PCC Chapter 22. Infection Prevention & Control

For which range of time must a nurse wash her hands before working in the operating room? 1) 1 to 2 minutes 2) 2 to 4 minutes 3) 2 to 6 minutes 4) 6 to 10 minutes

ANS: 3 In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap used. PTS:1DIF:EasyREF:p. 639 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Virus 2) Bacterial spores 3) Yeast 4) Mold

NS: 1, 3, 4 If there is potential for contact with bacterial spores, hands must be washed with soap and water; alcohol-based solutions are ineffective against bacterial spores. PTS:1DIF:ModerateREF:p. 618 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct? 1) The virus mutates too rapidly to develop a vaccine. 2) Vaccines are developed only for very serious illnesses. 3) Researchers are focusing efforts on an HIV vaccine. 4) The virus for the common cold has not been identified.

ANS: 1 More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection, others continue to research the common cold. PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown

ANS: 1 Scrupulous hand washing is the most important part of medical asepsis. Donning gloves, applying sterile drapes before procedures, and wearing a protective gown may be needed to ensure asepsis, but they are not the most important aspect because microbes causing most healthcare-related infections are transmitted by lack of or ineffective hand washing. PTS: 1 DIF: Easy REF: p. 617 KEY: Nursing process: Interventions | Client need: Safe Care Environment | Cognitive level: Comprehension

A patient who has a temperature of 101°F (38.3°C) most likely requires: 1) acetaminophen (Tylenol). 2) increased fluids. 3) bedrest. 4) tepid bath.

ANS: 2 Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low-grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily bedrest, is necessary with a fever. PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? 1) Endogenous nosocomial 2) Exogenous nosocomial 3) Latent 4) Primary

ANS: 1 Thrush in this patient is an example of an endogenous nosocomial infection. This type of infection arises from suppression of the patient's normal floras as a result of some form of treatment, such as antibiotics. Normal floras usually keep yeast from growing in the mouth. In exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent infection causes no symptoms for long periods. An example of a latent infection is human immunodeficiency virus infection. A primary infection is the first infection that occurs in a patient. PTS: 1 DIF: Difficult REF: p. 608 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patient's door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure

ANS: 1 To maintain sterile technique, the nurse should close the patient's door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between people and the sterile field to prevent contamination. PTS: 1 DIF: Moderate REF: p. 629 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. The nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. The NAP: 1) uses a paper towel to turn off the faucet. 2) holds fingertips above the wrists while rinsing off the soap. 3) removes all rings and watch before washing hands. 4) cleans underneath each fingernail.

ANS: 1, 3, 4 Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of the hands and fingers to be effective. The fingers should be held lower than the wrists. PTS: 1 DIF: Moderate REF: pp. 633-634 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall

Which of the following protect(s) the body against infection? Select all that apply. 1) Eating a healthy, well-balanced diet 2) Being an older adult or an infant 3) Leisure activities three times a week 4) Exercising for 30 minutes 5 days a week

ANS: 1, 3, 4 Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle factors can make the body more susceptible to infection. PTS:1DIF:EasyREF:pp. 612, 616 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

As a general rule, how much liquid soap should the nurse use for effective hand washing? At least: 1) 2 mL 2) 3 mL 3) 6 mL 4) 7 mL

ANS: 2 APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing. PTS:1DIF:EasyREF:p. 633 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? 1) Cell-mediated 2) Passive 3) Humoral 4) Active

ANS: 2 Intravenous administration of immunoglobulin G provides the patient with passive immunity. Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive immunity occurs when antibodies are transferred from an immune host, such as from a placenta to a fetus. Passive immunity is short lived. Active immunity is longer lived and comes from the host. Humoral immunity occurs by secreted antibodies binding to antigens. Cell-mediated immunity does not involve antibodies but rather is a fight of infection from macrophages that kill pathogens. PTS:1DIF:ModerateREF:ESG, Chapter 22, Supplemental Materials, Humoral Immunity KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patient's room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patient's door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.

ANS: 2 Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its contents inside a special isolation bag that is held by a second healthcare worker at the patient's door. The items must be placed on the inside of the bag without touching the outside of the bag. PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? 1) Contact 2) Protective 3) Droplet 4) Airborne

ANS: 2 Protective isolation is used to protect those patients who are unusually vulnerable to organisms brought in by healthcare workers. Such patients include those with low white blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care units and labor and delivery suites, also use forms of protective isolation. PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering

ANS: 2 The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering. PTS:1DIF:ModerateREF:pp. 637-638 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1) Continue using the gloves inside the package because the package is intact. 2) Remove gloves from the sterile field and use a new pair of sterile gloves. 3) Throw all supplies away that were to be used and begin again. 4) Use the gloves and make sure the yellow edges of the package do not touch the client.

ANS: 2 The gloves should be discarded because the gloves are likely to be contaminated from an outside source. The supplies do not have to be thrown away because they have not been contaminated. PTS:1DIF:ModerateREF:pp. 629, 646 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? 1) Droplet transmission 2) Airborne transmission 3) Direct contact 4) Indirect contact

ANS: 2 The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect contact or droplet transmission. PTS:1DIF:ModerateREF:p. 608 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

Why is a lotion without petroleum preferred over a petroleum-based product as a skin protectant? 1) It prevents microorganisms from adhering to the skin. 2) It facilitates the absorption of latex proteins through the skin. 3) It decreases the risk of latex allergies. 4) It prevents the skin from drying and chaffing.

ANS: 3 Non-petroleum-based lotion is preferred because it prevents the absorption of latex proteins through the skin, which can cause latex allergy. Both types of lotion help prevent the skin from drying and becoming chafed. Neither prevents microorganisms from adhering to the skin. PTS: 1 DIF: Moderate REF: p. 634[answer not directly given in the text. Answer must be inferred from the content.] KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds. 3) washes hands only when leaving each room. 4) uses cold water for medical asepsis.

ANS: 3 Patients acquire infection by contact with other patients, family members, and healthcare equipment. But most infection among patients is spread through the hands of healthcare workers. Hand washing interrupts the transmission and should be done before and after all contact with patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface. When no visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15 seconds. PTS:1DIF:EasyREF:p. 618 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension

What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family members

ANS: 3 Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers. PTS:1DIF:EasyREF:p. 609 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Recall

A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? 1) Phagocytosis 2) Complement cascade 3) Inflammation 4) Immunity

ANS: 3 The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the body from future infection. PTS:1DIFgrinifficultREF:p. 610 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1) Incubation 2) Prodromal 3) Decline 4) Convalescence

ANS: 3 The stage of decline occurs when the patient's immune defenses, along with any medical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he is infected and is capable of infecting others. The prodromal stage is characterized by the first appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to healing as the organisms disappear. PTS:1DIF:ModerateREF:p. 609 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

In which situation would using standard precautions be adequate? Select all that apply. 1) While interviewing a client with a productive cough 2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter

ANS: 3, 4 Standard precautions should be instituted with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a client, if the disease is not spread by air or droplets, there is no likelihood of the nurse's encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne precautions would be needed in addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate after surgery. PTS: 1 DIF: Easy REF: pp. 619-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. 1) Question the order because the patient must remain in isolation. 2) Place an N-95 respirator mask on the patient and transport him to the test. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport.

ANS: 3, 4 Transporting a patient who requires airborne precautions should be limited; however, when necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is being transported should be notified about the precautions before transport. PTS: 1 DIF: Difficult REF: pp. 623-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would most likely be found in a test of immunoglobin levels? 1) IgA 2) IgE 3) IgG 4) IgM

ANS: 4 IgM are the first antibodies made in response to infection. IgE is the antibody primarily responsible for this allergic response. IgA antibodies protect the body in fighting viral and bacterial infections, and appear later. IgG antibodies also appear later—perhaps up to 10 days later. PTS:1DIF:ModerateREF:p. 612 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

A patient infected with a virus but who does not have any outward sign of the disease is considered a: 1) pathogen. 2) fomite. 3) vector. 4) carrier.

ANS: 4 Some people might harbor a pathogenic organism, such as the human immunodeficiency virus, within their bodies and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a mosquito or tick that bites or stings. PTS:1DIF:ModerateREF:p. 607 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? 1) When fingers feel sticky 2) After 5 to 10 seconds 3) When leaving the client's room 4) Once fingers and hands feel dry

ANS: 4 The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution dries, usually 10 to 15 seconds, to ensure effectiveness. PTS: 1 DIF: Easy REF: p. 634 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall