PREPU fundamentals exam 1 ch 24

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 drains hands lower than the wrist wets hands and wrists

has manicured nails that are 1-in. (2.5-cm) long

A physician 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? helps to determine prescribed antibiotic therapy permits selection of antibiotic concentration narrows the therapeutic range to avoid prolonged use helps in reducing proliferation of multidrug-resistant organisms

helps to determine prescribed antibiotic therapy

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

increased respiratory rate lymph node enlargement fever

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

into a private room

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? Droplet precautions Strict reverse isolation Medical asepsis technique Surgical asepsis technique

Surgical asepsis technique

The student nurse observes another nurse wash her hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium Difficile (C diff). Why is this behavior incorrect? The bathroom is highly contaminated with the Clostridium difficile bacteria. Clostridium difficile bacteria is eradicated by the use of hand sanitizer only. The nurse must make sure that the bathroom has been cleaned recently before washing her hands. The behavior is not a problem as long as the nurse uses gloves in the room.

The bathroom is highly contaminated with the Clostridium difficile 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? The sterile field is set up at waist level. The top flap of the package is opened away from the new nurse's body. The new nurse touches 1.5 in (4 cm) from the outer edges. Direct visualization of the sterile field is maintained.

The new nurse touches 1.5 in (4 cm) from the outer edges.

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: the client's symptoms are typical of an older adult client. without an elevated temperature, infection is not present. an infection was present and has dissipated. an older adult can have an infection without a fever.

an older adult can have an infection without a fever.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene? The nurse uses hand hygiene instead of gloves when in contact with blood. The nurse uses gloves in place of hand hygiene. The nurse refrains from using hand moisturizer following hand hygiene. The nurse keeps fingernails less than 1/4 in (0.63 cm) long.

The nurse keeps fingernails less than 1/4 in (0.63 cm) long.

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? Wear a mask with face shield during invasive procedures. Apply a nonparticulate (N-95) respirator when entering the room. Have the client wear a mask during care. Wear a protective gown and gloves with any direct contact.

Apply a nonparticulate (N-95) respirator when entering the room.

The nurse is caring for a client that requires a dressing change. When applying the principles of asepsis, what aspect of care should the nurse include? It is impossible to completely eliminate microorganisms from an object. All nonsterilized surfaces are considered to be equally contaminated. Visibly clean objects are considered to be sterile. Blood and body fluids are major reservoirs for microorganisms.

Blood and body fluids are major reservoirs for microorganisms.

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? Limiting visitors to family members over the age of 18 Incentivizing health care workers to utilize hand hygiene Encouraging visitors to adhere to isolation precautions Revising the facility's infection control protocols

Incentivizing health care workers to utilize hand hygiene

What is the second line of defense in microbial invasion? Disability Infection Disease Inflammation

Inflammation

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? The resident microorganisms mutated and became virulent The client's immune system became further weakened The client's normal flora proliferated because of a nutritional deficit The client's normal flora began producing spores

The client's immune system became further weakened

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others? "All visitors who enter the room must wear N95/surgical masks." "No visitors are allowed in the room to decrease the spread of disease." "Everyone who enters the room must wear a gown and gloves." "Under no circumstances should you touch the client."

"All visitors who enter the room must wear N95/surgical masks."

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond? "It is possible that you are not washing your hands well enough." "There are a lot of infectious processes around and there is nothing that can be done." "As we age, our immune system does not function as well." "You will have to limit who comes to visit since they may be exposing you."

"As we age, our immune system does not function as well."

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation? "Do not touch this, or I will have to start over. " "I have set up this sterile field for your procedure, so please do not touch anything around the tray." "It is alright if you want to look at the supplies. Just be careful not to touch them." "Everything is ready, I will leave the tray here for the provider."

"I have set up this sterile field for your procedure, so please do not touch anything around the tray."

A client who has had repeated infections asks the nurse what he can do to improve his ability to resist infection. Which suggestion would be least appropriate for the nurse to give? "Make sure to get enough sleep at night." "Limit your intake of water each day to about 4 to 5 glasses." "Try to eat lots of fruits and vegetables." "Keep your skin well-moistened with creams"

"Limit your intake of water each day to about 4 to 5 glasses."

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

The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate? "Infections in newborns are rare because they have little difficulty localizing infections" "Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding." "It usually takes about a month or two until the baby's immune system to become completely functional." "If you notice that the newborn has a fever, then you need to have him seen by the doctor fairly quickly."

"Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."

A client is being screened for a parasitic infection and the physician 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: 2 days. 3 days. 5 days. 4 days.

3 days.

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. 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. Any partially uncovered sterile package need not be considered contaminated.

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

An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate? Contact Fomite Airborne Droplet

Airborne

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 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 A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior

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

Which term describes foreign particles that enter a host and stimulate the body's immune response? Macrophage Antigen Phagocyte Antibody

Antigen

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

Client receiving chemotherapy

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

Cover exposed wrist skin

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile? Since the bottle has been open, previously used, and unexpired, "lip" it by pouring a small amount into a waste container or waste cup. Discard the bottle and get a new one because the saline has expired. Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening. Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container.

Discard the bottle and get a new one because the saline has expired

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

Fungi

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform? Open sterile packages so that the first edge of the wrapper is directed toward you. Consider the outside of the sterile package to be partially sterile. Consider the outer 3-in edge of a sterile field to be contaminated. Hold sterile objects above waist level to prevent accidental contamination.

Hold sterile objects above waist level to prevent accidental contamination.

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply. Pain with redness and swelling Inside edges of the ulcer appear to be drawing together Scabs forming over the ulcer Localized heat Purulent or malodorous drainage

Pain with redness and swelling Localized heat Purulent or malodorous drainage

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? Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps Wrap all used materials together and discard in biohazard container Don a new pair of gloves to dispose of materials Perform hand hygiene

Perform hand hygiene

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? Place a surgical mask on the client and transport to the CT department at the specified time. Request that the examination be done at the bedside. Question the need for the examination, because the client must remain under airborne precautions. Notify the CT department in advance so other clients and staff can be removed from the area.

Place a surgical mask on the client and transport to the CT department at the specified time

Which should be documented by the nurse? The fact that the nurse washed her hands before a procedure The fact that sterile technique was used for a given procedure The specific items that the nurse transferred into a sterile field The fact that the nurse donned gloves two different times during a procedure

The fact that sterile technique was used for a given procedure

The charge nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction? The new nurse avoids touching the inner surface of the wrapper or sterile item. The new nurse holds the wrapped item in the dominant hand to open, opening top flap away from the body. The new nurse pulls the four corners of the wrapper back toward the wrist, covering hand and wrist. The new nurse slides the item from the wrapper into the side of the sterile field.

The new nurse slides the item from the wrapper into the side of the sterile field.

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? WBC of 10,500 mcL WBC of 7,500 mcL WBC of 25,000 mcL WBC of 5,500 mcL

WBC of 25,000 mcL

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

airborne precautions droplet precautions contact precautions

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? a 12-year-old girl an 80-year-old woman an 18-month-old infant a 2-year-old toddler

an 80-year-old woman

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action? change to contact precautions continue with droplet precautions change to airborne precautions change to standard precautions

change to airborne precautions

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess? clear mucus dyspnea productive cough abnormal breath sounds

clear mucus

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? airborne droplet vehicle contact

contact

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: increased effectiveness of phagocytosis. increased humoral immunity response. decreased susceptibility to infection. decreased cellular immunity.

decreased cellular immunity.

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

droplet

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

droplet

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? wear gloves when touching the client avoid direct contact with the client perform hand hygiene before and after entering the client's room wear a mask and gown in the client's room

perform hand hygiene before and after entering the client's room

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing? stationary resolution prodromal invasion

prodromal

The nurse observes an 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? applies a mask with face shield performs hand hygiene before donning gloves removes gloves and walks out of the room asks the client to state name and date of birth

removes gloves and walks out of the room

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? increased vitamin C increased T cells decreased antibiotics surgical asepsis

surgical asepsis

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? the client placed in contact isolation who was admitted with a draining abdominal wound the client admitted with diarrhea who tested positive for Escherichia coli (E. coli) the client admitted with a rash who reports recent exposure to measles the client who is 48-hours postsurgical procedure

the client who is 48-hours postsurgical procedure

The most lethal infection in an older adult client is: urinary. optic. otic. skin.

urinary.

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

wearing a particulate respirator for all care and interaction with this client

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: elevated within normal limits stable decreased

within normal limits (5,000 to 10,000 is normal)