P&P chapter 9: Medical Asepsis

ANS: A, B, C, D The mere presence of a pathogen does not mean that an infection will begin. Development of an infection occurs in a cyclic process, often referred to as the chain of infection, which depends on the following six elements: an infectious agent or pathogen, a reservoir or source for pathogen growth, a portal of exit from the reservoir, a mode of transmission, a portal of entry to the host, and a susceptible host.

1. For an infection to take place, which of the following must be present? (Select all that apply.) a. Pathogen and reservoir b. Portals of exit and entry c. Mode of transmission d. Susceptible host

ANS: transmission-based precautions Transmission-based precautions are infection control practices that reduce and eliminate sources and transmission of infection and help to protect patients and health care providers from disease.

1. Infection control practices that reduce and eliminate sources and transmission of infection are known as _______________.

ANS: A Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. The techniques used in maintaining surgical asepsis are more rigid than those performed under medical asepsis.

1. The nurse understands that the priority nursing action needed when medical asepsis is used includes: a. handwashing. b. surgical procedures. c. autoclaving of instruments. d. sterilization of equipment.

ANS: C In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive H. influenzae type b disease, invasive N. meningitidis disease, and other serious bacterial respiratory infections spread by droplet transmission, such as diphtheria (pharyngeal), M. pneumoniae, and pertussis. Pertussis is spread by large particle droplets. For infection spread via airborne routes, use airborne precautions, in addition to standard precautions. Examples of such illnesses include measles, varicella, and TB. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. People who have infections that are spread by large particle droplets, such as pertussis, need more than just standard precautions. Pertussis is not spread through direct patient contact. For patients known or suspected to have serious illnesses easily transmitted by direct patient contact, or by contact with items in the patient's environment, use contact precautions in addition to standard precautions. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection, C. difficile, Escherichia coli, Shigella, hepatitis A, rotavirus, and skin infections that are highly contagious or that may occur on dry skin.

10. The patient is admitted to the pediatric unit with severe pertussis. The nurse explains to the parents and the child that the patient will be treated with the use of: a. airborne precautions. b. standard precautions only. c. droplet precautions. d. contact isolation.

ANS: A Droplet precautions are instituted when droplets are larger than 5 µm, as in the case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted for pulmonary TB and measles.

11. Droplet precautions will be instituted for the patient admitted to the infectious disease unit with: a. streptococcal pharyngitis. b. herpes simplex. c. pulmonary TB. d. measles.

ANS: A In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including C. difficile, E. coli, Shigella, hepatitis A, or rotavirus; or (2) skin infections that are highly contagious or that may occur on dry skin. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. Patients who may be infected by pathogens that can be spread through direct patient contact may need more. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via the airborne route. In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella, and TB. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via large particle droplets. In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive H. influenzae type B disease, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children, as well as mumps, parvovirus B19, and rubella.

12. The patient has been hospitalized for several days and has received multiple intravenous antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea. The nurse should institute: a. contact precautions. b. standard precautions only. c. airborne precautions. d. droplet precautions.

ANS: A The reservoir is the site or source of microorganism growth. Control: sources of body fluids and drainage. Perform hand hygiene. Bathe the patient with soap and water. Change soiled dressings. Dispose of soiled tissues, dressings, or linen in moisture-resistant bags. Place syringes, uncapped hypodermic needles, and intravenous needles in designated puncture-proof containers. Keep table surfaces clean and dry. Do not leave bottled solutions open for prolonged periods. Keep solutions tightly capped. Keep surgical wound drainage tubes and collection bags patent. Empty and dispose of drainage suction bottles according to agency policy. The portal of entry is the site through which a microorganism enters a host. Urinary: Keep all drainage systems closed and intact, maintaining downward flow. The portal of exit is the means by which microorganisms leave a site. Respiratory: Avoid talking, sneezing, or coughing directly over a wound or sterile dressing field. Cover nose and mouth when sneezing or coughing. Wear mask if suffering respiratory tract infection. Transmission is the means of spread. Reduce microorganism spread. Perform hand hygiene. Use personal set of care items for each patient. Avoid shaking bed linen or clothes; dust with damp cloth. Avoid contact of soiled item with uniform.

13. What should the nurse do to break the chain of infection at the reservoir level? a. Change a soiled dressing. b. Keep drainage systems intact. c. Cover the nose and mouth when sneezing. d. Avoid contact of the uniform with soiled items.

ANS: C For diseases transmitted by large droplets (larger than 5 µm), such as streptococcal pharyngitis, pneumonia, scarlet fever in infants or small children, pertussis, mumps, meningococcal pneumonia or sepsis, or pneumonic plague, place the patient in a private room, or cohort the patient and wear a mask when closer than 3 feet from the patient. For diseases transmitted by small droplet nuclei (smaller than 5 µm), such as measles, chickenpox, disseminated varicella zoster, and pulmonary or laryngeal TB, place the patient on airborne precautions in a private room with negative airflow of at least six air exchanges per hour, and wear a respirator or mask. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. For diseases transmitted by direct patient or environmental contact, such as colonization or infection with multidrug-resistant organisms, respiratory syncytial virus, major wound infection, herpes simplex, and scabies, place the patient on contact precautions in a private room, or cohort the patient. Wear gloves and gowns.

14. The patient is admitted with mumps. The nurse knows that she will have to: a. put the patient in a private room. b. place the patient on standard precautions. c. wear a mask when closer than 3 feet to the patient. d. place the patient on contact precautions.

ANS: C Soap and water is still necessary for hand hygiene if hands are visibly soiled. Recent research has shown that handwashing with plain soap sometimes results in paradoxical increases in bacterial counts on the skin. Alcohol-based products have been more effective for standard handwashing or hand antisepsis than soap or antiseptic soaps. Studies have shown the efficacy of alcohol-based hand sanitizers in reducing infection in a variety of settings from intensive care to long-term care. Studies have shown that health care workers with chipped nail polish or long or artificial nails have high numbers of bacteria on their fingertips. For this reason, the CDC recommends that health care workers not wear artificial nails and extenders, and that they keep natural nails less than one-quarter of an inch long when caring for high-risk patients.

2. Handwashing with soap and water is: a. the most effective way to reduce the number of bacteria on the nurse's hands. b. more effective than alcohol-based products for washing hands. c. necessary for hand hygiene if hands are visibly soiled. d. not necessary if the nurse wears artificial nails.

ANS: A, B, C, D If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before having direct contact with patients, before putting on sterile gloves, and before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient); after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; when moving from a contaminated body site to a clean body site during care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves.

2. If hands are not visibly soiled, the nurse may use an alcohol-based hand rub in which of the following situations? (Select all that apply.) a. Before having direct contact with patients b. After contact with a patient's intact skin c. After contact with body fluids or excretions d. After removing gloves

ANS: health care-acquired infection (HAI) health care-acquired infection Health care-acquired infections (HAIs) are those that develop as a result of contact with a health care facility/provider; the infection was not present or incubating at the time of admission.

2. The nurse has a "scratchy throat" and has been sniffling for 2 days. While at work, she wears a protective mask when coming into contact with her patients. She does this in an attempt to protect them from a __________________.

ANS: A, B, C, D Signs of infectious pulmonary or laryngeal TB include documentation of positive AFB smear or culture, signs or symptoms of TB, cavitation on chest x-ray study, history of recent exposure, and physician progress notes indicating a plan to rule out TB. A TB skin test is not recommended by the CDC.

3. The nurse is planning to care for a patient diagnosed with possible tuberculosis (TB). Assessment of possible TB may be based on which of the following? (Select all that apply.) a. A positive AFB smear or culture b. Signs or symptoms of TB c. Cavitation on chest x-ray study d. History of recent exposure e. TB skin test

ANS: A The most important and most basic technique in preventing and controlling transmission of infection is hand hygiene. Use of disposable gloves may help reduce the transmission of infection, but it is not the single most important technique to prevent and control the transmission of infection. Neither the use of isolation precautions nor the sterilization of equipment is the single most important technique to prevent and control the transmission of infection.

3. When caring for patients, the nurse understands that the single most important technique to prevent and control the transmission of infection is: a. hand hygiene. b. the use of disposable gloves. c. the use of isolation precautions. d. sterilization of equipment.

ANS: Asepsis Asepsis is the absence of pathogenic (disease-producing) microorganisms.

3. ________________ is the absence of pathogenic (disease-producing) microorganisms.

ANS: medical asepsis Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis.

4. The nurse is preparing to provide care for the patient. Before making patient contact, she washes her hands. This practice is known as __________________.

ANS: C Perform hand hygiene using plenty of lather and friction for at least 15 to 20 seconds. Interlace fingers and rub palms and back of hands with circular motion at least 5 times each. Keep fingertips down to facilitate removal of microorganisms. Hot water can be damaging to the skin. Regulate the flow of water so that the temperature is warm. Warm water removes less of the protective oils on the hands than hot water. Jewelry and watches can be a place for pathogens to hide. Push wristwatch and long uniform sleeves above wrists. Avoid wearing rings. If worn, remove during washing. This provides complete access to fingers, hands, and wrists. Wearing of rings increases the numbers of microorganisms on the hands. The position of hands and arms will aid in washing pathogens away. Wet hands and wrists thoroughly under running water. Keep hands and forearms lower than elbows during washing. Hands are the most contaminated parts to be washed. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink.

4. Which of the following measures is appropriate when a nurse is washing his or her hands? a. Use very hot water. b. Leave rings and watches in place. c. Lather for at least 15 to 20 seconds. d. Keep the fingers and hands up and the elbows down.

ANS: D A sense of loneliness may develop because normal social relationships become disrupted. The nurse should plan care to control the risk that the patient may feel isolated. Denial and regression are not risks related to isolation. Aggression is not a risk for the patient on isolation precautions.

5. The nurse shows an understanding of the psychological implications for a patient on isolation when planning care to control the risk for: a. denial. b. aggression. c. regression. d. isolation. e. depression.

ANS: Surgical asepsis Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores.

5. _______________, also known as sterile technique, includes procedures used to eliminate all microorganisms from an area.

ANS: C Transfer the specimen to a container without soiling the outside of the container. Place the container in a plastic bag and label the outside of the bag or as per agency policy. Specimens of blood and body fluids are placed in well-constructed containers with secure lids to prevent leaks during transport. Use single bags that are impervious to moisture and sturdy to contain soiled articles. Use the double-bagging technique if necessary for heavily soiled linen or heavy wet trash. Linen or refuse should be totally contained to prevent exposure of personnel to infective material. Avoid allowing the isolation gown to become wet; carry the wash basin outward, away from the gown; avoid leaning against wet tabletops. Moisture allows organisms to travel through the gown to the uniform. Remove all reusable pieces of equipment. Clean any contaminated surfaces with hospital-approved disinfectant. All items must be properly cleaned, disinfected, or sterilized for reuse.

6. An appropriate technique for the nurse to implement for the patient on isolation precautions is to: a. double-bag all disposable items and linens. b. put another gown over the one worn if it has become wet. c. place specimen containers in plastic bags for transport. d. hand items to be reused directly to a nurse standing outside the room.

ANS: standard precautions Standard precautions, the primary strategies for prevention of infection transmission, apply to contact with (1) blood, (2) body fluids, (3) nonintact skin, and (4) mucous membranes, as well as with equipment or surfaces contaminated with these potentially infectious materials.

6. The primary strategies for prevention of infection transmission with regard to contact with blood, body fluids, nonintact skin, and mucous membranes are known as ______________.

ANS: A Apply the gown first, making sure that it covers all outer garments. Pull sleeves down to the wrist. Tie securely at the neck and waist. Next, apply either a surgical mask or a fitted respirator around the mouth and nose. Goggles or a face shield is put on after the gown and mask are applied. Gloves are put on last.

7. Before entering the room of a patient on isolation where all protective barriers are required, the nurse first puts on the: a. gown. b. gloves. c. eyewear. d. mask/respirator.

ANS: respirators OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special respirators. These respirators are high-efficiency particulate masks that have the ability to filter particles at 95% or better efficiency. Health care workers who use these respirators must be fit-tested in a reliable way to obtain a face-seal leakage of 10% or less.

7. OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special ________________.

ANS: QuantiFERON-TB Gold test (QFT-G) QuantiFERON-TB Gold test The CDC now recommends use of the QuantiFERON-TB Gold test (QFT-G) (CDC, 2005), a blood test, in place of the traditional TB skin test. The advantages of the QFT-G test are that it does not boost responses measured by subsequent tests, and the results are not subject to reader bias.

8. The nurse is applying for a position at a local hospital. As part of the employment criteria, she will be required to be assessed for TB exposure. She should be prepared for the ___________ blood test to be scheduled.

ANS: B Suspect tuberculosis (TB) in any patient with respiratory symptoms lasting longer than 3 weeks accompanied by other suspicious symptoms, such as unexplained weight loss, night sweats, fever, and a productive cough often streaked with blood. Isolation for patients with suspected or confirmed TB includes placing the patient on airborne precautions in a single-patient negative-pressure room. In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; (2) skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis, decubiti, pediculosis, scabies, staphylococcal furunculosis in infants and young children, or zoster; or (3) viral/hemorrhagic conjunctivitis or viral hemorrhagic infection (Ebola, Lassa, or Marburg). In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis; and invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis. Other serious bacterial respiratory infections spread by droplet transmission include diphtheria (pharyngeal), Mycoplasma pneumoniae, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children. Serious viral infections spread by droplet transmission include adenovirus, influenza, mumps, parvovirus B19, and rubella.

8. The patient is presenting to the hospital with a high fever and a productive cough. He says that he hasn't felt right since he returned from visiting Somalia about a month before admission. He also states that he has lost about 20 pounds in the last month and frequently wakes up in the middle of the night sweaty and "clammy." What should the nurse prepare to do? a. Place the patient on contact isolation. b. Place the patient in a negative-pressure room. c. Place the patient on droplet precautions. d. Use standard precautions only.

ANS: C In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and TB. Airborne precautions are not appropriate for viral infections spread by droplet transmission, including adenovirus, influenza, mumps, parvovirus B19, and rubella. Contact precautions would be appropriate for a patient with pediculosis.

9. For patients with which of the following conditions should the nurse implement airborne precautions? a. Rubella b. Influenza c. Tuberculosis d. Pediculosis

ANS: standard precautions Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes.

9. The nurse knows that the basic concept of all patient care that is implemented to prevent the spread of infection from blood, body fluids, secretions, excretions, nonintact skin, and mucus membranes is __________________.