Saunders NCLEX Infection Control w/ Rationales

A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic?

Is painless and indurated. R- The characteristic lesion of syphilis is painless and indurated. the lesion is referred to as a chancre. Genital warts are characterized by cauliflowerlike growths or growths that are soft and fleshy. Scabies is characterized by erythematous, papular eruption. Genital herpes is accompanied by the presence of 1 or more vesicles that then rupture and heal.

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction?

"I should not use insect repellents because it will attract the ticks." R- In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

A client is seen on the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding the measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction?

"I should use a hot mist vaporizer to liquefy secretions." R- The client should be instructed to use a humidifier to help liquefy secretions and promote drainage.

The nurse is preparing an IV set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike but then touches the spike with a finger. What should the nurse do next?

Discard the IV tubing and use a new set for the infusion. R- The IV tubing's insertion spike must remain sterile. If it is touched during preparation of the infusion, the tubing must be discarded and replaced with a sterile set.

An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information?

"My contact lenses can be worn if they are cleaned properly" R- If the adolescent wears contact lenses, he or she should be instructed to discontinue wearing the until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.

The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother?

"One week after the onset of jaundice." R- Because HAV is not infectious 1 week after the onset of jaundice, a return to school at that time is permitted if the child feels well enough.

The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan?

Always apply the condom before inserting the penis into the vagina. R- To be effective, condoms must be applied before any vaginal penetration occurs. A condom must be used with every sexual encounter if it is to be safe. A lubricated condom may be used to increase sensitivity of the glans. Natural membrane condoms are less effective than latex in preventing the spread of some STIs.

The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding?

Ceftriaxone. R- Treatment for gonorrhea consists of antibiotic therapy, usually ceftriaxone and doxycycline. Acyclovir is the treatment of genital herpes simplex virus; azithromycin is the treatment for Chlamydia infection, and penicillin G benzathine is the treatment for syphilis.

The nurse is preparing to give a bed bath to an immobilized patient with tuberculosis. The nurse should wear which items when performing this care.

Particulate respirator, gown, and gloves. R- The nurse who is in contact with a patient with tuberculosis should wear an individually fitted particulate respirator, as well as gloves per standard precautions. the nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving bed baths.

The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which interventions?

Private room, gown, gloves, and face shield. R- Isolation guidelines from the CDC place MRSA at the tier 2 transmission category. Contact precautions are required and include a private room, gloves, gown and face shields in case of a splash from the wound drainage occurs, such as with wound irrigation. A room with negative-pressure airflow is required for airborne precautions from small droplet infections infections such as measles, chickenpox, or tuberculosis. A respiratory protection device is recommended for larger droplet infections such as pneumonia.

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others?

Blood and body fluid precautions. R- The AIDS virus is transmitted through contact with oral secretions, sexual contact with infected semen or vaginal secretions, through contacted with infected blood or blood products, from mother to fetus during childbirth, or during breast-feeding. Blood and body fluid precautions will prevent contact with infectious matter from the AIDS virus. Strict isolation is not needed and may contribute to feelings of isolation in the client. Enteric or contact precautions alone are insufficient to prevent transmission of the AIDS virus.

A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription.

Question the primary health care provider about whether a portable chest radiograph may be obtained. R- The client who is placed o contact precautions has a high microorganism count in some type of body secretion. The client is placed in a private room whenever possible and is removed from the room only when absolutely necessary.

An RN is providing instructions to an AP assigned to give a bed bath to a client who is on contact precautions. The RN instructs the AP to use which protective item when giving the bed bath?

A gown and gloves. R- Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless it is anticipated that splashes of blood, bodily fluids, secretions, or excretions may occur. Shoe protectors are not necessary.

An assistive personnel is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client?

Allowed the drainage tubing to rest under the leg. R- Proper care of an indwelling urinary catheter is especially important to prevent infection in the client. The drainage tubing is not placed under the leg; for the same reason, the drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder. The tubing must drain freely at all times. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens.

The nurse is assigned to care for an infant following a cleft lip repair. The nurse is asked to observe the parent in the procedure for cleaning the lip repair site. The nurse determines that the parent is performing the procedure correctly if the parent uses which solution to clean the site?

Sterile water. R- The lip repair site is cleansed with sterile water using a cotton swab; it is cleansed after feeding and as prescribed. The mother should be instructed to use a rolling motion from the suture line outward. The other options are incorrect solutions and can affect tissue integrity.

The nurse is caring for a client with acute viral hepatitis A who resides in a group home. Which outcome indicates that the most important goal has been achieved?

Avoids transmitting the virus to other in the group home. R- All of the options are expected outcomes of care for this client. However, because the disease is communicable to other, 1 of the most important goals in management of acute viral hepatitis is preventing the spread of infection.

The nurse employed on a medical unit in a hospital receives a call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions?

Droplet precautions. R- Droplet precautions are required for a client with mycoplasmal pneumonia because this type of pneumonia is transmitted by droplet nuclei larger than 5 mm. The nurse wears a mask while in the client's room. Enteric precautions are necessary when exposure from feces is likely; gloves are necessary and possibly a gown and face shield if splashes are expected to occur, Contact precautions are implemented when exposure to contaminated material, such as wound drainage, can occur and requires the use of gloves and possibly a gown. Protective isolation is instituted when it is necessary to protect the client from others.

The nurse prepares the client for irrigation of an abdominal wound. After prep, the nurse would appropriately don which item to perform the procedure?

Gloves, gown and goggles. R- Irrigation of a wound can cause splashing of the irrigation solution and wound exudates. Contact precautions are requires, and the nurse needs to protect her/himself in the event that splashing occurs.

The ambulatory care nurse is seeing a client for a follow-up visit after treatment for toxic shock syndrome (TSS). To assess the client's recovery from TSS, the nurse should ask whether which signs and symptoms have resolved?

High fever, abdominal pain, vomiting, and diarrhea. R- The classic symptoms of TSS are high fever 101F or higher, vomiting, and severe diarrhea. Other symptoms include headache, myalgia, chills, abdominal pain, dizziness, lethargy, possible confusion, and agitation. Vaginal bleeding or discharge is not part of the clinical picture. TSS typically is caused by Staphylococcus aureus infection associated with tampon use during menses.

The nurse in the health care clinic is preparing to obtain a throat swab for culture in a client suspected of having a beta-hemolytic streptococcal infection. Which actions are appropriate in collecting this specimen? SATA

Instruct the client to tilt the head back; Swab the tonsillar pillars and the posterior pharynx wall; Tell the client that the test will help to identify microorganisms; Place a tongue depressor on the client's tongue before swabbing the throat. R- When collecting a throat culture, the client is told that the test is performed to help identify microorganisms causing the symptoms. The client is instructed to tilt the head back, and both tonsillar pillars and the posterior pharynx wall are swabbed. A tongue depressor is used in the collection so that the swab doesn't come in contact with the normal floras of the mouth. The swab is immediately placed in a labeled culture tube and transported to the laboratory.

The nurse is conducting a community surveillance study for the purpose of communicable disease control. The nurse knows that performing an active surveillance method of assessment is best for what reason?

Results in detection of a more accurate number of cases. R- The best outcome of any type of surveillance is accuracy. An active surveillance method focuses on assessment rather than interventions and is best because it results in detection of a more accurate number of cases. Relying on the initiative of PHCPs to report cases is a passive method that results in an upward swing of cases reported based on the latest disease trend.

Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process?

Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant. R- When an infant is receiving ribavirin, exposure precautions need to be observed. anyone entering the infant's room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history pf respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs.

The nurse participating in a health fair is setting up a booth on prevention of human immunodeficiency virus (HIV) transmission. A poste is planned that will list sexual behaviors in 1 or 2 columns, "safe" and "not safe". Which behavior should the nurse place in the "not safe" column?

Use of natural skin condoms. R- Abstinence is the safest way to avoid HIV infection. Another reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of HIV as long as the condom is used properly and remains in place. The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through.

The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? SATA

A 47-year-old mother of a child with cystic fibrosis; A 54-year-old man scheduled for a routine diabetes check; A 35-year-old registered nurse scheduled for an annual pelvic exam; an 87-year-old woman from a nursing home scheduled for a surgical follow-up. R- Influenza vaccinations are recommended yearly and developed according to predicted strain for clients at high risk. Influenza immunization is recommended for high-risk clients. Anyone in close contact with clients with chronic respiratory or other chronic disorder should receive the vaccine. Adults with chronic metabolic disease such as diabetes mellitus are in high risk population. Residents of chronic care facilities are at risk for influenza. Health care workers are in the high-risk population. The influenza vaccine does not treat an active infection with the virus.

The nurse working in the emergency department is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room. R-The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Nigeria.

The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client?

Avoid frequent douching. R- The client who has been diagnosed with PID should avoid frequent douching because it decreases the natural flora that controls the growth of infectious organisms. The client should wear cotton undergarments, and clothes should not fit tightly. IUD's increase the client's susceptibility to infection. Sanitary pads should be changed at least every 4 hours. Tampons should be avoided during the acute infection.

The nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome (AIDS) who has blood tinged sputum with previous suctioning. The nurse plans to use which items as part of standard precautions for this client?

Gloves, gown, mask, and protective eyewear. R- Standard precautions include the use of gloves whenever there is actual or potential contact with blood or body fluids. During procedures that aerosolize blood, the nurse wears a mask and protective eyewear or a face shield. Impervious gowns are worn in those instances when it is anticipated that there will be contact with splashes of secretions or blood.

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? SATA

Inhalation of bacterial spores, Through a cut or abrasion in the skin, Ingestion of contaminated under cooked meat. R- Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deer flies.

A nursing instructor asks a nursing student about a client admitted with TB. What comment by the student indicates that there is a need for further teaching?

"It is a fast-growing infectious disease." R- Mycobacterium tuberculosis is a non-moving, slow-growing, acid-fast rod transmitted via the airborne route.

The nursing instructor determines that the nursing student understands the purpose of standard and transmission-based precautions if which statements are made? SATA

"They prevent transmission of organisms from client to client"; "From primary health care provider to clients"; "From clients to primary health care providers"; "From primary health care providers and clients to people outside pf the hospital." R- The purpose of these precautions is to prevent the transmission of organisms from clients to primary health care providers, from PHCPs to client, from client to client, and from PHCPs and clients to people outside of the hospital. Hospital visitors are not included in these infection-based precautions.

The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a donut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation?

Ask the nurse to refrain from eating and drinking in that area. R- A potential complication with hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern fro clients who may carry the virus, their families at risk from contact with the client and with the environmental surfaces and staff who may acquire the virus from contact with the client's blood. This risk is minimized by the use of standard precautions; appropriate hand washing and sterilization procedures; and the prohibition of eating, drinking or other hand-to-mouth activities in the hemodialysis unit.

The nurse is caring for a client with newly diagnosed human immunodeficiency virus (HIV). Besides preventing the transmission of the disease, what are the goals of medication therapy?

Decreasing the viral load; Delaying disease progression; Maintaining or increasing CD4+ T cell counts; Preventing HIV-related symptoms and opportunistic diseases. R- Antiretroviral therapy can delay disease progression and when taken consistently and correctly, ART can reduce viral load by 90%-99%. This makes adherence to treatment regimens extremely important. Prophylactic medications can significantly decrease morbidity and mortality rates.

A client with active TB demonstrates less than expected interest in learning about the prescribed medication therapy. The nurse assesses that his client may ultimately need which intervention as a last resort?

Directly observed therapy. R- TB is a highly communicable disease that is reportable to local public health department. This agency has regulations that may be enforced to ensure compliance with TB therapy. The client may be required to have directly observed therapy to reduce the risk to the public.

The nurse is preparing a plan of care for a client with a diagnosis of agranulocytosis who is being admitted to the hospital. The nurse determines that which is the priority when formulating the client's plan of care?

Potential for infection. R- Agranulocytosis is characterized by a reduced number of leukocytes and neutrophils in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms.

The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control?

The caregiver washes her hands before removal of the dressing and again before applying the clean dressing. R- The single most effective technique to prevent the spread of germs and bacteria is hand washing. The initial step with all aseptic procedures is hand washing. Using previously opened gauze, not washing the hands after sneezing, and not applying new gloves after removing the old dressing increase the risk of wound contamination as a result of poor aseptic technique.

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting his family members and others. How should the nurse respond to provide reassurance?

The family will be treated prophylactically, and the client won't be contagious after 2 to 3 consecutive weeks of medication therapy. R- Family member or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client usually is not contagious after taking the medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or medication-resistant tuberculosis.

A patient with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs?

Three sputum cultures are negative. R- The client must have sputum cultures performed every 2 to 4 weeks after initiation of anti-tuberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered non-infectious at the point.

The nurse is preparing tp insert an intravenous angiocatheter into a client's inner forearm. Before cannulating the vein, what motion will the nurse implement to cleanse the site?

Using a circular motion from the center outward. R- The nurse cleans the skin by using circular motion from inward to outward. This is the standard, accepted aseptic technique to carry microorganisms away from the insertion site. The same technique is used to cleanse any are requiring surgical asepsis.

The school nurse prepares a list of home care instructions for the parents of school children diagnosed with pediculosis capitis. Which instruction should the nurse include in the list?

Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits. R- Pediculosis capitis is an infestation of the hair and scalp with lice. Thorough home cleaning is necessary to remove any lice or nits that may fall from the host. Combs and brushes should be soaked in hot water for 10 minutes or pediculicide for 1 hour. Never use pediculicides on children or on linens. Anti-lice sprays may be harmful.

The nurse is giving a bed bath to a client and discovers that an additional washcloth and towel are needed. Which is the most appropriate action to take to obtain the needed items?

Wash hands, leave the client's room, and obtain the needed items. R- To avoid spreading the client's germs, the nurse's hands must be washed before leaving. By going to the linen room without washing the hands first, the nurse will spread those germs into the clean linen. It is not appropriate to ask the unit secretary or a family member to obtain the supplies. It is never appropriate to borrow other clients' supplies because this action may spread germs.

The home health nurse visits a client with suspected scabies. Which precaution should the nurse institute during the assessment of the client?

Wear a gown and gloves only. R- The CDC recommends wearing gloves and gowns for close contact with patients with scabies. Scabies is transmitted from client to client by direct skin contact. All contacts that the client has had should be treated at the same time

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Wearing a gown and gloves. R- Gowns and gloves are required of the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary.

The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness?

Raw oysters. R- The client is taught to avoid raw or undercooked seafood, meat, poultry, and eggs. The client also should avoid unpasteurized milk and dairy products. Fruits that the client peels are safe, as are bottled beverages. The client may be taught to avoid sorbitol, but this is to diminish diarrhea and has nothing to do with food-borne infections.

A client who is admitted for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The AP assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. What should the nurse tell the AP?

Standard precautions are sufficient because the disease is transmitted sexually. R- Chlamydial infection is sexually transmitted infection and frequently called nongonococcal urethritis in the male client. It requires no special precautions in the delivery of nursing care. Caregivers cannot acquire the disease during administration of care, and use of standard precautions is the only necessary measure.

A hospitalized patient has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed?

Supine in semi-Fowler's. R- Placing the client in a semi-Fowler's position allows gravity to aid in drainage of the abdominal cavity. This helps to prevent the formation of abscesses high in the abdomen. Abscesses in this location could rupture, potentially causing peritonitis. The color, odor, and amount of vaginal secretions are also noted and recorded.

A patient has been receiving a series of medications as part of intravenous anti-neoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client?

WBC count 2000mm3. R- The normal WBC count is 5000-10,000mm3. When the WBC count drops, neutropenic precautions should be implemented to protect the client from infection.

The nurse places a hospitalized patient with active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room?

Wash hands and place a high-efficiency particulate air respirator mask over the nose and mouth. R- The nurse wears a HEPA respirator mask when caring for a client with active TB. Hands are always thoroughly washed before and after caring for the client. A surgical mask will not protect against Mycobacterium tuberculosis.

The nurse teaches the mother of a child diagnosed with bacterial conjunctivitis about measure to prevent transmission of the infection. Which statement by the mother indicates a need for further teaching?

"It is all right to share towels and washcloths as long as they are bleached after use." R- Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These measures include frequent hand washing and not sharing towels and washcloths, regardless of the bleaching process.

A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the mother asks the nurse when the child can return to school, what should the appropriate response be?

"The child should be kept home until the antibiotic eye drops have been administered for 24 hours" R- Viral conjunctivitis is extremely contagious. The child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hours.

The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement?

"I should use disposable plates, forks, and knives." R- Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils or other possessions. It is not necessary to discard any of these.