Chapter 26 Asepsis and Infection Control
Of the following hospitalized patients, who is most at risk for acquiring a health care-associated infection? a. A 60-year-old who smokes two packs of cigarettes per day b. A 40-year-old who has an indwelling urinary catheter in place c. A 65-year-old who is a vegetarian and slightly underweight d. A 60-year-old who has a white blood cell count of 6000
Answer: b. A 40-year-old who has an indwelling urinary catheter in place Hospital-acquired infections are associated with indwelling urinary catheters. A normal white blood cell count, smoking cigarettes, or being a vegetarian has not been associated with hospital-acquired infections. LO: 26.6
The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? a. "I need to take hot baths because they are relaxing." b. "I need to sit whenever possible to conserve my energy." c. "I need to avoid long periods of rest because it causes joint stiffness." d. "I need to do some exercises, such as walking, when I am not fatigued.
Answer: a. "I need to take hot baths because they are relaxing." Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse would instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and the need to select the incorrect client statement. Also, focus on the subject, fatigue. This will assist in directing you to the correct option as the action that would exacerbate fatigue.
The nurse correctly identifies which patient as having the greatest risk for infection? a. An 80-year-old male with an enlarged prostate b. A 24-year-old female long-distance runner c. A 50-year-old obese male d. A 40-year-old sexually active female
Answer: a. An 80-year-old male with an enlarged prostate LO: 26.2
When the patient is diagnosed with pertussis, which isolation precaution should the nurse implement? a. Droplet b. Airborne c. Contact d. Protective
Answer: a. Droplet LO: 26.6
When teaching a student nurse about removing PPE, the nurse would include which correct order of equipment removal? a. Gloves, gown, eyewear, and mask b. Mask, eyewear, gown, and gloves c. Gown, mask, eyewear, and gloves d. Gloves, gown, mask, and eyewear
Answer: a. Gloves, gown, eyewear, and mask LO: 26.6
The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? a. Hairdressers b. The homeless c. Children in day care centers d. Individuals living in a group home
Answer: a. Hairdressers Rationale: Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts. Test-Taking Strategy: Focus on the subject, a latex allergy, and note the strategic word, most. Recalling the sources of latex and of the allergic reaction will direct you easily to the correct option.
The nurse knows that the antigen-antibody reaction is an example of what type of immunity? a. Humoral b. Cellular c. Innate d. Passive
Answer: a. Humoral LO: 26.1
The nurse knows which skill does not require the use of sterile technique? a. NG tube insertion b. Foley catheterization c. Tracheostomy care d. PICC line insertion
Answer: a. NG tube insertion LO: 26.6
The nurse uses what term to identify a disease-causing organism? a. Pathogen b. Normal flora c. Vector d. Microorganism
Answer: a. Pathogen LO: 26.1
The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient? a. Private room b. Private, negative-airflow room c. Mask worn by the staff when entering the room d. Mask worn by the staff and the patient when leaving the patient's room
Answer: a. Private room A private room decreases the chance of another patient contracting the infection. The other precautions (i.e., private room with negative airflow, mask worn by staff when entering the room, and mask worn by staff and patient when leaving the patient's room) are airborne precautions, which are not necessary in managing this patient. LO: 26.6
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and would incorporate which action as a priority in the plan? a. Protecting the client from infection b. Providing emotional support to decrease fear c. Encouraging discussion about lifestyle changes d. Identifying factors that decreased the immune function
Answer: a. Protecting the client from infection Rationale: The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options b, c, and d may be components of care but are not the priority. Test-Taking Strategy: Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory to answer the question. Remember that physiological needs are the priority. This will direct you to the correct option.
The nurse is teaching a group of patients about diseases that are transmitted by ticks. Which term would the nurse use when identifying the function of a tick in spreading disease? a. Vectors b. Bacteria c. Viruses d. Fungi
Answer: a. Vectors LO: 26.2
A client presents at the primary health care provider's office with complaints of a ringlike rash on the upper leg. Which question would the nurse ask first? a. "Do you have any cats in your home?" b. "Have you been camping in the last month?" c. "Have you or close contacts had any flulike symptoms within the last few weeks?" d. "Have you been in physical contact with anyone who has the same type of rash?"
Answer: b. "Have you been camping in the last month?" Rationale: The nurse would ask questions to assist in identifying a cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ringlike rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option a is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another. Test-Taking Strategy: Focus on the strategic word, first. Also focus on the data in the question. Eliminate options c and d because they are comparable or alike. It is important in the initial assessment for the nurse to determine the cause of the rash. If the client sustained a bite while out in the woods, Lyme disease should be suspected.
The nurse recognizes that the stethoscope most correctly represents which possible link in the chain of infection? a. Source b. Portal of exit c. Portal of entry d. Mode of transmission
Answer: d. Mode of transmission LO: 26.2
A client is diagnosed with scleroderma. Which intervention would the nurse anticipate to be prescribed? a. Maintain bed rest as much as possible. b. Administer corticosteroids as prescribed for inflammation. c. Advise the client to remain supine for 1 to 2 hours after meals. d. Keep the room temperature warm during the day and cool at night.
Answer: b. Administer corticosteroids as prescribed for inflammation. Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated, and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present. Test-Taking Strategy: Focus on the subject, scleroderma. Think about the pathophysiology associated with this condition and read each option carefully to assist in answering correctly.
A client calls the nurse in the emergency department and reports being just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action would the nurse take? a. Advise the client to soak the site in hydrogen peroxide. b. Ask the client if they ever sustained a bee sting in the past. c. Tell the client to call an ambulance for transport to the emergency department. d. Tell the client not to worry about the sting unless difficulty with breathing occurs.
Answer: b. Ask the client if they ever sustained a bee sting in the past. Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if they ever experienced a bee sting in the past. Option A is inappropriate advice. Option c is unnecessary. The client would not be told "not to worry." Test-Taking Strategy: Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment, the first step.
The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection? a. Virus b. Bacterium c. Fungus d. Spore
Answer: b. Bacterium The cause of an infection in the surgical wound in a hospitalized patient who has had abdominal surgery is most likely bacteria because it is present on the skin as normal flora. Fungi and spores are the focus of removal during the surgical preparation. Viruses are target specific and do not usually live on the skin. LO: 26.1, 26.2
Which isolation precaution should the nurse implement for the patient who has been diagnosed with hepatitis A? a. Airborne b. Contact c. Droplet d. Protective
Answer: b. Contact LO: 26.6
The nurse recognizes which term to identify the second line of defense that leads to local capillary dilation and leukocyte infiltration? a. Normal flora b. Inflammatory response c. Immune response d. Humoral immunity
Answer: b. Inflammatory response The second line of defense is the inflammatory response. Inflammation is a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. Normal flora is the body's first line of defense. The immune response is the body's attempt to protect itself from foreign and harmful substances. Humoral immunity is a defense system that involves white blood cells (B lymphocytes) that produce antibodies in response to antigens or pathogens circulating in the lymph and blood. LO: 26.1
The nurse recognizes which situation to be inappropriate to use alcohol-based hand sanitizer? a. Patient with pneumonia b. Patient with Clostridium difficile c. Status post-appendectomy d. Patient with HIV
Answer: b. Patient with Clostridium difficile LO: 26.6
The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? a. Wearing gloves b. Wearing a gown and gloves c. Wearing a gown, gloves, and a mask d. Wearing a gown and gloves to change the bed linens, and gloves only for the bath
Answer: b. Wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or if the nurse is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn. Test-Taking Strategy: Focus on the subject, the method of transmission of infection from Kaposi's sarcoma. Read the question, noting the task that is presented; in this case, it is bathing and changing linens. Eliminate option 3, because the method of transmission is not respiratory. Eliminate options 1 and 4 because neither provides adequate protection based on the method of transmission.
The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? a. An illness resulting from living in an unclean environment b. A result of lack of knowledge about food preparation c. A disease resulting from pathogens in or on the body d. An acute or chronic illness resulting from traumatic injury
Answer: c. A disease resulting from pathogens in or on the body A disease resulting from pathogens in or on the body is the definition of an infection. An illness resulting from living in an unclean environment, from lack of knowledge about food preparation, or from trauma can lead to an infection but does not define an infection. LO: 26.1, 26.2
A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient? a. Airborne precautions b. Droplet precautions c. Contact precautions d. Protective isolation
Answer: c. Contact precautions Contact precautions are used with C. difficile because transmission of this contagious disease is possible through contact with the patient or with the equipment or items in the patient's room. Airborne precautions are used when a contagious disease is spread by small droplets that remain suspended in the air for a long period. Droplet precautions are used when a disease is spread by large droplets in the air. Protective isolation is used for patients who are immunosuppressed. LO: 26.6
The nurse is caring for a patient who is comatose. When performing oral hygiene, which interval is most appropriate? a. Every shift b. Twice daily c. Every 4 hours d. Daily
Answer: c. Every 4 hours LO: 26.6
What is the proper order of removal of soiled personal protective equipment (PPE) when the nurse leaves the patient's room? a. Gown, goggles, mask, gloves, and exit the room b. Gloves, wash hands, remove gown, mask, and wash hands c. Gloves, gown, wash hands, goggles, mask, and wash hands d. Goggles, mask, gloves, gown, and wash hands
Answer: c. Gloves, gown, wash hands, goggles, mask, and wash hands Gloves are removed before the rest of personal protective equipment because they usually are the most contaminated. Gowns are removed by untying the waist and then the neck and grasping inside the neck. Hand hygiene is performed. Protective eyewear or goggles are removed next by grasping them by the earpieces. The mask is removed last because it prevents the spread of respiratory microorganisms. Hands should be washed thoroughly after the equipment has been removed. LO: 26.6
A patient admitted after abdominal surgery has a nursing diagnosis of risk for infection. The nurse identifies which goal to be most appropriate? a. Patient will ambulate length of hallway this shift. b. Patient will consume 20% of meals by the end of the week. c. Patient's incision will be without signs or symptoms of infection at discharge. d. Patient will verbalize need to stop antibiotics medication when symptom free.
Answer: c. Patient's incision will be without signs or symptoms of infection at discharge. LO: 26.4
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. Keep the sterile field at least 6ft away from the client's bedside. b. Instruct the client to refrain from coughing and sneezing during the dressing change. c. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. d. Keep a box of facial tissues nearby for the client to use during the dressing change.
Answer: c. Place a mask on the client to limit the spread of micro-organisms into the surgical wound.
When the nurse is wearing sterile gloves, which action would result in the gloves becoming nonsterile? a. Fold gloved hands until procedure begins. b. Change a dressing using aseptic technique. c. Place sterile gloved hands below waist. d. Use correct protocol when donning sterile gloves.
Answer: c. Place sterile gloved hands below waist. LO: 26.6
The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? a. Swelling in the genital area b. Swelling in the lower extremities c. Positive punch biopsy of the cutaneous lesions d. Appearance of reddish-blue lesions noted on the skin
Answer: c. Positive punch biopsy of the cutaneous lesions Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions. Test-Taking Strategy: Focus on the subject, diagnosing Kaposi's sarcoma. Eliminate options a and b first, because these symptoms occur late in the development of Kaposi's sarcoma. Then, note the word confirmed in the question. This word will assist in directing you to the option that will confirm the diagnosis, the biopsy of the lesions.
The nurse understands that which set of vital signs most likely indicates infection? a. T: 98.6F (37.0C), P: 75 beats/min, R: 18 breaths/min, BP 120/80 mm Hg b. T: 99.0F (37.2C), P: 80 beats/min, R: 18 breaths/min, BP 110/70 mm Hg c. T: 100.5F (38.0C), P: 96 beats/min, R: 22 breaths/min, BP 150/100 mm Hg d. T: 98.9F (37.1C), P: 66 beats/min, R: 18 breaths/min, BP 98/ mm Hg
Answer: c. T: 100.5F (38.0C), P: 96 beats/min, R: 22 breaths/min, BP 150/100 mm Hg LO: 26.3
A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism? a. Direct contact b. Vector c. Vehicle d. Airborne
Answer: c. Vehicle Contaminated food is a vehicle for transmitting an infection. Direct contact requires close proximity between the susceptible host and an infected person. A vector is a nonhuman carrier, such as an insect or animal. In airborne transmission, the organism is carried through the air on a small droplet or dust particles. LO: 26.3
The nurse anticipates correctly that what medication category would be ordered to treat athlete's foot? a. Antiviral b. Antibiotic c. Antihelminth d. Antifungal
Answer: d. Antifungal LO: 26.2
The nurse is explaining to the patient why antibiotics are being administered. The answer would be correct if the nurse stated antibiotics are effective against which microorganism? a. Viruses b. Fungi c. Parasites d. Bacteria
Answer: d. Bacteria LO: 26.2
The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse would question the client about an allergy to which food item? a. Eggs b. Milk c. Yogurt d. Bananas
Answer: d. Bananas Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options a, b, and c are unrelated to latex allergy. Test-Taking Strategy: Recall knowledge regarding the food items related to a latex allergy. Eliminate options a, b, and c because they are comparable or alike and relate to dairy products.
The nurse is preparing to perform suctioning on a new tracheostomy with the potential forceful explosion of secretions identifies what PPE (personal protective equipment) should be worn? a. Gloves and eyewear b. Gloves, gown, and mask c. Eyewear and gown d. Eyewear, mask, gown, and gloves
Answer: d. Eyewear, mask, gown, and gloves LO: 26.6
What response would the nurse provide to correctly identify the most effective method to prevent hospital-acquired infections? a. Use of sterile technique b. Isolation protocols c. Antibiotic use d. Handwashing
Answer: d. Handwashing LO: 26.2
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? a. Prodromal b. Incubation c. Convalescence d. Illness
Answer: d. Illness The illness stage is when the client experiences manifestations specific to the infection.
A nurse is preparing to change a sterile dressing and has put on a pair of sterile gloves. To maintain surgical asepsis, what else must the nurse do? a. Keep the amount of splashes on the sterile field to a minimum. b. If a sneeze is imminent, cover the nose and mouth with a gloved hand. c. With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing. d. Regard the outer 1 inch of the sterile field as contaminated.
Answer: d. Regard the outer 1 inch of the sterile field as contaminated. Considering the outer 1 inch of the sterile field as contaminated is a principle of sterile technique. Moisture contaminates the sterile field. Sneezing or coughing would contaminate the sterile glove and necessitate replacing the contaminated glove with a new sterile one. The hand used to clean the wound would not be used to apply a dry dressing. The hand would have to be regloved. LO: 26.6
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? a. The flap closest to the body b. The right side flap c. The left side flap d. The flap farthest from the body
Answer: d. The flap farthest from the body
A nurse is caring for a client who has had a cough for 3 weeks ad is beginning to cough up blood. The client has manifestations of which of the following conditions? a. Allergic reaction b. Ringworm c. Systemic lupus erythematosus d. Tuberculosis
Answer: d. Tuberculosis A cough for 3 weeks and beginning to cough up blood are manifestations of tuberculosis.
The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which statement(s) by the patient indicates further education is needed? (Select all that apply.) a. "I should take antibiotics every time I am sick." b. "I should take all antibiotics as prescribed." c. "I should save all unused antibiotics." d. "I should stop taking antibiotics when I feel better." e. "If I develop a rash while taking these I will call the provider."
Answers: a. "I should take antibiotics every time I am sick." c. "I should save all unused antibiotics." d. "I should stop taking antibiotics when I feel better." LO: 26.2
The nurse knows that standard precautions are indicated for which group(s) of patients? (Select all that apply.) a. All patients b. Patients with HIV c. Patients with MRSA d. Patients with TB e. Patients who are bleeding
Answers: a. All patients e. Patients who are bleeding LO: 26.6
The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply.) a. Decreased cough reflex b. Decreased lung elasticity c. Increased activity of the cilia d. Abnormal swallowing reflex e. Increased sputum production
Answers: a. Decreased cough reflex b. Decreased lung elasticity d. Abnormal swallowing reflex LO: 26.2
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) a. Fever b. Malasie c. Edema d. Pain or tenderness e. Increase in pulse and respiratory rate
Answers: a. Fever b. Malaise e. Increase in pulse and respiratory rate A fever indicates that the infection is affecting the whole body, and, therefore, systemic. Malaise indicates that the infection is affecting the whole body. An increase in pulse and respiratory rate indicates that the infection is affecting the whole body.
A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) a. Planning and evaluating control and prevention strategies b. Determining public health priorities c. Ensuring proper medical treatment d. Identifying endemic disease e. Monitoring for common-source outbreaks
Answers: a. Planning and evaluating control and prevention strategies b. Determining public health priorities c. Ensuring proper medical treatment e. Monitoring for common-source outbreaks
Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. a. Use nonlatex gloves. b. Use medications from glass ampules. c. Place the client in a private room only. d. Keep a latex-safe supply cart available in the client's area. e. Avoid the use of medication vials that have rubber stoppers. f. Use only a blood pressure cuff from an electronic device to measure the blood pressure.
Answers: a. Use nonlatex gloves. b. Use medications from glass ampules. d. Keep a latex-safe supply cart available in the client's area. e. Avoid the use of medication vials that have rubber stoppers. Rationale: Most health care facilities use latex-free products and supplies but there may be some supplies that are not available as latex-free. If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is unnecessary to place the client in a private room. Test-Taking Strategy: Focus on the subject, the client at high risk for an allergic response to latex. Recalling that items that contain rubber are likely to contain latex will direct you to the correct interventions. Also, noting the closed-ended word "only" in options c and f will assist in eliminating these options.
The nurse recognizes which statements by the student nurse regarding handwashing indicate a need for further education? (Select all that apply.) a. Wash hands first, then wrists. b. Rinse from fingertips to wrists. c. Dry using a scrubbing motion. d. Turn off faucet with clean, dry paper towel. e. Dry the hands in the same order as washing them.
Answers: a. Wash hands first, then wrists. b. Rinse from fingertips to wrists. c. Dry using a scrubbing motion. LO: 26.6
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) a. The provider drops a sterile instrument onto the near side of the sterile field. b. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. c. The procedure is delayed 1 hr because the provider receives an emergency call. d. The nurse turns to speak to someone who enters through the door behind the nurse. e. The client's hand brushes against the outer edge of the sterile field.
Answers: b. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. d. The nurse turns to speak to someone who enters through the door behind the nurse.
The nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) a. Apply 3 to 5 mL of liquid soap to dry hands. b. Wash the hands with soap and water for at least 15 seconds. c. Rinse the hands with hot water d. Use a clean paper towel to turn off hands faucets. e. Allow the hands to air dry after washing.
Answers: b. Wash the hands with soap and water for at least 15 seconds. d. Use a clean paper towel to turn off hands faucets.
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all the apply.) a. Place the client in a room that has negative air pressure of at least six exchanges per hour. b. Wear a mask when providing care within 3ft of the client. c. Place a surgical mask on the client if transportation to another department in unavoidable. d. Use sterile gloves when handling soiled linens. e. Wear a gown when performing care that might result in contamination from secretions.
Answers: b. Wear a mask when providing care within 3ft of the client. c. Place a surgical mask on the client if transportation to another department in unavoidable. e. Wear a gown when performing care that might result in contamination from secretions.
The patient is on protective precautions. The nurse knows which statements are true regarding these precautions? (Select all that apply.) a. A positive-pressure room with a HEPA filtration system is required. b. Special respirator masks should be available and one size fits all. c. No live plants are allowed in the room. d. The patient may eat any foods desired. e. Everyone entering the room wears a mask.
Answers: c. No live plants are allowed in the room. e. Everyone entering the room wears a mask. LO: 26.6
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) a. A bottle containing a sterile solution b. The edge of the sterile drape at the base of the field c. The inner wrapping of an item on the sterile field d. An irrigation syringe on the sterile field e. One gloved hand with the other gloved hand
Answers: c. The inner wrapping of an item on the sterile field e. One gloved hand with the other gloved hand
The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. a. Record site, date, and time of the test. b. Give the client a list of potential allergens if identified. c. Estimate the size of the wheal and document the finding. d. Tell the client to return to have the site inspected only if there is a reaction. e. Have the client wait in the waiting room for at least 1 to 2 hours after injection.
Answers: a. Record site, date, and time of the test. b. Give the client a list of potential allergens if identified. Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected. A list of potential allergens is identified and reviewed and given to the client. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients need to be monitored for only about 30 minutes to assess for any adverse effects. Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate option c, because any results must be accurately measured and not estimated. Eliminate option d because of the closed-ended word "only." Eliminate option e, because it is unreasonable to have the client wait 1 to 2 hours.
Of the following assessment findings, which cues indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) a. Redness or warmth at the affected site b. Purulent drainage at the incision site c. Tenderness and localized pain d. Wound with well-approximated edges e. White blood cell count 6500 cells/mm3
Answers: a. Redness or warmth at the affected site b. Purulent drainage at the incision site c. Tenderness and localized pain Purulent drainage, tenderness, localized pain, and redness or warmth are results of the inflammatory response to an infection. Well-approximated edges are a desired outcome of wound healing. The normal white blood count for adults is 5000 to 10,500 cells/mm3. LO: 26.3
A client arrives at the health care clinic and tells the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that the tick was removed and flushed down the toilet. Which actions are most appropriate? Select all that apply. a. Tell the client that testing is not necessary unless arthralgia develops. b. Tell the client to avoid any woody, grassy areas that may contain ticks. c. Instruct the client to immediately start to take the antibiotics that are prescribed. d. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. e. Tell the client that if this happens again, to never remove the tick but to vigorously scrub the area with an antiseptic.
Answers: b. Tell the client to avoid any woody, grassy areas that may contain ticks. c. Instruct the client to immediately start to take the antibiotics that are prescribed. d. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. Rationale: A blood test is available to detect Lyme disease; however, the test is unreliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks need to be removed with tweezers; then the area is washed with an antiseptic. Options a and e are incorrect. Test-Taking Strategy: Focus on the subject, measures to take if Lyme disease is suspected. Also note the strategic words, most appropriate. Eliminate option a, because treatment needs to begin before the arthralgia develops. Eliminate option e, because ticks need to be removed.
