Prep U's - Chapter 24 - Asepsis and Infection Control

A team of nurses is caring for a client with tuberculosis. They have not been fitted for N95 respirators. How will the team proceed with care? A. utilize a powered air purifying respirator (PAPR). B. refrain from providing care until a nurse who has been fitted arrives. C. use a regular mask and continue to provide care as usual. D. enter the room as normal but maintain a 3-foot (1-meter) distance from the client.

Answer: A Rationale: A PAPR is an alternative that can be used if a caregiver has not yet been fitted with a N95 respirator. All the other options are inappropriate.

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify: A. decreased cellular immunity. B. increased humoral immunity response. C. increased effectiveness of phagocytosis. D. decreased susceptibility to infection.

Answer: A Rationale: As a person ages, there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to infection.

What is the primary purpose for the demonstrated glove application? A. Cover exposed wrist skin. B. Anchor gown sleeves. C. Minimize risk of a glove tear. D. Help adjust for glove size.

Answer: A Rationale: Gloves are intended to protect hands and wrists from exposure to microorganisms. This is best accomplished by extending the gloves up the arm to cover the cuffs of the gown. While the proper application of the gloves does anchor the cuffs, the primary purpose is directed at the risk management of microorganism expose to the wrists. This application has no value to adjusting for glove size or to prevent tearing of the glove.

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client? A. MRSA in the wound. B. Coronary artery bypass grafting. C. Vancomycin-resistant enterococci and urinary tract infection. D. Clostridium difficile and colitis.

Answer: A Rationale: In many situations, clients with like infections can be placed together. The presence of similar causative microorganisms negates the risks of cross-contamination. Each of the other listed clients would encounter a risk for MRSA.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern? A. WBC of 25,000 mcL B. WBC of 20,000 mcL C. WBC of 10,000 mcL D. WBC of 5,500 mcL

Answer: A Rationale: Leukocytes, also called white blood cells (WBCs), and the inflammatory response make up the second line of defense to microbial invasion. A normal WBC count is 5,000 to 10,000 cells/mm3. A count above this range is indicative of infection.

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that: A. an older adult can have an infection without a fever. B. the client's symptoms are typical of an older adult client. C. without an elevated temperature, infection is not present. D. an infection was present and has dissipated.

Answer: A Rationale: Older adults may not show a fever or may produce only a low-grade fever when an infection is present.

Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care? A. skin is dry and intact. B. redness size over sacral area is with minimal increase. C. slight bleeding noted while old dressing is removed. D. blanching over elbow area noted.

Answer: A Rationale: The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare.

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action? A. Open a new sterile dressing kit. B. Wash the client's hands. C. Continue changing the dressing. D.Restrain the client's hands.

Answer: A Rationale: The nurse's next action is to obtain a new sterile dressing kit before continuing with the dressing change procedure. Continuing the dressing change without obtaining a new kit would increase the client's risk for infection. The client's hands do not need to be cleansed after touching the contents of the kit, and it would be inappropriate to restrain the client's hands (unless the client is unaware of the event or has trouble remembering what is occurring).

The nurse notes that the client's temperature is 101.2°F (38.4°C) at 8 a.m. Elevated temperature may be due to several factors. What could be the reason for this? A. very hot coffee B. respiratory infection C. loose stool D. recent bed bath

Answer: B Rationale: Assess vital signs frequently to detect infection or to monitor its progress. The accuracy of such assessment is important in determining if infection is present. In client with an infection, look for elevations in temperature (above 38.4°C [101°F]), pulse rate, and respiratory rate.

The most common infection in children is: A. urinary B. respiratory C. gastrointestinal D. neurologic

Answer: B Rationale: The most common infections in early childhood are respiratory infections.

Otitis media occurs in children because the: A. eustachian tube is long and twisted. B. eustachian tube is shorter and straighter. C. eustachian tube has a downward turn. D. eustachian tube is widened.

Answer: B Rationale: The most common infections in early childhood are respiratory infections. In children, the eustachian tubes are shorter and straighter; middle ear infections (otitis media) are common because bacteria can easily pass from the nasopharynx to the ear canal.

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct? A. Slide one gloved hand under the other glove for removal. B. Touch the inside of the gown and pull it away from the torso. C. Remove respirator at the doorway of the client's room. D. Remove the goggles before removing other equipment.

Answer: B Rationale: The outside of the equipment is considered contaminated. Removal follows a prescriptive sequence. Most personal equipment is removed at the door of the client's room. The contaminated glove grasps the other contaminated glove for removal. The nurse's clean hand reaches under the other glove for removal. Goggles are removed by holding the earpieces. Clean hands touch the inside of the gown for removal, pulling away from the torso. Roll these items up, inside out, for disposal. Grasp ties on mask on respirator for removal after leaving the room.

A client is being screened for a parasitic infection and the health care provider orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: A. 5 days B. 4 days C. 3 days D. 2 days

Answer: C Rationale: Usually when a client is being screened for a parasitic infection, stool specimens are collected daily for 3 days. Parasites lay eggs in the GI tract that can be detected on examination. Moving organisms can easily be detected in fresh specimens.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? A. sending a VRE-positive client to the radiology department for a chest X-ray without a face mask. B. 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. C. delivering a meal tray to a VRE-positive client without first donning gloves and a gown. D. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing.

Answer: B Rationale: Direct client contact between a VRE-positive client and another client without handwashing carries a significant risk of infection, especially when contact includes body fluids. Handwashing is necessary before a procedure such as staple removal, but foregoing this infection control measure is less likely to spread VRE unless the nurse failed to handwash after the procedure. VRE does not normally require droplet or airborne precautions. Delivering an item to a client without gloves or a gown is less of a risk than failing to wash the hands after such contact.

Which nursing action is a component of medical asepsis? A. insertion of an intravenous catheter. B. handwashing after removing gloves. C. drawing blood from a central line. D. insertion of an indwelling urinary catheter.

Answer: B Rationale: Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood).

The nurse is assisting a colleague with wound care. The colleague has established the sterile field and is pouring out normal saline into a sterile container, as seen in the picture above. What is the nurse's best action while observing the colleague perform the task? A. encourage the colleague to hold the bottle closer to the sterile container. B. observe the colleague and take no further action. C. remind the colleague that the container should be centered on the sterile field. D. obtain a new dressing tray for the colleague.

Answer: B Rationale: The colleague is demonstrating appropriate sterile technique. Consequently, there is no need to obtain a new dressing tray. The container cannot overlap the nonsterile edges of the field, but it does not necessarily need to be centered. The bottle should be held 4 to 6 in (10 to 15 cm) above the container, as pictured.

Any microorganism capable of disrupting normal physiologic body processes is a: A. bacterium B. fomite C. pathogen D. virus

Answer: C Rationale: Microorganisms that are capable of harming people are called pathogens or pathogenic.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? A. "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." B. "I will not visit my family member in the first 3 days of my cold." C. "I will obtain a mask from the staff and wash my hands before touching my family member." D. "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."

Answer: C Rationale: Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is an older adult or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? A. The nurse performs hand hygiene before putting on gloves. B. The nurse applies nonmedicated hand cream after performing hand hygiene. C. The nurse performs hand hygiene after touching the client's surroundings. D. The nurse removes her gown and then removes her gloves.

Answer: D Rationale: Gloves should be removed prior to a gown. Hand hygiene is necessary before applying gloves and after touching a client's surroundings. The use of moisturizers is acceptable.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? A. Perform hand hygiene. B. Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps. C. Wrap all used materials together and discard in biohazard container. D. Don a new pair of gloves to dispose of materials.

Answer: A Rationale: Inverting the gloves into each other encloses the soiled surface and blocks a potential exit route for microorganisms. After removing gloves, the next step would be to perform hand hygiene which should be conducted before touching the loved one. Used materials are not always disposed of in biohazard containers. Donning new gloves should not be necessary as materials should have already been disposed of prior to removing the gloves. Lotions that work in conjunction with soaps and lotions should be used when applying lotion after performing hand hygiene but this is not the next step.

A nurse at the health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action(s) is appropriate by the nurse when using masks? Select all that apply. A. Change the mask if it becomes damp. B. Position the mask so that it covers the nose and mouth. C. Avoid touching the mask once it is in place. D. Discard used masks into a regular wastebasket. E. Touch only the strings of the mask during removal.

Answer: A, B, C, E Rationale: The nurse should avoid touching the mask once it is in place because touching the mask transfers microorganisms to the hands. The mask should be changed every 20 to 30 minutes or when it becomes damp, to preserve its effectiveness. The nurse should touch only the strings of the mask during removal to prevent transfer of microorganisms to the hands. The mask should be positioned over the nose and the mouth to provide a barrier to nasal and oral ports of entry. The nurse should discard used masks into a lined or waterproof waste container and not a regular wastebasket.

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

Answer: B Rationale: A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe an illness that is contracted after eating food.

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup? A. Fungi B. Virus C. Bacteria D. Parasites

Answer: B Rationale: A virus invades a living cell many times its size, uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup.

To eliminate needlesticks as potential hazards to nurses, the nurse should: A. stick the uncapped needle into a Styrofoam block and deposit it in a plastic container. B. immediately deposit uncapped needles into a puncture-proof plastic container. C. place the uncapped needle on a tray and carry it to the medicine room for disposal. D. slide the needle into the cap and deposit it in a puncture-proof plastic container.

Answer: B Rationale: All uncapped needles should be placed in a puncture-proof plastic unit immediately after use.

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measure will the nursing staff implement to help prevent the spread of MRSA to clients who are currently negative for MRSA? A. prophylactic antibiotic therapy for higher-risk clients who are negative for MRSA. B. diligent hand hygiene. C. consistent use of gloves when on the unit. D. early discharge for clients who are positive for MRSA when medically appropriate.

Answer: B Rationale: As with all forms of infection, thorough handwashing is the most important infection control measure. It is inappropriate to reduce a client's length of stay based on their MRSA status, and prophylaxis is not normally used. It is unnecessary to wear gloves at all times on the unit; even when used appropriately, gloves have less of an impact than thorough hand hygiene.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? A. Shigella in the intestinal tract. B. Escherichia coli in the intestinal tract. C. Escherichia coli in the urinary tract. D. Shigella in the urinary tract.

Answer: B Rationale: Escherichia coli resides in the intestinal tract, is normal flora, and does not cause harm or infection in the client. Shigellosis is an infectious disease caused by a group of bacteria called Shigella, closely related to E. coli. Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria.

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? A. The top flap of the package is opened away from the new nurse's body. B. The new nurse touches 1.5 in (4 cm) from the outer edges. C. Direct visualization of the sterile field is maintained. D. The sterile field is set up at waist level.

Answer: B Rationale: Only the outer 1 in (2.5 cm) of the sterile package is safe to touch. In this case, the nurse touches 1.5 in (4 cm), which is inside the sterile field. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? A. Tuberculosis and pneumonia. B. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD). C. Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus. D. Clostridium difficile and diabetic ketoacidosis.

Answer: B Rationale: Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together. C. difficile requires contact isolation and is contagious. Diabetic ketoacidosis is considered a medical diagnosis and requires standard precautions. A surgical incision from an appendectomy is considered clean. A draining leg ulcer can transmit an infection to a client with a clean surgical incision. In both of these cases, rooming these clients together violates infection control standards. Tuberculosis requires airborne precautions and pneumonia requires standard precautions. Based on the mode of transmission of tuberculosis, these clients cannot room together.

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? A. The nurse uses soap and cold water to wash hands. B. The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. C. The nurse rinses thoroughly with water flowing away from the fingertips. D. The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands.

Answer: B Rationale: The nurse must wash at last 1 in (2.5 cm) above the area of contamination to properly performed hand hygiene. The nurse should use warm to hot water to wash hands. The amount of liquid soap varies depending on the concentration of the soap. The nurse rinses with water flowing toward the fingertips.

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor? A. picks up the glove at the folded edge with the thumb and forefinger. B. reaches down to the bed to pick up a sterile drape. C. washes hands for 20 seconds with soap and water. D. stretches the glove over the hand without touching the unsterile area.

Answer: B Rationale: The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully.

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms? A. The client's normal flora proliferated because of a nutritional deficit. B. The client's immune system became further weakened. C. The client's normal flora began producing spores. D. The resident microorganisms mutated and became virulent.

Answer: B Rationale: Unless the supporting host becomes weakened, normal flora remains controlled. If the host's defenses are weakened, as in cases of HIV/AIDS, even benign microorganisms can cause opportunistic infections. This phenomenon is not due to mutations, spore production or the direct effects of a nutritional deficit.

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to assess? Select all that apply. A. decreased pulse rate B. increased respiratory rate C. absence of pain D. fever E. lymph node enlargement

Answer: B, D, E Rationale: Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, and lymph node enlargement.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? A. increased T cells B. increased vitamin C C. surgical asepsis D. decreased antibiotics

Answer: C Rationale: Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason? A. narrows the therapeutic range to avoid prolonged use. B. permits selection of antibiotic concentration. C. helps to determine prescribed antibiotic therapy. D. helps in reducing proliferation of multidrug-resistant organisms.

Answer: C Rationale: Gram staining helps to order antibiotic therapy while waiting for specific culture results, whereas minimum inhibitory concentration permits selection of antibiotic concentration, helps in reducing proliferation of multidrug-resistant organisms, narrows the therapeutic range, and avoids prolonged use.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? A. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. B. Don a second pair of sterile gloves over the first pair. C. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. D. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability.

Answer: C Rationale: It is appropriate to adjust the gloves as long as the nurse only touches sterile surface to sterile surface. Leaving the thumb and finger in the thumb hole or only using the correctly gloved hand to perform the sterile procedure would not be appropriate, nor would donning a second pair of gloves, in this case.

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

Answer: C Rationale: Once a sterile field is set up, only sterile items can be placed on the field. To add paper-wrapped sterile items, after performing hand hygiene, the nurse would open the items by separating the sealed flaps and dropping the contents onto the sterile field. Wearing sterile gloves to open the package would containment the gloves. Opening the package away from the field would containment the sterile field. It is not necessary to set up a separate sterile field.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? A. with a client with a myocardial infarction. B. with another client with a draining wound. C. into a private room. D. with a client with pneumonia.

Answer: C Rationale: The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse? A. fill out a risk management form. B. go to employee health for testing. C. wash the area with soap and water. D. find out who left the scalpel blade on the procedure tray.

Answer: C Rationale: The first action by the nurse should be to wash the hands gently with soap and water to reduce exposure of blood or pathogens to the wound. Filling out a risk management form is required but should be done after first aid care is performed. Finding out who left the blade on the tray is not relevant at this time, but further education for the unit may be required at a later time. Going to employee health is the step that will be taken after immediate first aid.

A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take? A. Have all clients in the waiting room don face masks. B. Ask the child to stay at least 2 feet (0.6 meters) away from all other clients. C. Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes. D. Ask the parent to take the child home.

Answer: C Rationale: The nurse should educate clients and visitors to health care facilities to cover the mouth/nose with a tissue when coughing; to promptly dispose of used tissues; to use surgical masks on the coughing person when tolerated and appropriate; to use hand hygiene after contact with respiratory secretions; and to use spatial separation, ideally greater than 3 feet (1 meter), between people with respiratory infections in common waiting areas when possible. Having all clients in the waiting room don face masks would be inconvenient and unnecessary. Asking the parent to take the child home would be inappropriate.

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? A. "I may have gotten the virus when I got a tattoo while I was in prison." B. "I received a blood transfusion in 1989, which could be a factor in contracting the disease." C. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." D. "I can't transmit the virus other people if I shake their hands."

Answer: C Rationale: There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992. The virus cannot be contracted or spread through a toilet seat.

Which client presents the most significant risk factors for the development of Clostridium difficile infection? A. 44-year-old client who is paralyzed and whose pressure injury on the coccyx required a skin graft. B. 30-year-old client who has recently contracted human immunodeficiency virus (HIV). C. 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis. D. 56-year-old client with acute kidney injury who receives hemodialysis three times weekly.

Answer: C Rationale: Two common factors that increase a client's risk of becoming infected with Clostridium difficile are age greater than 65 and current or recent use of antibiotics. The client who is 81 years of age and received recent, long-term antibiotic therapy is at significant risk C. difficile infection. These risk factors supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.

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? A. Any partially uncovered sterile package need not be considered contaminated. B. When a sterile item touches something that is not sterile, it may not be contaminated. C. A commercially packaged surgical item is not considered sterile if past expiration date. D. Sterility may not be preserved even when one sterile item touches another sterile item.

Answer: C Rationale: When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is: A. it is an antiviral vaccine used to eradicate wound infection. B. It counteracts the effects of the inflammatory process. C. it induces humoral immunity in the client's blood. D. it is a vaccine given to booster antibodies towards the tetanus pathogen.

Answer: D Rationale: Active immunity is produced when the immune system is stimulated, either naturally or artificially, to produce antibodies. Natural immunity occurs after an infection has run its course.

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection? A. reverse isolation B. droplet C. airborne D. contact

Answer: D Rationale: Any multidrug resistant organism requires contact precautions to help prevent the spread of the organism to others. This will include MRSA. Airborne precautions can be utilized with diseases in which the causative organism is passed through the air after the infected person has coughed, sneezed, or talked. Tuberculosis is an example. Droplet precautions are warranted when the disease is spread through large particle droplets such as rubella and mumps. Reverse isolation is used to protect the client from any new infectious organisms. This can be utilized for client's who may be immunocompromised or already have a serious infection and the nursing team is trying to prevent further infections from complicating the client's health.

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism? A. "Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it." B. "If you do not wear gloves you will also get the infection." C. "Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." D. "The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

Answer: D Rationale: Contact precautions, which are not optional, block transmission of pathogens by direct or indirect contact. Explaining that the loved-one understands is not teaching information. Educating the visitor about drug-resistant infections is important but does not explain how to prevent transmission of the infection. Telling the visitor that he or she will get the infection if the visitor does not wear gloves is incorrect, the visitor is at a greater risk of getting and spreading the infection. Wearing gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? A. avoid direct contact with the client. B. wear a mask and gown in the client's room. C. wear gloves when touching the client. D. perform hand hygiene before and after entering the client's room.

Answer: D Rationale: Hand hygiene is the most important way to prevent transmission of infection.

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter? A. Remove all jewelry, including wedding bands, before hand washing. B. Use an alcohol-based hand rub to decontaminate the hands. C. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. D. Keep hands lower than elbows to allow water to flow toward fingertips.

Answer: D Rationale: Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms.

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from: A. viral infection. B. hepatitis. C. chickenpox. D. bacterial infection.

Answer: D Rationale: If the infection is severe or prolonged, the body cannot manufacture neutrophils quickly enough, resulting in the release of immature granulocytes into the blood. This increase in the number of immature cells is called a shift to the left or leftward shift in the granulocyte differential count.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? A. Encouraging visitors to adhere to isolation precautions. B. Revising the facility's infection control protocols. C. Limiting visitors to family members over the age of 18. D. Incentivizing health care workers to utilize hand hygiene.

Answer: D Rationale: Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. Revising the agency's infection control protocols is not nursing centered. Encouraging visitors to adhere to isolation precautions is important but does not affect the immediate surroundings and personal space that can cause a contaminated work environment. Limiting visitors to family members over the age of 18 is not client-centered care and will not decrease transmission of pathogens.

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness? A. There is really nothing that can be done to prevent childhood illness. B. It is recommended that infection in children be allowed to run its course to build immunity. C. Grouping infectious children together helps to prevent future infection. D. Early infection treatment is needed to prevent the spread of infection.

Answer: D Rationale: Prevention of infections in early childhood requires good hygienic care of children and their food, adequate vaccinations, early infection treatment to prevent spread or complications and isolation of both healthy and those infected from infected people.

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

Answer: D Rationale: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? A. Medical asepsis B. Universal precautions C. Contact precautions D. Surgical asepsis

Answer: D Rationale: Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter. Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins? A. Neutrophils B. Monocytes C. Eosinophils D. T-lymphocytes

Answer: D Rationale: T-lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan? A. signs and symptoms of infection. B. vital sign monitoring. C. hand hygiene measures. D. intravenous antibiotic administration.

Answer: D Rationale: The discharge education plan would most likely include teaching the client and caregivers about the signs and symptoms of infection, hand hygiene measures, and vital sign monitoring. Because the client's infection has resolved, the client would probably not require intravenous antibiotic administration.

The nurse observes unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? A. applies a mask with face shield. B. performs hand hygiene before donning gloves. C. asks the client to state name and date of birth. D. removes gloves and walks out of the room.

Answer: D Rationale: The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used as barriers to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients. Asking the client to state his or her name and date of birth is important to make sure the specimen is collected with the correct laboratory label. To protect the UAP from direct contact with the urine, a face mask is indicated.

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? A. Call for help and ask for new supplies. B. Proceed with the procedure since it was only touched by the client. C. Change the sterile field but reuse the sterile equipment. D. Discard the sterile field and the supplies and start over.

Answer: D Rationale: The nurse's next appropriate action would be to discard the sterile field and the supplies and start over. The client touching the end of the sterile field contaminated the field and the items on the field. The nurse cannot reuse the sterile equipment because the items are no longer sterile. The nurse cannot proceed with the procedure since the items have been contaminated. Calling for help and asking for new supplies is not the best answer. The field has been contaminated also.

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate? A. Question the need for the examination, because the client must remain under airborne precautions. B. Notify the CT department in advance so other clients and staff can be removed from the area. C. Request that the examination be done at the bedside. D. Place a surgical mask on the client and transport to the CT department at the specified time.

Answer: D Rationale: Transport clients in airborne precautions out of the room only when necessary and place a surgical mask on the client if possible. Use airborne precautions for clients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster). The nurse should not question the need for the examination or request that the examination be done at the bedside. It is not necessary to notify the CT department and allow for all clients and staff to be removed from the area.

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. A. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over the hand. B. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. C. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas. D. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves.

Answer: D, A, B, C Rationale: The correct order of putting on sterile gloves is as follows. First, the nurse should open the package, taking care not to touch the inner surface of the package or gloves. Then, the nurse should pick up the glove at the folded cuff with the thumb and forefinger and insert fingers while pulling the glove over the hand. Next, the nurse should place the finger of the gloved hand inside the cuff of the remaining glove, taking care not to touch outside of the folded cuff. Once both gloves are on, the nurse adjusts the gloves touching only sterile areas. If gloves are donned not following this order, there is an increased risk for contamination of the sterile gloves.