Chapter 26, Asepsis and Infection Control

A patient admitted to the hospital for fever, diarrhea, and vomiting receives the lab reports. The neutrophils are 20%. The patient becomes worried and asks a nurse about it. What probable reason for reduced neutrophil count should the nurse tell the patient? 1. Sepsis 2. Allergy 3. Viral infection 4. Mild food poisoning

1. Sepsis The patient has a reduced neutrophil count, which is seen in overwhelming bacterial infections like sepsis. Allergy, viral infections, and mild food poisoning are not associated with low neutrophil counts.

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection. Patients on isolation precautions may interpret the needed restrictions as a sign of rejection by the health care worker.

3. Explain the reasons for isolation procedures and provide meaningful stimulation. Patients on isolation precautions may interpret the needed restrictions as a sign of rejection by the health care worker.

2. When caring for a patient with rubella, in addition to standard precautions, which precautions would be used? a. Droplet precautions b. Airborne precautions c. Contact precautions d. Universal precautions

ANS: A An illness transmitted by large-particle droplets, like rubella, requires droplet precautions in addition to standard precautions. Airborne precautions are used for illness transmitted via small particles, such as tuberculosis, varicella, and rubeola. Universal precautions are a part of standard precautions.

A nurse is teaching about the chain of infection. In which order from the first link to the last should the nurse arrange the six main components of the infection chain? 1. The portal of exit 2. The infectious agent 3. The portal of entry 4. The susceptible host 5. The source of infection 6. The mode of transmission

Correct order: 1. The infectious agent 2. The source of infection 3. The portal of exit 4. The mode of transmission 5. The portal of entry 6. The susceptible host The infectious agent, the source of infection, the portal of exit, the mode of transmission, the portal of entry, and the susceptibility of host are the six main components of the chain of infection. An infectious agent is a disease-causing organism that is the first link of the chain of infection to spread disease. The source of infection is the second link in the chain of infection, which includes inanimate objects, human beings, and animals. The portal of exit is a means for the infectious agent to escape from the source of infection. The process of transportation of a pathogen is referred to as the mode of transmission. The portal of entry is a means for successful transmission of the pathogen from the source to a susceptible host. The chain of infection completes with transportation of the pathogen into a susceptible host which begins to show symptoms of an infection. An intact immune system or a weak pathogen reduces the risk of infection. A weak immune system or a strong pathogen increases the risk of infection.

Which patient is at most risk of acquiring health care-associated infections?

Nosocomial infections, also referred to as health care-associated infections, are acquired during the patient's stay in a health care setting such as primary clinic, hospital, or long-term care facility. Use of an invasive medical device (such as an intravenous line or an indwelling urinary catheter), postoperative complications, and overuse of antibiotics are common causes of nosocomial infections. Failure to regularly change primary intravenous tubing may increase the risk of acquiring nosocomial infections. Food poisoning results from the consumption of contaminated food and would be treated with antibiotics and analgesics. Food poisoning is not a nosocomial infection. A slight increase in the white blood cell count is commonly observed in patients with upper respiratory tract infections. This would not place the patient at risk of nosocomial infection unless intubation is performed. Hypertension and dementia are common age related medical illnesses of patients 60 years of age or older. These patients are not considered to be at increased risk for nosocomial infections.

Which patient should the nurse place in precautionary protective isolation?

The nurse should follow protective isolation precautions for the 20-year old patient who is suffering from leukemia and has undergone stem cell transplantation. Leukemia patients usually have a compromised immune system. Protective isolation precautions such as positive pressure rooms and respiratory masks are used in patients with compromised immune function. The nurse should follow airborne precautions while caring for a patient with chicken pox because the mode of transmission of the infection is airborne. The nurse should follow contact precautions while caring for a patient with herpes simplex infection because the infection is transmitted through direct or indirect contact. The nurse should follow droplet precautions while caring for a patient with meningococcal sepsis because the mode of infection transmission is droplets.

The nurse is learning about various modes of infection transmission. What are the vehicles for transmission of infection? Select all that apply. A. Mosquito B. Flies C. Blood D. Food E. Water

Correct C, D, E Infections can be transmitted through blood, food, and water. These act to help the microorganisms spread from one person to another. Mosquitoes and flies are vectors and can spread infection through external and internal transmission.

Which sequence should the nurse follow while removing sterile gloves? 1. Peel off the second glove, turning it inside out 2. Keep the removed glove crumpled in the hand that is still gloved 3. Perform hand hygiene 4. With the dominant hand, pull off the nondominant hand glove without touching exposed skin 5. Throw away the gloves in an appropriate receptacle

1. With the dominant hand, pull off the nondominant hand glove without touching exposed skin 2. Keep the removed glove crumpled in the hand that is still gloved 3. Peel off the second glove, turning it inside out 4. Throw away the gloves in an appropriate receptacle 5. Perform hand hygiene The nurse should follow a standard sequence while removing the gloves in order to prevent the spread of microorganisms. With the dominant hand, the nurse should pull off the glove of nondominant hand without touching the exposed skin. The nurse should keep the removed glove crumpled in the gloved hand. The nurse should then peel off the second glove turning it inside out and keeping the first glove inside the second glove. Finally, the nurse should throw away the used gloves in an appropriate container and perform hand hygiene.

An infection occurs as a result of a cyclical process. The six components of an infection are a. infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host. b. infectious agent, reservoir, portal of exit, vehicle of movement, portal of entry, and susceptible host. c. infectious agent, reservoir, portal of exit, vehicle of transmission, portal of entry, and unsusceptible host. d. invading agent, reservoir, portal of exit, vehicle of transmission, portal of entry, and susceptible host.

ANS: A The six components of an infection are the infectious agent, the source of infection, the portal of exit, the mode of transmission, the portal of entry, and the susceptible host.

The nurse is caring for a patient that has a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection-control practices should the nurse implement? (Select all that apply.) a. Wear a protective gown when entering the patient's room. b. Don a particulate respirator mask when administering medication to the patient. c. Ensure that all staff serving the patient's meal trays don gloves prior to delivering of tray. d. Instruct all visitors to wear a surgical mask when entering the patient's room. e. Use sterile gloves when performing dressing changes. f. Use a face shield before irrigating the patient's wounds.

ANS: A, C, F Wearing a gown, wearing gloves when delivering trays, and using a face mask will ensure staff, patient, and visitor safety and will protect the individual from transmitting the infection from the patient to him or herself or others. Use of a particulate respirator mask is necessary when encountering someone on airborne precautions, and this organism is not transmitted via air. The use of sterile gloves is not necessary with this type of infection.

1. You are making a home visit to a family of 5 children. The youngest, aged 5, has a temperature of 101.1°F, is lethargic, and has a poor appetite. This assessment leads you to the diagnosis of influenza. Based on your knowledge that influenza is an airborne communicable disease, all of the following patient teachings regarding infection are appropriate for the mother and family except a. keep children home from day care and school while symptoms are present. b. remind family that they only need to wash their hands if they are visibly dirty. c. do not share tissues, dishes, or personal care items to reduce the risk of transmission. d. encourage the family to receive their annual influenza vaccine.

ANS: B The family needs to wash their hands frequently, especially after eating, coughing, sneezing, or touching contaminated material such as a tissue. Keeping the children home from day care and school while symptoms are present and not sharing personal items, such as towels and toothbrushes, as well as dishes, are good rules of thumb for individuals with an airborne infection. The family should be encouraged to receive annual influenza vaccines.

3. During normal patient care that does not soil hands, effective hand hygiene between patients requires a. at least a 20-second soap and water scrub. b. at least a 23-minute scrub with antimicrobial soap. c. use of an alcohol-based antiseptic handrub. d. a mask must be worn while scrubbing is occurring.

ANS: C Hands that are not visibly soiled can be cleaned with an alcohol-based handrub. A mask or antiseptic soap is not necessary in this situation.

Of the following patients, which patient is at a higher risk of infection? a. 27-year-old female who is an athlete b. 60-year-old male with arthritis c. 12-year-old female with a broken leg d. 36-year-old female with HIV

ANS: D The patient with HIV has an incompetent immune system, which makes her at risk for infection. The other patients are all healthy.

4. A nurse is caring for an overweight 60-year old woman with a reddened area over her coccyx. The priority nursing diagnosis for this patient is a. Imbalanced Nutrition: More Than Body Requirements related to immobility. b. Impaired Physical Mobility related to pain and discomfort. c. Chronic Pain related to overweight. d. Risk for Infection related to altered skin integrity.

ANS: D The priority diagnosis is focused on the risk of developing an infection due to altered skin integrity. Imbalanced nutrition, impaired physical mobility, and chronic pain, all related to overweight, are potential or problem diagnoses that require the attention of the nurse after implementing care for the initial diagnosis.

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 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.

Of the following hospitalized patients, who is most at risk for acquiring a health-care-associated infection? a. 60-year-old who smokes two packs of cigarettes per day b. 40-year-old who has an indwelling urinary catheter in place c. 65-year-old who is a vegetarian and slightly underweight d. 60-year-old who has a white blood cell count of 6000

Answer: b 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.

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 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.

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 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.

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 are used with C. difficile because transmission of a 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 of time. Droplet precautions are used when a disease is spread by large droplets in the air. Protective isolation is used for patients who are immunosuppressed.

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 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. In airborne transmission, the organism is carried in droplet or dust particles.

What is the proper order of removal of soiled personal protective equipment 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, goggles, gown, mask, and wash hands d. Goggles, mask, gloves, gown, and wash hands

Answer: c Gloves are removed before the rest of personal protective equipment because they usually are the most contaminated. Protective eyewear or goggles are removed next by grasping them by the earpieces. Gowns are removed by untying the waist and then the neck and grasping inside the neck. The mask is removed last because it prevents the spread of respiratory microorganisms. Hands should be washed thoroughly after the equipment has been removed and before leaving the room.

A nurse is preparing to change a sterile dressing and has donned two 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 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 would necessitate replacing the contaminated glove with a new sterile one. The hand used to clean the wound would never be used to apply a dry dressing. The hand would have to be re-gloved.

Of the following assessment findings, which signs indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) a. Thick, white drainage in the Jackson-Pratt tubing b. Redness or warmth at the affected site c. Purulent drainage at the incision site d. Temperature 100.4 F (38 C) e. Tenderness and localized pain f. Wound with well-approximated edges g. Purulent drainage at the incision site

Answers: a, b, c, d, e, g Purulent drainage at the site and thick, white drainage in the Jackson-Pratt tubing indicate the presence of white blood cells and microorganisms at the site of infection. Fever, localized pain, and redness are results of the inflammatory response to an infection. Well-approximated edges are a desired outcome of wound healing.

In which situations does the nurse wear clean gloves as part of standard precautions? (Select all that apply.) a. In the care of a patient diagnosed with an infectious process b. When the patient is diaphoretic c. During care of each individual under treatment in the facility d. In the presence of urine or stool e. When taking the patient's blood pressure

Answers: a, c, d The nurse uses standard precautions for situations in which an infectious disease is known or when there is a possibility of contact with blood or body fluids (except perspiration). Gloves are not necessary when taking the blood pressure of a patient who is not in isolation and who does not have any other risk factors.

Put the following steps for removal of protective barriers after leaving an isolation room in order: 1. Remove gloves. 2. Remove eyewear or goggles. 3. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side. 4. Untie bottom, then top mask strings and remove from face. 5. Perform hand hygiene.

Correct 1. Remove gloves. 2. Remove eyewear or goggles. 3. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side. 4. Untie bottom, then top mask strings and remove from face. 5. Perform hand hygiene. This sequence ensures that the risk of contamination to other surfaces or health care personnel is minimized.

Which order should the nurse follow while applying personal protective equipment? 1. Put on gown 2. Put on mask 3. Put on eyewear 4. Put on gloves 5. Wash hands

Correct 1. Wash hands 2. Put on gown 3. Put on mask 4. Put on eyewear 5. Put on gloves The nurse uses personal protective equipment to prevent the spread of the microorganisms and limit the severity of an infection. The nurse washes hands first for medical asepsis and to break the chain of infection. The nurse applies the gown first in order to reduce the risk of infections. The nurse then applies the surgical mask with ties or ear loops to ensure protection from transmissible infections during preoperative procedures. The nurse puts on the eyewear to fit over the mask, which ensures protection from microorganisms and prevents fogging. Last, the nurse applies the gloves to prevent the spread of microorganisms and maintain sterility.

Which practice should the nurse follow while preparing an individually wrapped sterile drape? 1. Avoid holding the drape above the waist and away 2. Avoid using thumb and index finger to lift the drape out of its cover 3. Avoid touching the outer 1-inch margin on the outside covering 4. Avoid placing the lower section of the drape on the designated work surface farthest away

Correct 3. Avoid touching the outer 1-inch margin on the outside covering The nurse should not touch the outer 1-inch margin on the outside covering of the sterile field to prevent contamination. The outer 1-inch margin is not sterile. The nurse should hold the drape above the waist and away because the area below the waist is considered contaminated. The nurse should lift the drape out of its cover with the thumb and index finger to prevent the contamination of the entire surface. The nurse should place the lower section of the drape on the work surface farthest from himself or herself to prevent contamination.

During a health fair a nurse examines a family of four people. The 66-year-old father is healthy with no history of respiratory problems. The 60-year-old mother has a family history of chronic respiratory problems. Their 26-year old son and 20-year-old daughter have been on medication for asthma since birth. Who should be given the pneumonia vaccine in this case? Select all that apply. A. Father B. Mother C. Son D. Daughter E. None of the family members

Correct A, B, C, D A pneumonia vaccine is available and recommended for all persons with chronic respiratory problems and those over 65 years of age. As the father is over 65 years of age and the mother and both children have chronic respiratory problems, they all need a pneumonia vaccine.

The nurse works in a hospital. The nurse understands that healthcare-associated infections (HAI) are difficult to treat. Which patient may be at increased risk of developing HAI? Select all that apply. A. A patient who underwent bronchoscopy B. A patient who receives broad-spectrum antibiotics C. A patient who has an indwelling urinary catheter D. A patient suffering from diabetes mellitus E. A patient who has a fever

Correct A, B, C, D Bronchoscopy bypasses the natural defenses of the body and predisposes to HAIs. Broad-spectrum antibiotics suppress the normal flora and promote growth of resistant strains of microorganisms. An indwelling urinary catheter surpasses the natural defenses and also serves as a port of entry for microorganisms. Diabetes mellitus suppresses the body's immunity and increases the risk of HAIs. Fever does not affect the natural defense mechanism, and therefore does not increase the risk of HAIs.

The nurse reports to the primary health care provider about a postoperative patient's wound infection. The primary health care provider instructs the nurse to collect an initial wound drainage culture swab for culture and sensitivity. What are the reasons behind this instruction? Select all that apply. A. To determine the course of medications B. To determine the extent of inflammation C. To determine the causative microorganism D. To determine the patient's immune response E. To determine the response to the current therapy

Correct A, C A culture can be performed on blood, urine, sputum, and wound drainage to assess infection. A culture determines exactly which microorganism is causing an infection, while the sensitivity determines the course of antibiotics, if any, that can be used to treat the infection. Erythrocyte sedimentation rate (ESR) is a laboratory test that measures the extent of inflammation in the body and determines response to current therapy. Since this is an initial (first) wound culture, it will not determine the response to the current therapy. A differential white blood cell count helps to determine the patient's immune response to an infection.

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection of the respiratory system and has a productive cough. A nurse auscultates the lungs and finds that the breath sounds are clear. The disposable thermometer used by the nurse indicates fever. The nurse collects a urine specimen of the patient as ordered. What interventions should the nurse perform to prevent spread of infection? Select all that apply. A. Confirm fever using an electronic thermometer. B. Clean the bell and diaphragm of the stethoscope with soap and water. C. Place specimen containers on a clean paper towel in the patient's bathroom. D. Label the specimen in the bathroom where samples of patients are collected. E. Review agency policies and precautions necessary for the specific isolation system.

Correct A, C, E The nurse should be aware of the equipment used in an room and indications for isolation. If the disposable thermometer indicates fever, it is important to confirm it using an electronic thermometer. The nurse also needs to review agency policies and procedures. Methicillin-resistant Staphylococcus aureus (MRSA) can cause a health care-associated infection (HAI). Therefore, the nurse has to take precautions to prevent the spread of infections within the hospital. Specimen containers are to be kept in the patient's bathroom appropriately. If a stethoscope is to be reused, the diaphragm or bell should be cleaned with alcohol, rather than soap, and should be set aside on a clean surface to dry completely. After the sample is collected, labeling on the specimen container is to be done in front of the patient to avoid errors.

The nurse is caring for a patient after cardiac surgery. Which interventions should reduce the risk of an infectious illness? Select all that apply. A. Wash hands before and after giving care B. Monitor the patient's temperature every 4 hours C. Evaluate the patient's white blood count as ordered D. Follow strict aseptic techniques while suctioning the patient E. Encourage the patient to perform deep breathing and coughing exercises

Correct A, D, E Hand washing interrupts the infection cycle and helps to avoid the spread of infection. The nurse encourages the patient to perform deep breathing and coughing exercises, which helps to remove secretions and prevent respiratory complications. Following strict aseptic techniques helps to avoid the spread of disease-causing microorganisms. The nurse should monitor the patient's temperature to identify the start of an infection, but it will not help to prevent an infectious illness. The nurse should evaluate the patient's white blood count as an elevated total white blood count usually indicates an infection, but this will not help reduce the risk of an infectious illness.

A nurse is teaching a patient about the body's defenses against infection. Which areas of the human body should the nurse include that have normal flora on their surface? Select all that apply. A. Skin B. Lower throat C. Upper urethra D. Large intestine E. Lower intestine

Correct A, D, E Normal flora is a group of non-disease-causing microorganisms such as bacteria, fungi, and protozoa. These microorganisms live within or on the body and act as the first line of defense against infections. They are usually found in or on the skin, eyes, nose, mouth, large intestine, and lower intestine. Normal flora is not evident in the lower throat but is observed in the upper throat. Normal flora is not observed in the upper part of the urethra but is observed in the lower urethra.

The nurse works in a hospital. What precautions are necessary to help prevent healthcare-associated infections? Select all that apply. A. Frequently irrigate urinary catheters. B. Insert drug additives to IV fluids. C. Ensure a closed urinary catheter drainage system. D. Change the IV access site if inflamed. E. Use aseptic technique when suctioning the airway.

Correct C, D, E A closed urinary catheter drainage system helps to contain microorganisms and prevent spread of infection. An IV access site should be changed as soon as signs of inflammation appear. Inflammation can lead to infection. Microorganisms can be introduced into the airway if aseptic technique is not followed for suctioning. Repeated catheter irrigation may increase the risk of infection as it bypasses the normal defenses of the body. Adding drug additives to IV fluids also increases the risk of infections.

On reviewing the laboratory reports of a patient with a urinary tract infection, the nurse finds the WBC count to be 10,000 cells/mm3. The urine culture and sensitivity indicates no infection and the erythrocyte sedimentation rate (ESR) is normal. Which conditions does the nurse infer from these findings? Select all that apply. A. Subsided infection B. Resistance to antibiotics C. Mounting immune response D. Increased local inflammation E, Good response to current therapy

Correct A, E The normal laboratory values of the patient indicate improved health status. It implies that the infection has subsided and the treatment has been effective. The normal differential WBC count shows that there is no infection. Decreased ESR count indicates good response to current therapy. A high WBC count indicates that the body is mounting an immune response indicating infection is active. If the laboratory results show an increase in ESR, this indicates infection and helps to measure the extent of inflammation in the body. If the culture and sensitivity test show positive results, this determines the pathogens' resistance to antibiotic therapy.

On reviewing the laboratory reports of a patient with a urinary tract infection, the nurse finds the WBC count to be 10,000 cells/mm3. The urine culture and sensitivity indicates no infection and the erythrocyte sedimentation rate (ESR) is normal. Which conditions does the nurse infer from these findings? Select all that apply. A. Subsided infection B. Resistance to antibiotics C. Mounting immune response D. Increased local inflammation E. Good response to current therapy

Correct A, E The normal laboratory values of the patient indicate improved health status. It implies that the infection has subsided and the treatment has been effective. The normal differential WBC count shows that there is no infection. Decreased ESR count indicates good response to current therapy. A high WBC count indicates that the body is mounting an immune response indicating infection is active. If the laboratory results show an increase in ESR, this indicates infection and helps to measure the extent of inflammation in the body. If the culture and sensitivity test show positive results, this determines the pathogens' resistance to antibiotic therapy.

A hospital employee fails to properly dispose of a syringe used on a patient, and sustains a needle stick injury. A nurse in the emergency department assesses the hospital employee knowing that the employee is at risk for contracting numerous illnesses from the needle stick injury. Which types of infections could be contracted from the needle stick? Select all that apply. A. Hepatitis A B. Hepatitis B C. Hepatitis C D. HIV E. Tuberculosis

Correct B, C, D Hepatitis B, hepatitis C, and HIV can be contracted from a needle stick injury, as they are blood-borne infections. Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV). Hepatitis C is a liver infection caused by hepatitis C virus (HCV). HIV infection is caused by the HIV virus which can result in acquired immunodeficiency syndrome (AIDS). Hepatitis A spreads through the oro-fecal route. Tuberculosis spreads through droplet infection.

While dressing a surgical abdominal wound, the nurse notices that the patient has developed a localized infection. Which signs and symptoms does the nurse find in this patient? Select all that apply. A. Fever B. Swelling C. Redness D. Tenderness E. Increased heart rate

Correct B, C, D The type and location of an infection determines the specific signs and symptoms. Redness around a surgical wound, swelling, and tenderness at the surgical site are due to inflammation of the local tissue and are signs and symptoms of localized infections. Entry of infective organisms into the bloodstream affects the different systems of the body. Fever, increase in heart and respiratory rate, lethargy and anorexia are signs and symptoms of a systemic infection.

While dressing a wound, the nurse finds that a patient has uncontrolled wound drainage. Which interventions should the nurse perform in order to extend further care to the patient? Select all that apply. A. Use a fit-tested-N95 respirator B. Perform hand hygiene prior to wearing gloves C. Transfer the patient to a reverse ventilation room D. Mark "Isolation Precautions Required" on the chart E. Apply gloves and a gown when touching the patient

Correct B, D, E The nurse follows contact transmission-based precautions while caring for a patient with excessive wound drainage. The nurse marks "Isolation Precautions Required" on the chart for any patient on isolation, regardless of the type. Before touching the patient, the nurse performs hand hygiene prior to wearing gloves to avoid the spread of infection. The nurse uses gloves and a gown when touching the patient as protective personal equipment to prevent cross infection. The nurse should not transfer the patient to reverse ventilation room because the patient is not infected with airborne contagious diseases. The nurse is not required to use a fit-tested- N95 respirator because the patient is not infected with any airborne or droplet infections.

A 56-year-old immigrant patient has severe productive cough. The patient is diagnosed with tuberculosis (TB) and is placed in an isolation room. What are the possible reasons for this action? Select all that apply. A. To perform a chest x-ray B. To prevent the spread of infection C. To provide intravenous fluids D. To prevent patient's exposure to other infections E. To restrict the patient's movement

Correct B, E Tuberculosis of the lungs is an airborne infection, so patients with suspected or confirmed active TB are usually treated in an airborne infection isolation room to restrict their movement. This helps to prevent the spread of infection to others. Isolation rooms are not meant for chest x-ray procedures. Isolation of the patient is not required to administer intravenous fluids. Though all patients are prone to secondary contagious infections, the reason for isolation is to prevent the spread of infection from an isolated patient to other patients. Depending on the mode of spread of infection, there are different isolation precautions, such as airborne, droplet, contact, and protective environment.

The nurse works in a hospital. What precautions are necessary to help prevent healthcare-associated infections? Select all that apply. A. Frequently irrigate urinary catheters. B. Insert drug additives to IV fluids. C. Ensure a closed urinary catheter drainage system. D. Change the IV access site if inflamed. E, Use aseptic technique when suctioning the airway.

Correct C, D, E A closed urinary catheter drainage system helps to contain microorganisms and prevent spread of infection. An IV access site should be changed as soon as signs of inflammation appear. Inflammation can lead to infection. Microorganisms can be introduced into the airway if aseptic technique is not followed for suctioning. Repeated catheter irrigation may increase the risk of infection as

While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse violated? 1. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action. 2. Fluid flows in the direction of gravity. 3. A sterile field becomes contaminated by prolonged exposure to air. 4. None of the principles were violated.

Correct 3. A sterile field becomes contaminated by prolonged exposure to air. Avoid activities that create air currents, such as sneezing. When you sneeze, microorganisms travel through the air by droplets, contaminating the sterile field.

An elderly patient reports headache, chills, fatigue, increased frequency of urination, and urine leakage. Upon assessment, the nurse finds that the patient's temperature is 101°F, and the patient has confusion. Which condition is most supported by the assessment findings? 1. Hepatitis 2. Dementia 3. Pneumonia 4. Urinary tract infection

Correct 4. Urinary tract infection Urinary tract infection (UTI) occurs most commonly in elderly patients due to age related changes in the anatomical structures and inefficient immune system function. Fever, chills, headache, malaise, and confusion are the presenting signs and symptoms of a UTI in the elderly. Hepatitis, blood-borne disease, is an inflammation of the liver characterized by flu-like symptoms, nausea or vomiting, diarrhea, and headache. Dementia is a psychological disorder characterized by speech and language difficulty, trouble eating, forgetfulness, and balance problems. Pneumonia most commonly affects elderly people characterized by cough, chest pain, fever, and difficulty breathing.

The nurse observes that the protective personal equipment (PPE) became wet, soiled, and damaged while caring for a patient. Arrange the order of nursing interventions to prevent cross contamination. 1. Remove the soiled equipment and wash hands 2. Stop the patient care as soon as possible 3. Report the incident and document the process 4. Complete care and remove PPE 5. Inspect self and start applying appropriate PPE

Correct order 1. Stop the patient care as soon as possible 2. Remove the soiled equipment and wash hands 3. Inspect self and start applying appropriate PPE 4. Report the incident and document the process 5. Complete care and remove PPE If the nurse's PPE has become wet, soiled, or damaged, the nurse should stop the procedure as soon as possible to prevent self-damage and cross contamination. The nurse should remove the soiled equipment and wash hands to prevent spread of the infection. The nurse should then self-inspect for any leakage of body fluids or contamination from the patient and start over applying another set of PPE. The nurse then continues and completes the remainder of the procedure. The nurse should report the incident and document as needed in accordance with facility policy.