Asepsis

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond?

"As we age, our immune system does not function as well."

The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team?

"Avoid touching the outside of your gown when removing it."

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful?

"I will obtain a mask from the staff and wash my hands before touching my family member."

The nurse is getting ready to change the client's saturated, infected leg dressing. The client requests that the nurse delay it until the night shift. Which response would the nurse provide this client?

"Saturated dressings increase the risk of the spread of infection."

A client who has been diagnosed with a cold is upset that antibiotic therapy was not prescribed. Which nursing response is most appropriate?

"The common cold is a virus and will not respond to antibiotics."

The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?

"Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."

A nurse has finished giving care to a client who has a communicable respiratory infection. In which order should the personal protective equipment (PPE) be removed? 1. Gloves 2. Respirator 3. Gown 4. Goggles

1, 4, 3, 2

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A commercially packaged surgical item is not considered sterile if past expiration date.

A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area?

Area of active drainage

A client is being admitted to the hospital for elevated temperature for the past 24 hours. He had his right knee replaced 4 days ago in the same facility. Which assessment is a priority for now?

Auscultate lung sounds.

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

Client receiving chemotherapy

What is the primary purpose for the demonstrated glove application?

Cover exposed wrist skin

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

Create an area for sterile field and opening packages

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measure should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?

Diligent hand hygiene

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?

Early infection treatment is needed to prevent the spread of infection.

A nurse is working with an 82-year-old client following gallbladder surgery who is NPO and has peripheral IV access in the right hand. The client is occassionally incontinent of urine. What nursing action has the greatest potential to reduce the client's risk of surgical complications?

Encourage early ambulation

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

Exogenous healthcare-associated

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

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

The nurse is caring for a hospital client who was admitted for an exacerbation of congestive heart failure but who has just been diagnosed with Clostridium difficile-related diarrhea. How will the nurse categorize this development?

Health care-associated infection (HAI)

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?

Incentivizing health care workers to utilize hand hygiene

What is the second line of defense in microbial invasion?

Inflammation

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?

MRSA in the wound

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next?

Perform hand hygiene

The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?

Perform hand hygiene.

The nurse notices a student preparing to enter the room of a client with tuberculosis wearing gloves and a gown. What is the appropriate nursing action?

Remind the student that a fitted N95 respirator is required

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from the room.

The nurse has applied personal protective equipment (PPE) before caring for an immunocompromised client. When removing PPE, what action should the nurse perform?

Remove gloves with fingers on the inside of glove

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

Surgical asepsis technique

The student nurse observes another nurse wash her hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium Difficile (C diff). Why is this behavior incorrect?

The bathroom is highly contaminated with the Clostridium difficile bacteria.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?

The nurse keeps fingernails less than 1/4 in (0.63 cm) long.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

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

In which situation should the nurse avoid the use of alcohol hand rub for performing hand hygiene?

The nurse's hands are visibly soiled after changing an incontinence pad

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

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

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?

Use a sterile intravenous catheter.

Surgical asepsis is defined as:

absence of all microorganisms.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

an older adult client with a history of heart failure

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?

applying a new dressing with the gloves that were used to remove the old dressing

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

bacteria.

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:

bacterial infection.

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?

change to airborne precautions

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

decreased cellular immunity.

The process of phagocytosis involves

digestion of microbes by white blood cells.

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?

handwashing

A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

helps to determine prescribed antibiotic therapy

A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as:

iatrogenic.

To eliminate needlesticks as potential hazards to nurses, the nurse should:

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

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

into a private room

A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection?

older adult

The nurse works at an agency that requires its employees to wear a face mask as long as the employee is in the building. The nurse performs the following activities while working. Which action is an error by the nurse?

omitting hand hygiene following removal of the nurse's mask

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?

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

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?

place the specimens into plastic biohazard bags

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?

reaches down to the bed to pick up a sterile drape

The most common infection in children is:

respiratory.

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

urinary catheter

The most lethal infection in an older adult client is:

urinary.

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all care and interaction with this client

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

within normal limits

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

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

An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate?

Airborne

Standard precautions apply to which items? Select all that apply.

Blood Body fluid secretions Mucous membranes Nonintact skin

The nurse is providing care for a client with varicella. What action should the nurse perform?

Ensure the client is housed in a negative pressure room.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

Gown and gloves

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

Greater than 40.5°C

What is the primary goal of the observable action associated with the removal of contaminated gloves?

Prevent contamination of ungloved hand

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. Which would be the appropriate action to take to maintain a sterile field?

Stop the procedure, remove damaged gloves, perform handwashing, and put on new sterile gloves.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply.

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

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How should the nurse best perform chest auscultation?

Use a stethoscope that remains in the client's room

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

When hands are visibly soiled

The nurse is preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply.

place a mask on the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

surgical asepsis

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?

"Help me understand your thoughts about vaccinations."

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?

"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?

Assess client's pain level and manage pain accordingly.

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?

Discard the bottle and get a new one because the saline has expired.

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?

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

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

Hold sterile objects above waist level to prevent inadvertent contamination.

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.

Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders

The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?

Putting on gloves

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

The nurse manager for a long-term facility notes an increase in the rate of various infections among residents. Which would be the nurse's best initial action?

Review the current infection control protocols and adherence to them.

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate?

The client will state how to safely take the prescribed antibiotic.

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?

The client's immune system became further weakened

The charge nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction?

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

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?

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

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply.

The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

WBC of 25,000 mcL

A client is diagnosed with hepatitis B. Which recommendation(s) will the nurse include when teaching the client about how to prevent the spread of viral infections? Select all that apply.

Wash hands frequently Practice safe and protected sex Cover all open sores Avoid sharing sharp objects like razors and nail clippers

The nurse in the health center is conducting assessment related to risk for infection on different age clients. Which clients are at higher risk of acquiring infection? Select all that apply.

a 45-year-old female who is allergic to flu vaccine a 5-month-old infant with low grade fever due to teething the 65-year-old male suffering from diabetic foot ulcer

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room

A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is:

semen.

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

"I have set up this sterile field for your procedure, so please do not touch anything around the tray."

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?

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

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. What action best reduces the nurses' risk of needlestick injuries?

Avoid recapping needles except when absolutely necessary

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

Discard the sterile field and the supplies and start over.

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?

Hold sterile objects above waist level to prevent accidental contamination.

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.

increased respiratory rate lymph node enlargement fever

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense?

intact skin and mucous membranes