Fundamentals Exam 2

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

"As long as I change gloves between clients, it is not necessary to wash my hands."

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."

Causative agent

(bacteria, virus, fungus, prion, parasite)

Reservoir

(human, animal, food, organic mater on inanimate surfaces, water, soil, insects)

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (select all that apply)

-Irrigating a client's abdominal wound -Suctioning a client's new tracheostomy tube

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (select all that apply)

-check for personal items when changing the bed linens -keep the bath water temperature between 43.3C (110F) and 46.1C (115F) -wash the client's extremities from proximal to distal

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands

Mode of transmission

Contact -Direct physical contact: person to person -indirect contact with an inanimate object: object to person -fecal-oral transmission: handling food after using a restroom and failing to wash hands Droplet -sneezing, coughing, and talking Airborne sneezing and coughing Vector borne: animals or insects as intermediaries (tricks transmit Lyme disease; mosquitos transmit West Nile and malaria)

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet

Herpes zoster

Is a common viral infection that erupts years after exposure to chickenpox and invades a specific nerve tract

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Protective

Parasites

Protozoa (malaria, toxoplasmosis) and helminths (worms [flatworms, roundworms], flukes [Schistosomal])

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

Pull the curtain around the client's bed

native immunity

Restricts entry or immediately responds to a foreign organism (antigen) through the activation of phagocytic cells, complement, and inflammation. This occurs with all micro-organisms, regardless of previous exposure

A nurse is providing oral care for a client who is immobile. Which of these following actions should the nurse take?

Turn the client on his side before starting oral care.

specific adaptive immunity

allows the body to make antibodies in response to a foreign organism (antigen). This reaction directs against an identifiable micro-organism

Passive

antibodies are produced by an external source. -Temporary immunity that does not have memory of past exposure -Intact skin, the body's first line of defense -Mucous membranes, secretions, enzymes, phagocytic cells, the complement system, and protective proteins -Inflammatory response with phagocytic cells, the complement system, and interferons to localize the invasion and prevent its spread

active

antibodies are produced in response to an antigen. -requires time to react to antigens -provides permanent immunity Involves B- and T-lymphocytes Produces specific antibodies against specific antigens (immunoglobulins [IgA, IgD, IgE, IgG, IgM])

types of pathogens

bacteria, viruses, fungi, prions, parasites

Chain of infection

causative agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

A nurse is providing nail care for a client. Which of the following actions should the nurse take?

clean under the nail with an orange stick

susceptible host

compromised defense mechanisms (immunocompromised, breaks in skin) leave the host more susceptible to infections

Portal of exit

from (means for leaving) the host -respiratory tract (droplet, airborne): Mycobacterium tuberculosis and streptococcus pneumoniae -GI tract: Shigella, Salmonella enteritidis, Salmonella typhi, hepatitis A -Genitourinary tract: Escherichia coli, hepatitis A, HSV, HIV -Skin/mucus membranes: HSV and varicella -Blood/body fluids: HIV and hepatitis B and C -Transplacental

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

gloves

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

have the client wear a mask

Stages of infection

incubation, prodromal stage, illness stage, convalescence

Incubation

interval between the pathogen entering the body and the presentation of the first finding

prodromal stage

interval from onset of general findings to more distinct findings; during this time, the pathogen multiplies

convalescence

interval when acute findings disappear, total recovery taking days to months

illness stage

interval when findings specific to the infection occur

Virulence

is the ability of a pathogen to invade and injure a host

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

mask

Fungi

molds and yeasts (candida albicans, aspergillus)

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?

nonantimicrobial soap

Viruses

organisms that use the host's genetic machinery to reproduce (HIV, hepatitis, herpes zoster, herpes simplex virus [HSV])

Prions

proteins particles (new variant creutzfeldt-Jakob disease)

Bacteria

staphylococcus aureus, Escherichia coli, Mycobacterium tuberculosis

Portal of entry

to the host: might be the same as the portal of exit

A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?

use chlorhexidine to wash hands if the client is immunosuppressed