order: gloves, face shield or goggles, gown, and mask or respirator (CDC, 2015a). The hair should be covered with a cap first before putting on the mask and eyewear. Because moisture promotes the growth of microorganisms, the nurse should change the mask if it becomes moist.

For which reason would the nurse ask the patient about a history of hemodialysis? a) To identify the risk of gastrointestinal (Gl) bleeding b) To identify a risk factor for the hepatitis B virus c) To identify symptoms that indicate Gl alterations d) To identify the traumatic alterations of abdominal organs

b) To identify a risk factor for the hepatitis B virus Rationale: When the nurse asks about the history of hemodialysis, this is an attempt to identify a risk factor for the hepatitis B virus. When the nurse is asking the patient about taking anti-inflammatory medications, it indicates an effort to identify the risk of Gl bleeding. When the nurse asks the patient about recent weight loss, this indicates an attempt to identify the symptoms of Gl alterations. When the nurse is asking the patient regarding an abdominal surgery, this indicates any effort to identify traumatic alterations.

What is the rationale for removing finger rings when performing hand hygiene? a) To ensure complete antimicrobial action b) To prevent the harboring of microorganisms c) To prevent jewelry from being damaged by strong antimicrobial soap d) To provide enough time for the antimicrobial solution to be effective

b) To prevent the harboring of microorganisms Rationale: Jewelry may harbor or protect microorganisms from removal. The nurse should not wear rings to avoid infections. The nurse rubs the hands together by covering all the surfaces of the hands and fingers with antiseptic to ensure complete antimicrobial action. Although the nurse's jewelry may get damaged by the soap being used, that is not the rationale for removing the finger rings. The nurse should rub his or her hands together with an antiseptic for several seconds and allow the hands to dry before applying gloves to provide enough time for the antimicrobial solution to be effective.

Which piece of medical equipment is considered to be a critical item that must be kept sterile? a) Gastrointestinal endoscope b) Urinary catheter c) Endotracheal tube d) Anesthesia equipment

b) Urinary catheter Rationale: A urinary catheter is a critical item that enters sterile tissue presenting a high risk of contamination and must be sterilized. An endoscope, an endotracheal tube, and anesthesia equipment are semicritical and must be high-level disinfected or sterilized.

The nurse recognizes the importance of preventing which specific type of infection when assisting with a bronchoscopy? a) Localized b) latrogenic c) Endogenous d) Suprainfection

b) latrogenic Rationale: An iatrogenic infection is a health care-associated infection caused by an invasive or diagnostic procedure such as bronchoscopy. A localized infection occurs around the site of a wound. An endogenous infection often happens when a patient receives broad-spectrum antibiotics that affect the normal flora. Suprainfection develops when broad-spectrum antibiotics kill a wide range of normal flora.

After receiving education about controlling the exit and entry of microorganisms, which statement made by the patient indicates the need for further learning? a) "I will brush my teeth regularly." b) "I will apply lotion to my skin appropriately." c) "I will apply water-insoluble ointment to my lips." d) "I will clean my perineal area by wiping from the urinary meatus toward the rectum."

c) "I will apply water-insoluble ointment to my lips." Rationale: The patient should maintain the integrity of the skin and mucous membranes to reduce the risk of microorganism infections. The patient should apply water-soluble ointment to the lips to keep them lubricated and maintain skin integrity. The patient should brush the teeth regularly to prevent the drying of mucous membranes. The patient should apply lotion to the skin appropriately to keep the skin lubricated. The patient should clean the perineal area from the urinary meatus toward the rectum to prevent the entry of infectious microorganisms into the urinary tract.

In which position would the nurse place a patient with a right lung abscess? a) Supine position with both lungs at the same level b) 45-degree semi-Fowler position with left lung down c) 45-degree semi-Fowler position with right lung down d) Supine position with left lung at slightly lower level than the right

c) 45-degree semi-Fowler position with right lung down Rationale: In patients with a pulmonary abscess, the affected lung should be positioned down to prevent the flow of secretions to the healthy lung. A semi-Fowler position with the patient at 45 degrees is the best position to use to promote lung expansion. It also helps relieve the pressure from the abdomen onto the diaphragm. The supine position with both lungs at the same level does not help lung expansion nor address the abscess. In cases of bilateral lung diseases (the patient has right lung disease), the position should be determined by the severity of the disease. Having the left lung lower than the right would allow the abscess to drain into the healthy lung

The nurse is evaluating the outcome of a patient provided with negative-pressure wound therapy (NPWT) for pressure injuries. Which nursing action is appropriate for determining the patient's level of comfort while providing the treatment? a) Determining the drainage and odor of the wound b) Verifying proper negative pressure in the patient's wound c) Asking the patient to rate the pain using a scale of 0 to 10 d) Comparing the wound size with a baseline wound assessment

c) Asking the patient to rate the pain using a scale of 0 to 10 Rationale: Asking the patient to rate the pain using a scale of O to 10 helps the nurse determine the patient's level of comfort during the procedure. Inspecting the condition of the wound and noting the drainage condition and odor helps determine the status of wound healing but not the patient's level of comfort. Verifying airtight dressing seal and proper negative pressure helps achieve prescribed vacuum level of the therapy. Comparing the wound size and condition with a baseline wound assessment helps provide objective information of wound healing.

Which equipment would be required if wound drainage is present when applying an elastic bandage? a) Clips b) Bandages c) Clean gloves d) Adhesive tape

c) Clean gloves Rationale: Clean gloves are required when applying an elastic bandage if wound drainage is present to prevent contamination. Clips, bandages, and adhesive tape may be necessary, but the wound drainage makes preventing contamination a concern, and these materials do not address that.

Which is characteristic of abnormal healing if present in a primary-intention wound? a) Pale and fragile granulation tissue b) Necrotic or slough tissue present in the wound base c) Drainage present more than 3 days after closure d) Presence of fistula, tunneling, undermining, and/or a fruity odor

c) Drainage present more than 3 days after closure Rationale: Drainage more than 3 days after closure is characteristic of abnormal healing in a primary-intention wound Pale and fragile granulation tissue, necrotic or slough tissue in the wound base, and the presence of fistula, tunneling, undermining, and/or a fruity odor are characteristics of abnormal healing in a secondary-intention wound.

How would the nurse respond when a patient voices resentment about being placed in isolation for pulmonary tuberculosis? a) Provide a dark, quiet room to calm the patient. b) Contact the health care provider about changing the level of precautions. c) Explain the reasons for isolation procedures. d) Limit family and other caregiver visits to reduce the risk of spreading the infection.

c) Explain the reasons for isolation procedures. Rationale; The nurse should reinforce that infection control and isolation procedures are designed for patient safety and use simple language to provide an explanation. Explaining the reasons for isolation can help the patient accept and adapt to the isolation precautions. Keeping a patient in a dark, quiet room can increase the patient's perception of social isolation and decrease sensory stimulation. Reducing the level of precautions can lead to cross-contamination and hospital-acquired infections. Family and caregiver visits do not need to be limited unless the family members or caregivers are immunocompromised

Which method is effective in reducing the transmission of pathogens to patients and personnel in health care settings? a) Vaccinations b) Isolation precautions c) Hand-hygiene practices d) Use of clean equipment

c) Hand-hygiene practices Rationale: Hand-hygiene practices are the most effective way to break the chain of infection and control its transmission Vaccinations are effective measures to prevent the occurrence of infection in an individual. Even if a patient is isolated, the nurse caring for the patient has a risk of infection. Therefore, the nurse should perform hand hygiene before and after providing patient care. The use of clean equipment without hand hygiene may spread infection.

When reviewing the procedure for cleaning a reusable inner cannula during tracheostomy care, the nurse recognizes that which step needs correction? a) Dropping the inner cannula into normal saline solution b) Removing the inner cannula with the nondominant hand c) Holding the inner cannula over a basin and rinsing it with water d) Using a small brush to remove secretions inside the cannula

c) Holding the inner cannula over a basin and rinsing it with water Rationale: While holding the inner cannula over a basin, the nurse should rinse it with normal saline solution using the nondominant hand. The nurse should drop the inner cannula into normal saline solution. The nurse should touch only the outer aspect of the tube and remove the inner cannula with the nondominant hand. A small brush should be used to remove secretions inside and outside the cannula.

Which condition is likely to affect the gait of a patient with diabetes? a) Pain during ambulation b) Foot problems because of ill-fitting shoes c) Loss of cutaneous sensation in the feet d) Self-care deficit related to limited mobility

c) Loss of cutaneous sensation in the feet Rationale; The patient has diabetes. One of the common complications of diabetes is peripheral neuropathy, a loss of sensation in the lower limbs. Loss of sensation could cause an abnormal gait. The patient may not feel pain because of peripheral neuropathy; therefore, the gait may not be affected by pain. Wearing the wrong footwear may not cause a gait problem. A self-care deficit would be noted with additional assessment findings.

Which equipment is used by the health care provider while applying moist dressing to a patient who has pressure ulcers? a) Linen bag b) Braden Scale c) Montgomery ties d) Waterproof underpad

c) Montgomery ties Rationale: Montgomery ties are used for dressing pressure ulcer wounds in a patient. A linen bag is used while implementing negative-pressure wound therapy. The Braden Scale is used to assess the risk of pressure ulcers, but it may not be used while dressing pressure ulcer wounds. A waterproof underpad is used while irrigating the wound.

The nurse recognizes which stage of infection in a patient with herpes simplex who states, "My skin itches and tingles but there are no lesions on my body"? a) Illness stage b) Incubation period c) Prodromal stage d) Convalescence stage

c) Prodromal stage Rationale: The prodromal stage is defined as the interval from onset of nonspecific signs and symptoms to more specific symptoms related to the type of infection or disease. In this stage, the microorganisms grow and multiply. Itching and tingling sensations are nonspecific symptoms of herpes simplex that occur before the lesions appear. In the illness stage, the patient actually develops the signs and symptoms specific to the type of infection. The incubation period is an interval between entrance of the pathogen into the body and the appearance of the first symptoms. In the convalescence stage, acute symptoms of infection will disappear.

A patient with herpes simplex who reports itching and tingling is in which stage of infection? a) Illness stage b) Convalescence c) Prodromal stage d) Incubation period

c) Prodromal stage Rationale: The prodromal stage is the interval from the onset of nonspecific signs and symptoms to more specific symptoms. For example, herpes simplex begins with itching and tingling at the site before the lesion appears. The illness stage is the interval when a patient manifests signs and symptoms that are specific to a type of infection. The convalescence stage is the interval when acute symptoms of an infection disappear. The incubation period is the first stage of the infection process; it is the interval between the entrance of the pathogen into the body and the appearance of the first symptoms.

Which statement describes the rationale for applying a gauze pad and securing the edges with tape after insertion of an intravenous catheter? a) Retain moisture in the skin b) Decrease pressure on the skin c) Reduce the entry of microorganisms d) Prevent visualization of the insertion site

c) Reduce the entry of microorganisms Rationale: The nurse secures the edges of the dressing with tape to prevent the entry of microorganisms into the insertion site. The nurse secures the gauze pad with tape to help carry the moisture away from the skin to prevent contamination. Tape on the gauze elevates the hub and prevents pressure on the skin. Wrapping the dressing materials around the arm causes the arm to compress the veins and prevents the visualization of the insertion site.

Which type of urinary incontinence occurs as a result of spinal cord damage between Cl and S2? a) Functional incontinence b) Stress urinary incontinence c) Reflex urinary incontinence d) Urge urinary incontinence

c) Reflex urinary incontinence Rationale: Reflex urinary incontinence is the involuntary loss of urine at somewhat predictable intervals when the patient reaches a specific bladder volume; it is related to spinal cord damage between C1 and $2. Functional incontinence is the loss of continence with a cause outside the urinary tract. Stress urinary incontinence is caused by increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter. Urge urinary incontinence is caused by neurologic problems, bladder inflammation, or bladder outlet obstruction.

The nurse would intervene when a nursing student performs which action when using a surgical mask during a sterile surgical procedure? a) Drops the used mask in a trash receptacle b) Removes the mask when leaving the surgical room c) Removes the mask by touching the outer surface of the mask d) Ties the two lower ties snugly around the neck

c) Removes the mask by touching the outer surface of the mask RAtionale: After using a surgical mask, the mask should be removed by untying the bottom mask strings, followed by the top strings. The outer surface of the mask should never be touched while removing it. Used masks should be dropped in a trash receptacle. Surgical masks should be removed before leaving the surgical room to prevent infection. While using a surgical mask, the two lower ties of the mask should be tied around the neck.

The nurse would intervene when a nursing student takes which action when preparing a sterile field? a) Allows the flap to lie flat on the table's surface b) Grasps the outer edge of the tip of the outermost flap c) Stands close to the sterile field while opening the last flap d) Opens the outermost flap of the sterile kit away from the body

c) Stands close to the sterile field while opening the last flap Rationale: While preparing a sterile field, the nurse should open the last flap while standing away from the field to avoid contamination. The flap should be allowed to lie flat on the table surface. The outer edge of the tip of the outermost flap should be grasped because the outer surface of the package is considered unsterile. The outermost flap of the sterile kit should be kept away from the body to prevent contamination.

Which complication is a risk if a patient sleeps in dentures? a) Warping of the dentures b) Irritation of the gums c) Stomatitis d) Gingival infection

c) Stomatitis Rationale: Instructing the patient to avoid wearing dentures while sleeping will help prevent stomatitis. Keeping dentures covered in water and storing them in an enclosed, labeled cup placed on the patient's bedside stand will help prevent warping. Cleaning dentures on a regular basis will help prevent irritation and gingival infection.

In regards to surgical asepsis, which type of contamination occurred when the nurse sneezed on a sterile field that had been prepared for a dressing change? a) When the sterile field came in contact with a wet surface, the sterile field was contaminated by capillary action. b) When gravity caused a contaminated liquid to flow over the surface of the object, the field became contaminated. c) The sterile field becomes contaminated by prolonged exposure to air. d) The nurse came in contact with the edges of the sterile field, which are considered contaminated.

c) The sterile field becomes contaminated by prolonged exposure to air. Rationale: When a person sneezes, microorganisms travel by droplet through the air, contaminating the sterile field. There is no information that the surface was wet, that liquid was spilled, or that the nurse came in contact with the edges of the sterile field. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. When gravity causes a contaminated liquid to flow over the surface of the object, the field becomes contaminated. Because the edge of the drape touches an unsterile surface such as a table or bed linen, a 2.5-cm (1-inch) border around the sterile drape is considered contaminated

When preparing a sterile work surface, what is the rationale for the nurse opening the outermost flap away from the body, keeping the arm outstretched and away from the sterile field? a) To reassure the patient that sterility is being maintained b) To prevent a break in sterile technique after the procedure has begun c) To avoid contamination of the sterile field d) To free the dominant hand for unwrapping

c) To avoid contamination of the sterile field Rationale: Reaching over sterile field contaminates it. During the preparation of a sterile field, the nurse's arm should be stretched away from the sterile field to avoid contamination of the field. The reason for this step is not simply to reassure the patient. Assembling the necessary equipment before starting the procedure prevents a break in the technique. Opening the sterile item by holding the outside wrapper in the nondominant hand helps free the dominant hand to unwrap the outer wrapper.

Which nursing action may allow the transfer of pathogens when performing hand hygiene? a) Keeping hands down and elbows up while rinsing b) Drying from fingers to wrists c) Using wet paper towels to turn off the faucet after washing d) Cleaning the area under the fingernails with the fingernails of the other hand

c) Using wet paper towels to turn off the faucet after washing Rationale: Wet towel and hands allow transfer of pathogens from the faucet by capillary action. To turn off the hand faucet, the nurse should use a clean, dry paper towel and avoid touching the handles with his/her hands. The nurse should rinse the hands and wrists thoroughly, keeping hands down and elbows up. Drying from cleanest (fingertips) to least clean (wrist) avoids contamination. The nurse should clean the area under the fingernails with the fingernails of the other hand. The area under the nails can be highly contaminated, which increases the risk for transmission of infection from nurse to patient.

Which type of primary skin lesion will be exhibited by a patient with chickenpox? a) Wheals b) Nodules c) Vesicles d) Macules

c) Vesicles Rationale: Patients with chickenpox exhibit vesicles. A vesicle is a circumscribed elevation of the skin filled with serous fluid and is smaller than 1 cm (1/2 inch). A wheal is observed in patients with hives or mosquito bites, not chickenpox. A nodule is observed in patients with warts, not chickenpox. A macule is observed in patients with freckles and petechia, not chickenpox.

Which test would be performed immediately after the nurse experiences an accidental needlestick injury from a needle that was used on a patient with human immunodeficiency virus (HIV)? a) Baseline test b) Hepatitis C virus (HCV)-RNA test c) Viral load studv d) Postexposure prophylaxis

c) Viral load studv Rationale: When exposed to the blood of a patient who is HIV-positive, the nurse should undergo a viral load study immediately. This helps determine the amount of virus present in the blood. In the case of exposure to a patient who is positive for HCV, a baseline test is conducted immediately; an HCV-RNA test is then performed after 4 weeks to determine if the person has contracted HCV. Postexposure prophylaxis is a treatment, not the test.

After caring for a patient with diarrhea, which procedure would the nurse employ to clean visibly soiled hands? a) Wash with water. b) Clean with a waterless hand sanitizer. c) Wash with soap and water. d) Clean with an alcohol-based product.

c) Wash with soap and water. Rationale: If the nurse's hands are soiled after cleaning a patient with diarrhea, the nurse should wash the hands with soap and water to disinfect them and avoid transmission of microorganisms. Antimicrobial soap and water should be used if the contact with spores (e.g., Clostridium difficile) is likely to have occurred. Using only water would not disinfect the hands. If the hands are not visibly soiled after cleaning a patient, it would be appropriate for the nurse to use a waterless hand santizier or an alcohol-based hand product.

Which action would the nurse take while caring for a patient with an infection that is transmitted by large droplets? a) Wear a gown when giving patient care. b) Wear an N95 respirator in the patient's room. c) Wear a mask when working within 3 feet of the patient. d) Place the patient in a room with 12 air exchanges per hour.

c) Wear a mask when working within 3 feet of the patient. Rationale: While caring for a patient with a droplet infection, the nurse should wear a surgical mask when working within 3 feet of the patient to help prevent the spread of infection. Wearing a gown while in the room is Contact Precautions. Wearing an N95 respirator and placing the patient in a room with 12 air exchanges per hour should be performed with a patient who has an airborne infection.

During new hospital employee orientation, which education would the nurse provide regarding hepatitis B vaccination and exposure to the hepatitis C virus (HCV)? a) "Due to its serious side effects, health care employers typically restrict the hepatitis B vaccination series to employees who are at high risk." b) "The hepatitis B vaccine requires a booster in 6 months." c) "Prophylactic treatment will be prescribed for exposure to HCV." d) "At 4 weeks after exposure, an HCV-RNA test is offered to determine whether the employee contracted HCV."

d) "At 4 weeks after exposure, an HCV-RNA test is offered to determine whether the employee contracted HCV." RAtionale; At 4 weeks after exposure, the employee should be offered an HCV-RNA test to determine whether the employee contracted HCV. Health care emplovers typically make available the hepatitis B vaccine and vaccination series to all employees who may have occupational exposures, not just those at high risk. Hepatitis C is a communicable disease. At present the hepatitis B vaccine does not require any boosters. There is no prophylactic treatment for HV after exposure.

Regarding home care considerations for patients with infections, which statement made by the nursing student indicates the need for further learning? a) "I should determine potential sources of contamination." b) "I should evaluate handwashing facilities in the patient's home." c) "I should anticipate the need for alternative handwashing products." d) "I should ensure that teach-back about sterile asepsis has occurred."

d) "I should ensure that teach-back about sterile asepsis has occurred." Rationale: In the home, it is common to use clean instead of sterile asepsis technique. The nurse should consult with the patient's health care provider regarding questions about the proper aseptic technique to use in the home. The nurse should determine potential sources of contamination and possible preventive measures. The nurse should evaluate all handwashing facilities in the patient's home. The nurse should explore alternative handwashing products if a patient doesn't have running water or if the products are inappropriate to meet the hand hygiene needs.

After receiving instructions about cleaning instruments before sterilization, which statement made by the nursing student identifies the need for further learning? a) "I will use a brush to wash the objects." b) "I will wash the objects with warm water." c) "I will dry the objects before disinfection." d) "I will rinse the contaminated objects in hot water."

d) "I will rinse the contaminated objects in hot water." Rationale: Contaminated objects should be rinsed with cold running water. Hot water should not be used because it causes the protein in organic material to coagulate and stick to objects, which makes removal difficult. The nurse should use a brush to remove dirt or material in grooves or seams. The nurse should wash objects with soap and warm water. Objects should be dried before disinfection or sterilization.

According to the Centers for Disease Control and Prevention (CDC), in which circumstance is it appropriate to decontaminate the hands using an alcohol-based, waterless antiseptic agent? a) When hands are visibly dirty b) After using the toilet c) When hands are soiled with blood d) After removing gloves

d) After removing gloves Rationale: If hands are not visibly soiled (WHO, 2017), the nurse may use an alcohol-based, waterless antiseptic agent for routinely decontaminating hands after removing gloves (CDC, 2019a). When hands are visibly dirty, after using the toilet, and when hands are soiled with blood or other body fluids, the nurse should wash the hands with water and either a nonantimicrobial or antimicrobial soap.

A plan of care that includes isolation with positive airflow and instructions for the patient to wear a mask when outside of the room would be implemented for which condition? a) Mycobacterium tuberculosis b) Group A streptococcus c) Disseminated varicella zoster d) Allogeneic hematopoietic stem cell transplants

d) Allogeneic hematopoietic stem cell transplants Rationale: Placing the patient in a room with positive airflow and instructing the patient to use a mask when he or she is out of the room is a precaution used for patients who have undergone allogeneic hematopoietic stem cell transplants. Positive pressure rooms maintain a higher pressure inside the treated area than that of the surrounding environment. This means air can leave the room without circulating back in. In this way, any airborne particle that originates in the room will be filtered out. Mycobacterium tuberculosis requires airborne precautions, such as negative pressure airflow. The nurse should wear an N95 respirator whenever entering the room. Group A streptococcus requires droplet precautions. The nurse should wear a surgical mask for this type of precaution. Disseminated varicella zoster requires airborne precautions, such as negative pressure airflow. Thus the nurse should wear an N95 respirator whenever entering the room.

The nurse reviews the plan for oral care for a patient who is at a risk of oral mucositis because of chemotherapy. The nurse questions which item listed on the plan? a) Rinse with a bland rinse. b) Floss with unwaxed floss. c) Brush gently with a soft toothbrush. d) Apply oil-based moisturizer to the lips.

d) Apply oil-based moisturizer to the lips. Rationale: When chemotherapy injures the oral mucosa, the nurse should follow cancer nursing guidelines regarding care for oral mucositis (i.e., painful inflammation of oral mucous membranes), including frequent gentle brushing with a soft toothbrush, flossing, rinsing with bland rinse, limiting diet to soft foods, and applying water-based moisturizer to lips. The patient should also use unwaxed floss and gently brush the teeth with a soft toothbrush.

Which type of medication increases the risk of a patient developing an opportunistic infection in the mouth? a) Antipyretic drug b) Hypoglycemic drug c) Antihypertensive drug d) Broad-spectrum antibiotic

d) Broad-spectrum antibiotic Rationale: A patient who receives broad-spectrum antibiotics may develop an opportunistic infection when the normal flora of the mouth is disrupted by the antibiotic. The nurse should perform a thorough examination of the oral regions in such patients. Antipyretics, hypoglycemic drugs, and antihypertensive drugs do not lead to opportunistic infections. These drugs are not known to disrupt the normal flora of the mouth. These drugs are also not known to affect the immune system or increase susceptibility to infections.

Which nursing action indicates a need for correction regarding administration of a vitamin from an ampule? a) Drawing the medication quickly from the ampule b) Cleaning the patient's injection site with an antiseptic cotton swab c) Applying friction in a circular motion up to 5 cm (2 inches) while cleaning the site d) Extracting the medication from a previously opened ampule first, followed by the new ampule

d) Extracting the medication from a previously opened ampule first, followed by the new ampule Rationale: Ampules should not be allowed to stay open. The nurse should check and discard any unclosed, leftover ampules to prevent the chance of infection. The nurse should draw the vitamin solution quickly out of the ampule to prevent contamination of the medication. The nurse should clean the patient's skin with an antiseptic cotton swab to maintain asepsis. The nurse should apply friction in a circular motion from the center of the site outward in a 5-cm (2-inch) radius to prevent the chances of infection.

Which nursing intervention helps prevent transfusion-related sepsis? a) Administering antibiotics b) Educating the patient about a blood transfusion c) Wearing gloves during the procedure d) Following blood-banking standards

d) Following blood-banking standards Rationale: The infusion of infected blood and blood products may lead to sepsis, which can be prevented by following blood-banking standards. Blood-banking standards include appropriate collection, processing, storage, and transfusion. Ideally a unit of whole blood or packed red blood cells is transfused in 2 hours. This time can be lengthened to 4 hours if the patient is at risk for extracellular volume (ECV) excess. Beyond 4 hours there is a risk for bacterial contamination of the blood. Antibiotics have no preventive role in transfusion-related sepsis. Educating the patient about a blood transfusion may alleviate anxiety. However, it is not a preventive action against transfusion-related sepsis. Wearing gloves may prevent the spread of microorganisms but may not help prevent sepsis.

Which technique is appropriate for the nurse to use when pouring sterile solution from a bottle into a container? a) Holding the bottle with its label pointed outside the palm of the hand b) Placing the cap of the bottle with the inner surface facing down on the table c) Keeping the edge of the bottle close to the edge of the container d) Holding the bottle outside the edge of the sterile field

d) Holding the bottle outside the edge of the sterile field Rationale: The nurse should hold the bottle outside the edge of the sterile field, because the outside of the bottle is not sterile. The cap should be placed with its inner surface facing upward on the table because the inner surface should not be contaminated. The nurse should hold the bottle with its label in the palm of the hand to prevent the possibility of the solution wetting and fading the label. The edge of the bottle should be kept away from the container.

In regards to surgical hand asepsis, which statement describes the rationale for drying the skin starting at the hands and moving to the elbow? a) It allows the nurse to more easily visualize any areas that are still soiled. b) It prevents the hands from dripping water onto the floor, reducing the risk of a fall hazard. c) It expediates the drying of the hands so gloves can be applied. d) It allows the drying to occur from the cleanest to the least clean.

d) It allows the drying to occur from the cleanest to the least clean. Rationale: The nurse should grasp one end of sterile towel and dry one hand, moving from fingers to elbow in a rotating motion. This allows the nurse to dry from cleanest (hands) to least clean (elbows). Using this method to dry does not increase the visibility of soiled surfaces. If all surfaces are dried thoroughly, there should be minimal or no dripping of water on the floor. The rationale behind this technique is not to expediate the donning of gloves.

Which personal protective equipment (PPE) is the most important for the nurse to wear when entering the room of a patient with Mycobacterium tuberculosis infection? a) Gown b) Gloves c) Head cap d) N95 respirator

d) N95 respirator Rationale: Patients with Mycobacterium tuberculosis infection require airborne precautions because the droplets are smaller than 5 microns and remain for long periods in the air. Therefore a respirator is the most important PPE to prevent the transmission of the disease. Gowns and gloves are most important when a nurse performs a physical examination to avoid a contact infection. A head cap is typically only worn by personnel who are performing a surgical procedure.

Which adventitious sounds are heard if there is an inflammation of the pleural membrane? a) Rhonchi b) Wheeze c) Crackles d) Pleural friction rub

d) Pleural friction rub Rationale: Pleural friction rub is a combination of scratchy and high-pitched sounds heard in the presence of inflammation of the pleural membrane. Rhonchi are the coarse and low-pitched adventitious sounds that may clear with cough. Wheeze is a high-pitched whistling sound heard when there is an obstruction in the airway. Crackles are high-pitched adventitious sounds that are caused by excessive secretions in the bronchi.

Which is a characteristic of abnormal healing if present in a secondary-intention wound? a) Increase in inflammation in the first 3 to 5 days after injury b) Absence of epithelialization of wound edges by day 4 c) Presence of drainage for more than 3 days after closure d) Presence of necrotic or slough tissue at the base of the wound

d) Presence of necrotic or slough tissue at the base of the wound Rationale: The presence of necrotic or slough tissue at the base of the wound indicates abnormal healing in a secondary-intention wound. An increase in inflammation in the first 3 to 5 days after injury, an absence of epithelialization of the wound edges by day 4, and the presence of drainage for more than 3 days after wound closure are characteristic of abnormal healing of a primary-intention wound, not a secondary-intention wound

Which instruction would the home health nurse provide to a patient's family member who asks how to clean a pair of scissors and a leg brace that is contaminated with the patient's blood? a) Disinfect the items with boiling water. b) Place contaminated objects into a bag and double-bag them. c) Use bleach solution when cleaning equipment that is soiled by organic material. d) The first step is to rinse the contaminated object with cold running water to remove organic material

d) The first step is to rinse the contaminated object with cold running water to remove organic material Rationale: Cleaning is the removal of organic material (e.g., blood). The first step to ensure that an object is clean is to rinse the contaminated object or article with cold running water to remove organic material. Hot water causes the protein in organic material to coagulate and stick to objects, making removal difficult. The items should be rinsed with cold water, then washed with warm (not hot) water. In the home care setting, soiled materials that are disposable are placed in a bag. In general, cleaning involves the use of water and a detergent/disinfectant (that is not bleach).

When obtaining a wound culture to determine the presence of infection, from where should the specimen be taken? a) Necrotic tissue b) Wound drainage c) Drainage on the dressing d) The wound after it has first been cleaned with normal saline

d) The wound after it has first been cleaned with normal saline Rationale: By cleaning the area before obtaining the culture, the skin flora is removed. Drainage that has been present on the wound surface or on the dressing can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. Necrotic tissue normally does not produce drainage.