Ch. 34 - NCLEX Review Questions

D - If the nurse touches a sheet (nonsterile) with sterile gloves, the gloves are contaminated. The other actions do not contaminate sterile gloves.

A nurse is assigned to care for a client with a deep wound infection. Which of the following actions would result in the contamination of sterile gloves? A) The nurse grasps a sterile cotton-tipped swab to clean wound edges. B) The nurse takes a gauze pad in hand and places it in the wound. C) The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound. D) The nurse pulls up the sheet over the client's perineum for better draping.

3. Remove gloves and perform hand hygiene before administering the medication

The nurse has redressed a client's wound and now plans to administer a medication to the client. It is important to: 1. Leave the gloves on to administer the medication 2. Remove gloves and perform hand hygiene before leaving the room 3. Remove gloves and perform hand hygiene before administering the medication 4. Leave the medication on the bedside table to avoid having to remove gloves before leaving the client's room

B - When a client is in isolation, the nurse should take measures to improve the client's stimulation and make sure to explain the isolation procedures. Darkening the room can increase the sense of isolation. The nurse should not change the isolation level but should provide plenty of emotional support and make time for the client to prevent a sense of isolation. As long as family and caregivers follow infection precautions, there is no reason to limit contact with these individuals.

A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client seems angry but knows this is a normal response to isolation. The best intervention is to: A) Provide a dark, quiet room to calm the client. B) Explain the isolation procedures and provide meaningful stimulation. C) Reduce the level of precautions to keep the client from becoming angry. D) Limit family and other caregiver visits to reduce the risk of spreading the infection.

D - Gowns should be worn when there is a possibility that blood or body fluids could get on the nurse's clothes or when the client is on contact isolation status. The other options are not appropriate uses of gowns.

A gown should be worn when: A) The client's hygiene is poor. B) The client has acquired immunodeficiency syndrome (AIDS) or hepatitis. C) The nurse is assisting with medication administration. D) Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.

4. Perform hand hygiene before eating or handling food

After coming in contact with infected clients, and after handling contaminated equipment or organic material, visitors are encouraged to: 1. Wear gloves before eating or handling food 2. Use a private room to talk with family members 3. Leave the facility to prevent contamination of others 4. Perform hand hygiene before eating or handling food

A - Remove goggles by touching only the ear pieces. Next remove the gown and the nurse should untie the neck ties and allow the gown to fall from shoulders and only touch the inside of the gown. The mask is removed last by removing the elastic from the ears or untying the bottom mask string followed by the top mask string. In both cases the nurse's hands only touch the ties of the mask. Head covers are usually not worn in isolation rooms as a barrier.

Before the nurse washes the hands when leaving an isolation room, what is the last thing that is removed? A) Mask B) Gown C) Goggles D) Head cover

C - Airborne precautions are required for chickenpox and tuberculosis, because in these diseases small particles float in the air and a barrier is required to prevent contamination of the nurse. A respiratory protection device is form-fitted to the face to prevent the escape of air around the seal. Gloves and gown are also worn to prevent contamination and transport of infective particles to other clients. For viral pneumonia a regular mask is used as a barrier because the particles do not float in the air and are more likely to be found on surfaces unless coughing or spitting is occurring. Atelectasis is the collapse of alveoli, and airborne precautions are not needed. Herpes and scabies are spread by contact, and gloves and gown would be necessary; masks would not be needed. For multidrug-resistant respiratory syncytial virus the protection of the client would be as important as preventing the spread of these disorders. Therefore, gown, gloves, and mask would be used as in reverse isolation to prevent cross contamination of the client.

For which airborne disease(s) would the nurse be required to use gloves, respiratory devices, and gown when in close contact with the client? A) Herpes simplex, scabies B) Viral pneumonia, atelectasis C) Chickenpox, pulmonary tuberculosis D) Multidrug-resistant respiratory syncytial virus

B - If an infectious disease is transmitted directly from one person to another, it is a communicable disease. Portals of entry and exit are the mechanisms of disease transmission. A susceptible host is a person who can acquire an infection.

If an infectious disease can be transmitted directly from one person to another, it is: A) A susceptible host B) A communicable disease C) A portal of entry to a host D) A portal of exit from the reservoir

A - The blood is a reservoir for pathogens in hepatitis B and C. Neither organism can survive in the urinary, reproductive, or respiratory tract.

In infectious diseases such as hepatitis B and C, a reservoir for pathogens is: A) The blood B) The urinary tract C) The respiratory tract D) The reproductive tract

1. Illness Stage

The interval when a client manifests signs and symptoms specific to a type of infection is the: 1. Illness Stage 2. Convalescence 3. Prodromal Stage 4. Incubation Period

A - Good hand hygiene is the most effective way to break the chain of infection. Wearing gloves can help in decreasing disease transmission, but clean hands are required for it to be truly effective. Placing clients in isolation is costly and often unnecessary, and clients can be psychologically harmed by isolation. Even providing private rooms for clients will not be effective if health care workers do not follow good hand hygiene practices.

The most effective way to break the chain of infection is by: A) Practicing good hand hygiene B) Wearing gloves C) Placing clients in isolation D) Providing private rooms for clients

B - Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination by spitting (saliva can be a source of bacterial contamination) and scratching others, which can break the skin and become a source of risk. All of the barriers listed would minimize cross contamination from the client to the nurse. Even though gloves may be all that is needed because of limited contact with the client, after an hour the client will remain confused and may not understand. The client may become aggressive again and spit or scratch, and other barriers are needed to stop that source of possible risks. A sedative may be given if needed, but trying to perform an assessment when the client is asleep is not appropriate and will prevent the nurse from successfully establishing rapport with the client. Although masks and shields might be frightening to some confused clients, if the client is spitting and body fluids could be exchanged, a barrier should still be used.

The nurse has just admitted a client to rule out active hepatitis B. The client is confused, spitting and scratching everyone who enters the room. The nurse should: A) Wait an hour until the client calms down and then use gloves when touching the client. B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment. C) Administer a sedative and then perform the assessment after the client is asleep; no precautions would be needed. D) Realize that isolation equipment might further confuse the client and avoid using a face mask and shield but use gown and gloves.

C - A 1-inch margin is considered unsterile and is the barrier spacing between the sterile field in the center of the drape and the edge of the drape. Liquids spilled on a waterproof drape will not absorb from or be contaminated from the surface beneath. Although such a situation could be messy, bacteria would not cross from the unsterile to the sterile side. The edge of the table and the 1-inch border create the edge of the sterile field. Anything below the edge, including the side of the drape, becomes unsterile. Reaching over a sterile field is always a source of contamination and should not be done.

The nurse is setting up a sterile field for the physician. Which of the following statements concerning a sterile field is correct? A) The sides of the drape over the table are still sterile until they are touched. B) Reaching over the field is not a source of contamination if the nurse has on a clean gown and gloves. C) One inch around the border should be considered to be the barrier between the sterile field and under the table. D) A liquid spill onto the sterile field is a source of contamination from the table below the drape, even if the barrier is waterproof.

C - When the outside of the cuff is grasped with the contaminated gloved hand, then dirty to dirty remains intact. Pulling the glove away from the hand entirely without touching the wrist or fingers further minimizes the contamination by the gloved hand. If the nurse puts the gloved thumb inside the glove, the nurse has contaminated the bare hand with a contaminated thumb. Pulling the glove off by holding it at the back sounds good and could minimize contamination, but it is very difficulty to remove a glove this way without the risk of tearing the glove and creating contamination through the tear. If excessive secretions are present on gloves, then a towel or the drape could be used to wipe off excessive secretions before an attempt is made to remove the gloves.

To remove a glove that is contaminated, what should the nurse do first? A) Rinse the glove before removing it to minimize contamination. B) Pull the glove off the back of the hand until it slides off the entire hand and discard it. C) Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or fingers. D) Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the hand by the other gloved hand.

1. An autoclave is used

To sterilize surgical instruments, parenteral solutions, and surgical dressings: 1. An autoclave is used 2. Soap and water is used 3. Ethylene oxide gas is used 4. Chemicals are used for disinfection

C - Adequate hand washing will remove bacteria and wastes or contaminates to minimize cross contamination between clients. Use of alcohol-based waterless antiseptics between clients is also effective if the guidelines for using these cleansers are followed. Giving all clients antibiotics is impractical and is a source of new superinfections when persons who do not need antibiotics are given them and then the bacteria mutate to become resistant to older drugs. It would be both unethical and costly to try to control infections by treating everyone in the facility. Although wearing gloves to perform procedures that carry the risk of direct contact with contaminated material is a correct method of bacterial control, wearing gloves at all times is impractical, expensive, and unrealistic. Housekeeping staff are trained to use the correct agents for decontamination and disinfection of all surfaces that place clients at risk.

What is the single most effective method by which the nurse can break the chain of infection? A) Give all clients antibiotics. B) Wear gloves when caring for all clients. C) Wash hands between procedures and clients. D) Make sure housekeeping staff are using the right chemicals.

A - The cuff is folded and touched to apply the glove; thus, it becomes contaminated during application of the glove. Usually the cuff will fall down over the wrist, but if it does not, then it is considered unsterile and should not be touched during the procedure. All of the outer part of the glove is sterile unless it has been contaminated. The inner wrapper that held the sterile glove is not contaminated unless one touches it. Therefore, the outer part of the glove can touch it without contamination. The powder is sterile and will not contaminate anything it touches.

What part of a sterile glove is considered contaminated once the glove is applied by the open gloving method? A) The inner cuff of each glove B) The back of the gloved hands C) Any surface that the powder from the gloves touches D) The outer part of the glove that touched the inner wrapper

A - When surgical hand hygiene is performed, the hands should always be kept above the elbows so that the water runs from the hands to the elbows.

When a nurse is performing surgical hand hygiene, the nurse must keep the hands: A) Above the elbows B) Below the elbows C) At a 45-degree angle D) In a comfortable position

D - The rule is "sterile to sterile" to prevent contamination. The outer cover is considered unsterile. As long as the inner packet is not touched, the packet is considered sterile. The 1-inch border or barrier between the edge of the drape and the field is the dividing line for sterile versus nonsterile. Using a sterile glove to remove the inner packet is all right, but dropping it into the middle of the field will contaminate other items. A sterile assistant can take the item from the nurse, but placing it on the edge of the drape will contaminate the item because it is not inside the 1-inch border/barrier. Using sterile forceps to remove the inner packet is acceptable, but putting the item into the middle of the field will again risk potential contamination from reaching over the sterile field.

When transferring a sterile item to a sterile field, the nurse should: A) Open the outer package and let the sterile assistant take the item from the nurse to put on the edge of the drape. B) Use a sterile lifting tool (forceps) to pick up the inner package and transfer it to the middle of the field. C) Open the outer package and use a sterile glove to pick up the item and drop it on the sterile field in the middle of the drape. D) Open the package by peeling back the cover without touching the inner package and drop the item within the sterile field without touching the 1-inch border.

D - Keeping the solution in drainage tubes draining away from the drainage site on the body reduces the risk for bacteria growth. Running any solution backward in the tubing puts the client at risk by bringing any bacteria that may be present lower in the system back to the body, and cross contamination will occur. As in surgical areas, anything below the waist should be considered at potential risk for infection. Needles are not to be recapped or cut because of the increased risk of experiencing puncture wounds while doing so. Not all dressings need to be placed in red bags; only dressings with moisture require placement in a red bag. Bottles of solution that are sitting in the client's room should be closed to prevent airborne contaminants from entering and creating an unsterile situation.

Which of the following statements reflects the current trend in the directives from the Centers for Disease Control and Prevention (CDC) for minimizing risks of infection? A) Discard all dressings into red bags. B) Do not recap bottles of solutions to minimize risk of contamination. C) Recap syringes or break needles off before discarding into sharps containers. D) Keep all drainage tubing below the level of the waist and/or site of insertion.

D - In hand washing, rinsing is from clean to dirty; the arms are considered cleaner than the fingers and therefore rinsing is away from the cleaner part of the arm. In the surgical scrub the arm is considered more contaminated because the hands and nails are more thoroughly scrubbed; therefore, in a surgical scrub the hands are held above the elbows. In hand washing the fingers are held downward to rinse and are dried in the same manner. Keeping hands in sight is important in both cases, but no special position is needed after hand washing. Although a foot or knee pedal is a preferred method of soap and water delivery, using a faucet can be just as safe if a paper towel is used to turn off the water after the hands have been washed.

Which statement comparing a surgical scrub with a regular hand-washing session is correct? A) Water and soap are turned on with the leg or foot pedal in both cases. B) A surgical scrub lasts the same length of time as a hand washing between clients. C) The hands are held in the same position after the scrub as after regular hand washing to prevent contamination from other sources of contact. D) The fingers are held down to rinse in routine hand-washing but are held upright when performing a surgical scrub.