Foundations Chapter 23 Asepsis & Infection Control

Which mask should the nurse don when caring for a client with tuberculosis? -Low-efficiency particulate air (LEPA) -Filtered respirator -Surgical mask -No mask is needed

-Filtered respirator

Which piece of personal protective equipment (PPE) should be removed first? -Gloves -Respirator -Gown -Goggles

-Gloves

A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to don her PPE. Which would be appropriate? Select all that apply. -Gloves -Gown -Mask with face shield -Respirator

-Gloves -Gown -Mask with face shield

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? -Migration of leukocytes to the area of the wound -Constriction of the small blood vessels near the wound -Release of histamine -Production of antibodies

-Migration of leukocytes to the area of the wound

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. -Redness -Swelling -Pain -Coolness -Exudate

-Redness -Swelling -Pain -Exudate

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention? -Offer the student a mask. -Do nothing, as precautions observed are appropriate. -Teach that a gown and shoe coverings must be worn in addition to gloves. -Remind the student that a fitted N95 respirator is required.

-Remind the student that a fitted N95 respirator is required.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? -changing the soiled dressing -wearing clean unsterile gloves when changing the dressing -isolating the client's belongings -applying a face mask with shield

-changing the soiled dressing

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? -standard precautions -droplet precautions -contact precautions -airborne precautions

-contact precautions

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? -airborne -droplet -contact -none

-droplet

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: -droplet precautions. -universal precautions. -reverse precautions. -body-substance isolation

-universal precautions.

While assessing a client admitted with a transmissible spongiform encephalopathy, what finding might the nurse observe? -difficulty breathing -distended abdomen -unsteady gait -redden, circular rash

-unsteady gait

Convalescent period

Infection is contained and being progressively eliminated; The damaged tissue is repaired. Symptoms are decreasing.

Incubation stage

Pathogen is actively replicating without producing symptoms. This stage may be as short as a few hours(salmonella), up to many years(HIV).

Prodromal stage

The initial appearance of symptoms, though they are usually vague. They may include malasis, fatigue, anorexia, mild fever, myalgia, and headache. Flu like symptoms.

Acute stage

The maximum impact of the infectious process; there is rapid proliferation and spread of the pathogen. The symptoms are more pronounced and specific.

Resolution

Total elimination of the pathogen; no residual signs and symptoms.

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens? -Wear gloves and a gown when transporting the specimen. -Place each of the three sealed specimens in a separate paper bag. -Place the specimens into plastic biohazard bags. -Swab the outside of each specimen container with alcohol prior to transport.

-Place the specimens into plastic biohazard bags.

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure? -The nurse uses soap and cold water to wash hands. -The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands. -The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. -The nurse rinses thoroughly with water flowing away from the fingertips.

-The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.

What is the most common client site for development of healthcare-associated infections (HAI)? -Surgical wound -Respiratory tract -Bloodstream -Urinary tract

-Urinary tract

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply. -infectious disease -communicable disease -noncommunicable disease -contagious disease -health care-associated infection (HCAI)

-infectious disease -communicable disease -contagious disease

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse? -pouring the sterile solution from a height of 5 in (13 cm) -touching the tip of the bottle to the sterile container to avoid splashing -placing the cap on the table with edges down -discarding any unused sterile solution

-pouring the sterile solution from a height of 5 in (13 cm)

A client has a systemic infection that resulted from an untreated urinary tract infection. The client has malaise and is confused. The client is: -septic. -contagious. -lethargic. -toxic.

-septic

An infection or the products of infection carried throughout the body by the blood is called: -contamination. -infectious disease. -septicemia. -viral illness.

-septicemia.

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: -decreased -elevated -within normal limits -stable

-within normal limits A normal white blood cell count is 5,000 to 10,000 cells/mm3.

The nurse is preparing a sterile field for a dressing change. How would the nurse add paper- wrapped sterile items to the sterile field? -While wearing sterile gloves, unwrap the package and add to the field. -Separate the sealed flaps and drop contents onto field. -Open the package away from the field. -Set up another sterile field for the additional items.

-Separate the sealed flaps and drop contents onto field.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection? -Urine culture is positive for vancomycin-resistant enterococci (VRE). -The client reports nausea and vomiting. -The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C) -The nurse notes the client's urine is dark yellow with sediment.

-Urine culture is positive for vancomycin-resistant enterococci (VRE).

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection? -Urine culture is positive for vancomycin-resistant enterococci (VRE). -The client reports nausea and vomiting. -The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C) -The nurse notes the client's urine is dark yellow with sediment.

-Urine culture is positive for vancomycin-resistant enterococci (VRE). Nausea and vomiting, a fever, and dark yellow urine with sediment are possible signs of an infection, but does not confirm an infection.

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? -When a sterile item touches something that is not sterile, it may not be contaminated. -Any partially uncovered sterile package need not be considered contaminated. -A commercially packaged surgical item is not considered sterile if past expiration date. -Sterility may not be preserved even when one sterile item touches another sterile item.

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

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? -Sterile field is kept above waist level. -Put on sterile gloves before opening sterile package. -Maintain a 3-inch border around the sterile field. -Open sterile package towards the nurse to prevent reaching over.

-Sterile field is kept above waist level.

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? -"Washing the hands with soap and water is not necessary." -"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin." -"I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." -"We only wash our hands when they are visibly soiled."

-"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin."

A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control? -Airborne precautions -Droplet precautions -Contact precautions -Protective isolation

-Contact precautions

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism? -Direct contact -Vehicle -Droplet -Airborne

-Vehicle

The nurse manager is developing a plan to decrease the transmission of healthcare associated infections. What would be the best to implement? -staff education on utilizing hand hygiene -restricting visitors to over the age of 12 -providing alcohol-hand sanitizer to all clients. -having any visitor with a cough or cold wear a mask

-staff education on utilizing hand hygiene

The nurse is observing a sterile field that was prepared by another staff member. What would indicate that the sterile field is contaminated? -sterile drape positioned with the moisture-proof side facing up -edges of the sterile drape hanging over the edge of the work surface -sterile 4 in × 4 in (10 cm x 10 cm) gauze dressings, removed from the packaging in the middle of the sterile field -sterile gloves, removed from the outer wrapping, 4 in (10 cm) away from the edge of the sterile field

-sterile drape positioned with the moisture-proof side facing up

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? -"Any staff that enters my room will be wearing personal protective equipment (PPE)." -"I can leave my room any time I want as long as I wear a mask." -"I will tell my visitors to keep their distance from me." -"My personal belongings should remain in the room until I am discharged."

-"I can leave my room any time I want as long as I wear a mask."

The nurse determines that which client is at greatest risk for a wound infection? -A two-day postoperative client -An older adult client with dry skin -An infant with intact skin -A client with a urinary catheter

-A two-day postoperative client

An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate? -Standard -Airborne -Droplet -Contact

-Standard

A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply. -The nurse carries soiled items away from the body. -The nurse places soiled bed linen on the floor. -The nurse moves soiled equipment away from the body when cleaning it. -The nurse opens a window and dusts the room in the direction of the window. -The nurse cleans least soiled areas first and then moves to more soiled ones. -The nurse pours discarded liquids into a basin then pours them into the drain.

-The nurse carries soiled items away from the body. -The nurse moves soiled equipment away from the body when cleaning it. -The nurse cleans least soiled areas first and then moves to more soiled ones.

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 -sterile technique -putting on gloves -signs of healing

-hand washing

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene? -washes hands for 15 seconds -has manicured nails that are 1-in (2.5-cm) long -has wedding band on ring finger -drains hands lower than the wrist

-has manicured nails that are 1-in (2.5-cm) long Fingernails should be less than ¼-in (0.625-cm) long, as this reduces the reservoir for flora to accumulate, and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. A flat wedding band is acceptable. Allowing the hands to drain lower than the wrist promotes gravity drainage.

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

-iatrogenic.

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense? -the cell-mediated immune response. -early intervention with antibiotics. -staying home when sick. -intact skin and mucous membranes. -low levels of flora.

-intact skin and mucous membranes.

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? -contagious disease -infectious disease -communicable disease -noncommunicable disease

-noncommunicable disease

A nurse is caring for four clients. Which client has the highest risk of infection? -older male with an enlarged prostate -toddler with a benign heart murmur -woman in second trimester of pregnancy -young woman with a history of scoliosis

-older male with an enlarged prostate An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections

A nurse is caring for four clients. Which client has the highest risk of infection? -older male with an enlarged prostate -toddler with a benign heart murmur -woman in second trimester of pregnancy -young woman with a history of scoliosis

-older male with an enlarged prostate An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections.

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action? -to protect the integrity of the nurse's immune system -to prevent the nurse from developing disease -to eliminate disease-producing organisms from the nurse's skin -to sterilize the nurse's hands to prevent infection

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

Which factor has contributed to resistant microbial strains? -antibiotic use for bacterial infections -use of antibiotics in clients with viral infections -use of topical antibiotics on skin abrasions -mutation of common disease-causing viruses

-use of antibiotics in clients with viral infections

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? -wearing a particulate respirator for all client care and interaction -wearing a face mask when entering and staying at a distance from the client -wearing protective eye wear for all client contact -placing the client in a regular, private room

-wearing a particulate respirator for all client care and interaction

A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply. -Clostridium difficile -Norovirus -Staphylococcus aureas -Candida albicans -E. coli

-Clostridium difficile -Norovirus

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds: -"You will likely have an outbreak due to the stress of labor and delivery." -"You may have infection in your birth canal that you are unaware of." -"A cesarean section will prevent a herpes outbreak."

-"You may have infection in your birth canal that you are unaware of."

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood? -1500 -1200 -2000 -Wait until day 5 of treatment.

-1500 Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest.

Which client would the nurse consider the most infectious? -A client who is in the incubation period -A client who is in the prodromal stage -A client who is in the full stage of illness -A client who is in the convalescent period

-A client who is in the prodromal stage

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? -"Any staff that enters my room will be wearing personal protective equipment (PPE)." -"I can leave my room any time I want as long as I wear a mask." -"I will tell my visitors to keep their distance from me." -"My personal belongings should remain in the room until I am discharged."

-"I can leave my room any time I want as long as I wear a mask."

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." -"This antibiotic causes fewer side effects than a narrow spectrum antibiotic." -"Drug resistance can develop when the wrong antibiotic is used for pneumonia." -"Pneumonia is usually caused by multiple organisms."

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

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator? -"I will always wash my hands thoroughly and often." -"It is important to refrain from recapping needles." -"Masks, gloves, and gowns should be used to protect from infectious agents." -"Wearing an N95 respirator is critical when I care for clients in droplet precautions."

-"Wearing an N95 respirator is critical when I care for clients in droplet precautions."

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 -A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior -A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft -A client with renal failure who receives hemodialysis three times weekly

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

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? -Client receiving chemotherapy -Client who had leg surgery -Client on a short course of vancomycin -Client in the ICU for one day

-Client receiving chemotherapy The nurse should determine that the client receiving chemotherapy is the client at greatest risk for VRE infection due to having a compromised immune system from the chemotherapy. Other risk factors for VRE include recent abdominal or chest surgery, presence of urinary or central IV catheter, prolonged antibiotic use (especially with vancomycin), and lengthy hospital stays (especially in an ICU).

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? -Client with a urinary catheter -Clint with an intravenous catheter -Client with a surgical wound -Client with a diabetic foot ulcer

-Client with a urinary catheter

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? -Contact -Vehicle -Droplet -Airborne

-Contact

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse? -Discard the supplies and field and prepare a new sterile field. -Educate the client on sterile fields and continue preparing for the procedure. -Give the client the water pitcher and continue preparation. -Remove the supplies from the field and replace with new supplies.

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

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? -No action is needed. -Don another pair of sterile gloves -Complete a sentinel event report. -Notify the primary care provider.

-Don another pair of sterile gloves

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply. -Nurses need only apply clean gloves when performing or assisting with invasive client procedures. -During some care activities for an individual client, nurses may need to change gloves more than once. -Nurses may use a waterproof gown more than one time. -Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. -To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. -Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse.

-During some care activities for an individual client, nurses may need to change gloves more than once. -Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. -To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? -Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. -Removing the staples from a VRE-positive, postoperative client's incision without prior handwashing -Sending a VRE-positive client to the radiology department for a chest X-ray without a face mask -Delivering a meal tray to a VRE-positive client without first donning gloves and a gown

-Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

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

-Exogenous healthcare-associated

A 34-year-old woman is pregnant with her first child. The nurse notices on her lab results that she is not immune to rubella. When is it most imperative that the client protect herself from a rubella infection? -First trimester -Second trimester -Third trimester -Immediately postpartum

-First trimester Infection with rubella during the first trimester is of great concern as it frequently leads to congenital rubella syndrome. The later in the pregnancy that a woman develops rubella, a reaction is less likely and typically less severe. A reaction is also less likely during the postpartum interval.

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? -Fold soiled side to the inside and roll with inner surface exposed. -Fold soiled side to the outside and roll with outer surface exposed. -Fold soiled side to the inside and roll with outer surface exposed. -Fold soiled side to the outside and roll with inner surface exposed.

-Fold soiled side to the inside and roll with inner surface exposed.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? -Fungi -Rickettsiae -Protozoans -Helminths

-Fungi

A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply. -Hepatitis B -Hepatitis C -Tuberculosis -HIV

-Hepatitis B -Hepatitis C -HIV

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply. -Sterile gloves -Nonsterile gloves -Mask Gown -Hand hygiene

-Nonsterile gloves -Hand hygiene

A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumoniae, which is particularly prone to cause infections, also referred to as what? -Virulent -Pathogenic -Specific -Source

-Pathogenic

The nurse is caring for an older adult client hospitalized with a hip fracture. Which nursing intervention is a priority to decrease the incidence of infection? Select all that apply. -Perform thorough skin assessment -Assess duration of catheter use. -Encourage grandchildren to visit. -Offer pneumococcal vaccine. -Perform frequent handwashing.

-Perform thorough skin assessment -Assess duration of catheter use. -Offer pneumococcal vaccine. -Perform frequent handwashing.

A client reports fatigue, malaise, and a low-grade fever. What phase of the infectious process does the nurse determine the client is experiencing? -Incubation phase -Prodromal phase -Full stage of illness. -Convalescent phase

-Prodromal phase

The nurse is exiting the room of a client who has a Clostridium difficile infection. What actions would the nurse perform? Select all that apply. -Use the hand sanitizer. -Remove the respirator. -Remove gloves by securing the first glove inside the second glove. -Turn gown inside out and roll the gown into a bundle before discarding. -Wash hands with soap and water.

-Remove gloves by securing the first glove inside the second glove. -Turn gown inside out and roll the gown into a bundle before discarding. -Wash hands with soap and water.

Which action is the best example of a nurse donning/removing protective equipment properly? -Removing respirator after leaving client's room -Removing gown after leaving client's room -Donning gown after entering client's room -Donning respirator inside of client's room

-Removing respirator after leaving client's room

A nurse is preparing a sterile field for the health care provider to perform a biopsy on a client. Which actions follow recommended guidelines for maintaining the sterile field for this procedure? Select all that apply. -The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. -The nurse places the cap of an opened solution on the table with edges down. -The nurse discards a sterile field when a portion of it becomes contaminated. -The nurse calls for help when realizing a supply is missing. -The nurse drops a sterile item on a sterile field from the height of 12 inches (30 cm). -The nurse holds an agency-wrapped item with the top flap opening toward the body.

-The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. -The nurse discards a sterile field when a portion of it becomes contaminated. -The nurse calls for help when realizing a supply is missing. The nurse would not drop a sterile item on a sterile field from the height of 12 in (30 cm), rather 6 in (15 cm). The nurse would hold a wrapped item with the top flap opening away from the body.

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 keeps hands above waste level while donning sterile gloves. -The nurse touches an unsterile object to the instrument tray. -The nurse is talking with the scrub nurse over the sterile field. -The nurse disposes of an opened container of sterile saline after half is used.

-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.

A team of nurses is caring for a client with tuberculosis. They have not been fitted for an N95 respirator. How will the team proceed with care? -Refrain from providing care until a nurse who has been fitted arrives. -Use a regular mask and continue to provide care as usual. -Utilize a powered air, purifying respirator (PAPR). -Enter the room as normal, but maintain a 3-foot distance from the client.

-Utilize a powered air, purifying respirator (PAPR).

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? -Use a private room with the door closed. -Wear PPE when entering the room for all interactions that may involve contact with the client. -Place client in private room that has monitored negative air pressure. -Use respiratory protection when entering the room of client with known or suspected diphtheria.

-Wear PPE when entering the room for all interactions that may involve contact with the client.

A nurse is in charge of care for a client who has MRSA. Which of the following is an accurate guideline for using transmission-based precautions when caring for this client? -Place the client in a private room that has monitored negative air pressure. -Keep visitors 3 feet (1 m) from the client. -Use respiratory protection when entering the room. -Wear gloves whenever entering the client's room.

-Wear gloves whenever entering the client's room.

The community nurse is educating a family about infection control measures. What teaching will the nurse include? Select all that apply. -Hand hygiene is not needed in the home environment. -Wear personal protective equipment (PPE) when appropriate. -Standard precautions should be used when family members have active infections. -Do not share drinking glasses with family members who are ill. -Keep the entire living environment as clean as possible.

-Wear personal protective equipment (PPE) when appropriate. -Standard precautions should be used when family members have active infections. -Do not share drinking glasses with family members who are ill. -Keep the entire living environment as clean as possible.

Surgical asepsis is defined as: -absence of all virulent microorganisms. -absence of all microorganisms. -slowed growth of microorganisms. -use of hand washing, gowning, and gloving.

-absence of all microorganisms.

Which of the following are names of the transmission-based precautions defined by the Centers for Disease Control (CDC)? Select all that apply. -airborne precautions -droplet precautions -contact precautions -respiratory precautions -microbial precautions -body fluid precautions

-airborne precautions -droplet precautions -contact precautions

For which client would the use of standard precautions alone be appropriate? -a client with diphtheria who needs p.m. care -a client with TB who needs medications administered -an incontinent client in a nursing home who has diarrhea -a child with chickenpox who is treated in the emergency room

-an incontinent client in a nursing home who has diarrhea

The nurse is caring for a patient that has a colonized infection. What assessment findings does the nurse anticipate? -client does not yet show signs and symptoms -oral temperature of 101° F -active periods of nausea, vomiting, and diarrhea -reports feeling better because the infection is resolving

-client does not yet show signs and symptoms

The nurse is caring for an older adult with pneumonia. Which assessment finding requires immediate nursing intervention? -oral temperature 99° F -weight loss of one pound over 1 month -reports increased fatigue -client is more difficult to arouse

-client is more difficult to arouse

Which clients are at a heightened risk for infection? Select all that apply. -client with hypothermia -client with gastric tube feeding -client with an indwelling catheter -client with an IV catheter -client with hypertension

-client with gastric tube feeding -client with an indwelling catheter -client with an IV catheter

The nurse is caring for an older adult with influenza. Which precautions will the nurse begin? -airborne -droplet -contact -none

-droplet

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? -airborne -droplet -contact -none

-droplet

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? -Migration of leukocytes to the area of the wound -Constriction of the small blood vessels near the wound -Release of histamine -Production of antibodies

Migration of leukocytes to the area of the wound