CH. 24

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."

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?

"Stress leads to increased secretion of cortisol, which suppresses your immune response."

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?

"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

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."

The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?

"When your sputum culture is negative."

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?

"Your white blood cells have increased in the area."

9:04am You reviewed steps to follow to put on the first glove. The next thing you must do is put on the second glove. The second glove goes on the non-dominant hand.

- Hold the thumb of your gloved hand outward and place your fingers inside the cuff of the remaining glove -Lift it from the wrapper -Place your non-dominant hand into the glove and pull it on, taking care not to touch your skin with the outer surface of the glove

You've identified the steps for opening the package of sterile gloves. The next thing you must do is put on the first glove. The first glove goes on the dominant hand.

- Use the thumb and forefinger of your non-dominant hand to grasp the cuff of the sterile glove for your dominant hand. -Touch only the inside surface of the glove -Lift the glove about your waistline -Place your dominant hand into the glove and pull on the glove

Which of the following is a characteristic most likely associated with Standard Precautions?

-Face Mask -Personal Protective Equipment (PPE) -Hand Hygiene -Discard sharps in puncture Resistant container

Which of the following is a specific indication for aseptic technique?

-Invasive Procedure -Skin Integrity Broken

9:02am You've been asked to provide wound care for Mr. Juantos. You have explained to him what you would like to do to care for his wouterm-26nd and change his dressing. You need to include activities to prevent infection while putting on your sterile gloves. What steps will you take to break the chain of infection anytime sterile gloves are required?

-Maintain surgical asepsis - Perform hand hygiene

What best describes an important part of the aseptic technique process?

-Only Sterile objects in field -PPE -Only sterile touches sterile -Keep objects in view -Never leave sterile area

According to CDC when is hand washing performed over alcohol based hand rub:

-hands are visibly soiled -hands are contaminated with blood or bodily fluids -before eating and after using restroom -If you know or suspected you are exposed to certain organisms such as causing Anthrex, nora virus, or c diff

How do you perform hand hygiene using alcohol based hand rub

1. apply correct amount according to product label into palm of hands 2. Typically 1-3 ml is dispensed of foam or liquid 3. Rub hands together covering all surfaces of hands and fingers, finger nails 4. Rub hands together for 15 seconds until they are completely dry 5. Removed jewelry or keep jewelry on during hand hygiene

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days.

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

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

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

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

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?

Avoid touching the outer surfaces of the gown.

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.

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.

When performing an aseptic technique, which area is always considered contaminated?

Edges of sterile field

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

Viruses are the most significant and most commonly observed infection-causing agents in health care institutions. T/F

False

Which of the following is a characteristic most likely associated with personal protective equipment for standard precaustions?

Goggles/Face Shields

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.

What best describes an important part and most likely the 1st step of the aseptic technique process?

Hands up for scrubbing

Which best describes an indication for contact precautions?

History of Contact Isolation

Regarding aseptic technique, a tool should be immediately discarded if...

If sterility questioned

Regarding aseptic technique, a sterile field may be considered contaminated if...

If wet or prolonged exposure to air

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?

In a bag marked "biohazards"

There are five signs of acute infection that usually appear at the site of an injury or inflammation: redness, heat, swelling,________________ , and loss of function.

Pain

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

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

Which is important to do for a patient on contact precautions?

Preventative Edcuation

During the ______________stage of infection, early signs and symptoms of a disease are present but are often vague and nonspecific.

Prodromal

The nurse administered an antipyretic drug to a client with high-grade fever of 101.4°F (38.6°C). Which intervention should the nurse perform next?

Reassess temperature after 1 hour and document results in the chart.

You know how to put on sterile gloves. What if, while putting on your sterile gloves, you inadvertently touch the outside of the glove to your sleeve?

Remove the glove and perform hand hygiene before resuming procedure with a new pair of gloves.

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

The _______________ of a microorganism is the natural habitat of the organism, where growth and multiplication occur.

Reservoir

Which is a principle important for rooming two patients admitted on contact precautions?

Same Pathogen, same room

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:

Survival adaptation

Which should be documented by the nurse?

The fact that sterile technique was used for a given procedure

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.

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.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles?

The nurse removes her gown and then removes her gloves.

A health care--related infection refers to an infection that originates or takes place while in a health care facility. T/F

True

A significant and disturbing infection trend continues to be the development of microorganisms, particularly Staphylococcus aureus bacteria, that are resistant to one or more classes of antibiotics (e.g., methicillin, vancomycin). T/F

True

Clostridium difficile (CDI) is responsible for an estimated 14,000 to 20,000 deaths annually in the United States and is associated with an increase in hospital stays by 2.8 to 5.5 days. T/F

True

Transmission-based isolation precautions are used for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes. T/F

True

What is the most common client site for development of healthcare-associated infections (HAI)?

Urinary tract

Mosquitoes, ticks, and lice, also known as ____________, are carriers that transmit organisms from one host to another.

Vectors

An organism's potential to produce disease in a person depends on four factors: the number of organisms, the person's immune system, the length and intimacy of the contact between the person and the microorganism, and the organism's ,__________ or ability to cause disease.

Virulence

Which of the following is a characteristic most likely associated with proper hand hygiene?

Wash in/Wash out

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne

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

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?

be sure that there are gloves of various sizes and gowns for use

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

contact

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?

contact precautions

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 nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?

hand washing

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

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

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

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

keeping sterile field above waist level

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the:

prodromal period

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

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?

the client who is 48-hours postsurgical procedure

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?

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

A team of nurses is caring for a client with tuberculosis. They have not been fitted for N95 respirators. How will the team proceed with care?

utilize a powered air purifying respirator (PAPR)

You've assessed the situation. Before you begin the procedure of donning and removing sterile gloves, you must understand a few key points about setting up a sterile field. Do you know the key points to remember when setting up a sterile field?

-Always keep the sterile field in front of you -Never reach over a sterile field -Keep the sterile field at waist height or above -Consider the outer 1' of the field contaminated -Ensure that only sterile items touch sterile items

What constitutes personal protective equipment in the setting of contact precautions?

-Gown -gloves

You have now reviewed the steps to follow to put on the gloves. You need to finish putting the gloves on by extending the cuffs.

-Slide the fingers of one hand under the cuff of the other -Fully extend the cuff down the arm being careful to only touch the sterile outside of the glove -Repeat for other hand -Adjust gloves as needed

2 ways to perform hand hygiene?

-Soap and water -Alcohol-based hand rub

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

5 moments to perform hand hygiene:

-before touching patients -before clean or aseptic procedure -after body fluid exposure risk -after touching a patient -after touching a patients surroundings

The nurse is providing education to a senior circle group during an active flu season about the differences between viruses and bacteria. What statements made by the attendees indicates that the education has been effective? Select all that apply.

-"The virus enters the host cell's metabolism and replicates itself" -"There are some Immunizations that are available for select viruses. -"There are some viruses that may be associated with cancers."

9:02am Before you begin the procedure of donning and removing sterile gloves, you must assess the situation. What are the key things to assess before performing this skill?

-Determine the need for sterile field and gloves -Assess patient's chart for a possible latex allergy -Ask the patient regarding any history of allergy or sensitive reactions

Which of the following is a characteristic most likely associated with personal protective equipment for Standard Precautions?

-Gloves -Gown -Donning and Removing PPE

Which of the following is a characteristic most likely associated with proper hand hygiene?

-Hand Washing -Alcohol-based hand rub

9:03am You've noted the key points about setting up a sterile field. Now you may begin the procedure of donning sterile gloves. The first thing you must do is open the package. Put the steps in order:

-Peel back top layer of the outer wrapper -Remove the inner package -Place the inner package on the work surface with side marked "cuff end" closest to you -Open the packet so that your hand doesn't come into contact with the inside contents -Open the top fold, bottom fold, and sides of the package

What is important for a patient being placed on contact precautions?

-Private Room -Limit time pt leave the room -Wash in / Wash out -PPE -Special Linen Handling -Leave Equipment in room

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.

You've successfully put on your sterile gloves and provided wound care to Mr. Juantos. Now you must remove the gloves in a safe manner to prevent the spread of microorganisms that may be on the outside of the gloves.

-Use your dominant hand to grasp the other glove near the cuff end on the outside of the glove -Remove the glove inverting it as it is pulled off, to keep the contaminated area (the outer surface of the glove) on the inside. -Hold the removed glove in your gloved hand -Slide the fingers of ungloved hand inside the remaining glove, between the glove and your skin -Grasp the glove on the inside and remove it by turning it inside out, over the hand and the other glove -Discard the gloves and perform hand hygiene

When is using alcohol-based rub a good option for hand hygiene?

According to CDC, -if hands are not visibly soiled -hands have not come in contact with blood or bodily fluids -moving from a contaminated body site to a clean body site during pt care -before and after each pt contact -after contact with surfaces in pt environment -after removing gloves -before inserting urinary catheters, invasive devices that don't require surgical placement

The nurse is assigned to change the client's abdominal dressing after hernia repair. Which action will the nurse perform?

Change the dressing using sterile technique.

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?

Cleanse and disinfect the sphygmomanometer.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub.

Which client goal related to infection control is a priority?

Demonstrate adequate knowledge on infection control.

The nurse is caring for a client who developed a urinary tract infection while hospitalized. What intervention(s) will the nurse initiate to care for this health care-associated infection? Select all that apply.

-Standard precautions such as gloves and hand hygiene -Move client to a private room for safety precautions -Transmission-based precautions including proper disinfecting of equipment

The nurse instructor is discussing the relation of early ambulation and infection control. Which response from the student indicates the need for further explanation?

All clients must ambulate as early as possible to avoid infection.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

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