TLB-Chapter 24: Asepsis and Infection Control

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? "Washing the hands with soap and water is not necessary." "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." "We only wash our hands when they are visibly soiled."

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." Explanation: By explaining that alcohol-based hand rubs are effective in preventing the spread of microbes, the nurse directly addresses the client's concern. While washing with soap and water may not be necessary, it doesn't address the client's concern. Alcohol-based hand rub is an appropriate method for hand hygiene even when you plan to touch the client.

The nurse is teaching a community group about transmission of HIV. Which client statement by a community member demonstrates that further teaching is needed? "I can catch HIV by swimming in pools." "HIV is transmitted through sexual contact." "I should not share razors or toothbrushes with others." "Someone can be exposed to this virus by sharing needles."

"I can catch HIV by swimming in pools." Explanation: HIV is not transmitted through swimming pools; further teaching is needed to clarify this point. The other client statements appropriately reflect how HIV is transmitted and do not require further teaching.

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." "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."

"Wearing an N95 respirator is critical when I care for clients in droplet precautions." Explanation: N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.

Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur. 1. Incubation period 2. Prodromal stage 3. Full stage of illness 4. Convalescent period

1. Incubation period 2. Prodromal stage 3. Full stage of illness 4. Convalescent period RATIONALE The correct sequence of the stages of infection are (1) incubation period, (2) prodromal stage, (3) full stage of illness, and (4) convalescent period.

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood? 1500 1200 2000 Wait until day 5 of treatment.

1500 Explanation: Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest.

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it. 5, 2, 7, 1, 3, 4, 6 5, 7, 2, 1, 3, 4, 6 5, 1, 2, 7, 3, 4, 6 5, 3, 4, 7, 2, 1, 6

5, 7, 2, 1, 3, 4, 6 Explanation: The expected outcome to achieve when putting on and removing sterile gloves is that the gloves are applied and removed without contamination. The nurse performs this procedure using the steps in the order listed.

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? A. "This antibiotic is the best choice since the causative organism is not known." B. "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." C. "Drug resistance can develop when the wrong antibiotic is used for pneumonia." D. "Pneumonia is usually caused by multiple organisms."

A. "This antibiotic is the best choice since the causative organism is not known." RATIONALE Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness. The side effects of all antibiotics are similar. The antibiotic can cause resistance when used excessively in the absence of infection. Pneumonia may or may not be caused by multiple organisms; however, this isn't the best answer regarding the medication.

The nurse determines that which client is at greatest risk for a wound infection? A. A two-day postoperative client B. An older adult client with dry skin C. An infant with intact skin D. A client with a urinary catheter

A. A two-day postoperative client RATIONALE The client at greatest risk for a wound infection is the two-day postoperative client, as the surgery disrupted the integrity of the skin, thereby increasing the risk for wound infection. Although older adult clients are at greater risk for infection, this client's skin is dry (versus having an open or surgical wound); thus, this client is at less risk than the postoperative client. An infant with intact skin is not at risk for a wound infection. A client with a urinary catheter is at risk for a urinary tract infection versus a wound infection.

Which client presents the most significant risk factors for the development of Clostridium difficile infection? A. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis B. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior C. A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft D. A client with renal failure who receives hemodialysis three times weekly

A. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis RATIONALE Two common factors that increase a persons risk of becoming infected with C difficle are age greater than 65 and current or recent use of antibiotics. In this scenario, old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection? A. Create an area for sterile field and opening packages B. Place water-soluble lubricant on catheter tip prior to insertion C. Wash the perineal area with soap and water D. Ensure opening port of the catheter is closed

A. Create an area for sterile field and opening packages RATIONALE Pathogens require a portal of entry to cause infection. Insertion of an indwelling urinary catheter is a sterile technique; any contamination could cause a portal of entry. Using water-soluble lubricant on catheter tip prior to insertion is correct but will not prevent an infection nor will closing the opening port. Likewise, washing the perineal area with soap and water will reduce microorganisms but will not prevent infection alone.

Which piece of personal protective equipment (PPE) should be removed first? A. Gloves B. Respirator C. Gown D. Goggles

A. Gloves RATIONALE The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.

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

A. Hold sterile objects above waist level to prevent accidental contamination. RATIONALE Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 in of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? A. Migration of leukocytes to the area of the wound B. Constriction of the small blood vessels near the wound C. Release of histamine D. Production of antibodies

A. Migration of leukocytes to the area of the wound RATIONALE During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation. Antibody production is characteristic of the immune response to infection.

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. A. Redness B. Swelling C. Pain D. Coolness E. Exudate

A. Redness B. Swelling C. Pain E. Exudate RATIONALE Cardinal signs of infection include redness (heat), swelling, pain, and loss of function. As leukocytes and neutrophils enter the area, exudate made up of fluid, cells, and inflammatory by-products may be released by the wound. Warmth and heat at the site versus coolness are a sign of infection.

Which action is the best example of a nurse donning/removing protective equipment properly? A. Removing respirator after leaving client's room B. Removing gown after leaving client's room C. Donning gown after entering client's room D. Donning respirator inside of client's room

A. Removing respirator after leaving client's room RATIONALE The best example of proper utilization of protective equipment is the removal of a respirator after leaving the client's room, as doing so prevents contact with airborne microorganisms. Gowns should be removed before leaving the client's room. Gowns and respirators should be donned prior to entering the client's room.

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

A. The fact that sterile technique was used for a given procedure RATIONALE The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection? A. Urine culture is positive for vancomycin-resistant enterococci (VRE). B. The client reports nausea and vomiting. C. The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C) D. The nurse notes the client's urine is dark yellow with sediment.

A. Urine culture is positive for vancomycin-resistant enterococci (VRE). RATIONALE Infections result from pathogens that produce illness after invading body tissues and organs. The client with the indwelling urethral catheter is at risk for developing an infection. The finding that would most likely indicate an infection would be a positive result. Nausea and vomiting, a fever, and dark yellow urine with sediment are possible signs of an infection, but each of these findings alone does not confirm an infection.

In which situation is an alcohol-based rub not the appropriate option for hand hygiene? A. When the nurse's hands are visibly soiled B. When the nurse anticipates contact with the client's skin C. When the nurse leaves the room of an immunocompromised client D. When the nurse is caring for a client with an active infection

A. When the nurse's hands are visibly soiled RATIONALE Alcohol-based handrubs may be used if hands are not visibly soiled or have not come in contact with blood or body fluids. They should be used before and after each client contact, or when in contact with surfaces in the client's environment. Handwashing is required before eating or after using the restroom.

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an): A. bacteria. B. virus. C. fungi. D. protozoa.

A. bacteria. RATIONALE Bacteria may be transmitted through air, food, water, soil, vectors, or sexual activity.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? A. changing the soiled dressing B. wearing clean unsterile gloves C. when changing the dressing D. isolating the client's belongings E. applying a face mask with shield

A. changing the soiled dressing RATIONALE A reservoir is a place where microbes grow and reproduce. A soiled dressing can be a reservoir for microbes to breed. Changing the soiled dressing reduces the microbes at the wound. Wearing gloves, isolating client's belongings, and applying a face mask decrease the transmission of infection.

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? A. contact B. vehicle C. droplet D. airborne

A. contact RATIONALE Contact may be either direct or indirect.

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? A. fold soiled side to the inside and roll with inner surface exposed B. fold soiled side to the outside and roll with outer surface exposed C. fold soiled side to the inside and roll with outer surface exposed D. fold soiled side to the outside and roll with inner surface exposed

A. fold soiled side to the inside and roll with inner surface exposed RATIONALE To dispose of the gown, the nurse will fold the soiled side to the inside and roll with the inner surface exposed. The other answers are incorrect.

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 can't transmit the virus other people if I shake their hands." B. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." C. "I received a blood transfusion in 1989, which could be a factor in contracting the disease." D. "I may have gotten the virus when I got a tattoo while I was in prison."

B. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." 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 would the nurse consider the most infectious? A. A client who is in the incubation period B. A client who is in the prodromal stage C. A client who is in the full stage of illness D. A client who is in the convalescent period

B. A client who is in the prodromal stage RATIONALE The client is most infectious during the prodromal stage of the illness. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the client often is unaware of being contagious. As a result, the infection spreads. The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the client's general condition. The signs and symptoms disappear, and the person returns to a healthy state.

Which mask should the nurse don when caring for a client with tuberculosis? A. Low-efficiency particulate air (LEPA) B. Filtered respirator C. Surgical mask D. No mask is needed

B. Filtered respirator RATIONALE When caring for a client with tuberculosis, the nurse should don a filtered respirator mask to filter the inspired air. A surgical mask, also known as a procedure mask, is intended to be worn by health care professionals during surgery and during nursing to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose. Low-efficiency particulate air (LEPA) masks are not used in health care.

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply. A. Sterile gloves B. Nonsterile gloves C. Mask D. Gown E. Hand hygiene

B. Nonsterile gloves E. Hand hygiene RATIONALE When taking vital signs on a client after surgery, the nurse should practice hand hygiene. There is no need to use a gown or mask unless the client is diagnosed or suspected to have a transmittable infection. Since it is an aseptic versus sterile procedure, the nurse should use nonsterile gloves.

The nurse is caring for an older adult client in a long-term care facility who has been previously alert and oriented. The client has become agitated and disoriented to time and place. The client is afebrile. What action by the nurse may assist with the determination of a causative factor in the client's condition? A. Obtain a psychiatric consultation, because the client may be psychotic B. Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection C. Obtain a blood pressure reading, because the client may be hypertensive D. Give the client a meal, because the client may be hungry

B. Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection RATIONALE Many older clients do not mount a febrile response to infection, and increasing agitation or confusion in response to infection may be dismissed as normal signs of aging. It is likely the client may have developed a urinary tract infection, which is a common cause of change in mental status in older adults. Hypertension generally does not cause a change in orientation or agitation, and the client with hypertension may not display any symptoms at all. Psychosis or delirium does not usually develop for no reason in a client who has been previously alert and oriented. Hunger does not result in behavior that is disoriented or agitated.

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 after touching the client's surroundings. B. The nurse removes her gown and then removes her gloves. C. The nurse performs hand hygiene before putting on gloves. D. The nurse applies nonmedicated hand cream after performing hand hygiene.

B. The nurse removes her gown and then removes her gloves. 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.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? A. Use a private room with the door closed at all times. B. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. C. Place client in a private room that has monitored negative air pressure. D. Ensure that hard surfaces in the room are disinfected at least once per day.

B. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. RATIONALE The nurse should wear PPE upon entry into the room for all interactions that may involve contact with the client. The nurse should use a private room, if available, and the door may remain open. Placing a client in a private room that has monitored negative air pressure is appropriate for airborne infections. Frequent disinfecting is not indicated.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene? A. washes hands for 15 seconds B. has manicured nails that are 1-in. (2.5-cm) long C. has wedding band on ring finger D. drains hands lower than the wrist

B. has manicured nails that are 1-in. (2.5-cm) long RATIONALE Fingernails should be less than ¼-in. (0.625-cm) long, as this reduces the reservoir for flora to accumulate and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. A flat wedding band is acceptable. Allowing the hands to drain lower than the wrist promotes gravity drainage.

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds: A. "You will likely have an outbreak due to the stress of labor and delivery." B. "Have you discussed this with your physician?" C. "You may have infection in your birth canal that you are unaware of." D. "A cesarean section will prevent a herpes outbreak."

C. "You may have infection in your birth canal that you are unaware of." RATIONALE Viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? A. Pour the liquid onto gauze on the sterile field until the gauze is moist. B. Pour the liquid into the cap of the bottle and dip the gauze as needed. C. Pour the liquid into a sterile container within the sterile field. D. Pour the liquid into the palm of a sterile gloved hand for use.

C. Pour the liquid into a sterile container within the sterile field.

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care? A. Dip the IV catheter into an antiseptic before use. B. Clean the site with a disinfectant. C. Use a sterile intravenous catheter. D. Wear a mask and gown for the procedure.

C. Use a sterile intravenous catheter. RATIONALE Any item entering sterile tissues or the vasculature must be sterile. Therefore, an IV catheter must be sterile. It should not be dipped in an antiseptic before use. A chemical used on lifeless objects is called a disinfectant, whereas one used on living objects is an antiseptic. The nurse would clean the IV site with an antiseptic, not a disinfectant, before insertion. An IV insertion does not require the nurse to wear a mask and gown.

For which client would the use of standard precautions alone be appropriate? A. a client with diphtheria who needs p.m. care B. a client with TB who needs medications administered C. an incontinent client in a nursing home who has diarrhea D. a child with chickenpox who is treated in the emergency room

C. an incontinent client in a nursing home who has diarrhea RATIONALE Standard precautions apply to blood and all body fluids, secretions, and excretions except sweat. Transmission-based precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as is the case in answers A, B, and D.

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions? A. remind others to use a mask when caring for this client B. recognize that this type of infection requires droplet precautions C. be sure that there are gloves of various sizes and gowns for use D. include a N95 respirator mask for health care staff entering the room

C. be sure that there are gloves of various sizes and gowns for use RATIONALE All health care workers and visitors should don a gown and gloves prior to entering the client's room. These bacteria are not transmitted by droplet. An N95 respirator mask is not required for this client.

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? A. standard precautions B. droplet precautions C. contact precautions D. airborne precautions

C. contact precautions RATIONALE VRE is transmitted via contact. The nurse caring for a client with VRE should implement contact precautions which is wearing a gown and gloves while in the client's room. Droplet precautions include wearing a surgical mask while in the room. Special masks for airborne precautions are used for, but are not limited to: measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis. Standard precautions are used with all clients.

Which is not appropriate regarding the use of gowns as PPE? A. use of paper or cloth gowns B. donning a gown when splashing C. use of one gown per person per shift D. use of a new gown each time the nurse enters the room

C. use of one gown per person per shift RATIONALE A new gown should be used by the nurse each time the nurse enters the room.

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: A. decreased B. elevated C. within normal limits D. stable

C. within normal limits RATIONALE A normal white blood cell count is 5,000 to 10,000 cells/mm3.

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? Client with a urinary catheter Clint with an intravenous catheter Client with a surgical wound Client with a diabetic foot ulcer

Client with a urinary catheter Explanation: While all of the clients are at risk for infection, the client at the greatest risk is the one with a urinary catheter. This is because catheter-associated urinary tract infections are the most common type of hospital-acquired infections, accounting for more than 30% of HAIs in acute care hospitals. Most hospitalized clients receive an intravenous catheter. Clients go to the hospital for surgery so a surgical incision is expected. Clients with a diabetic foot ulcer may be admitted to the hospital for intravenous antibiotics.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety? A. The nurse places the client in a private room with the door open. B. The nurse uses droplet precautions when providing care for the client. C. The nurse keeps visitors 3 feet away from the infected person. D. The nurse places the client in a private room with monitored negative air pressure.

D. The nurse places the client in a private room with monitored negative air pressure. RATIONALE When a client is diagnosed with tuberculosis it is important for the nurse to remember that the client should be placed in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The nurse must wear the appropriate respirator when caring for the client, but visitors must wear masks. Simply being 3 feet away will not keep the visitor from being exposed to the client. The nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis.

What is the most common client site for development of healthcare-associated infections (HAI)? A. Surgical wound B. Respiratory tract C. Bloodstream D. Urinary tract

D. Urinary tract RATIONALE The urinary tract is the most common site for healthcare-associated infections (HAI).

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? A. remove the garments that are most contaminated B. make contact between two contaminated surfaces C. make contact between two clean surfaces D. handwashing before leaving the client's room

D. handwashing before leaving the client's room RATIONALE The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath.

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense? A. the cell-mediated immune response B. early intervention with antibiotics C. staying home when sick D. intact skin and mucous membranes E. low levels of flora

D. intact skin and mucous membranes RATIONALE The first line of defense against infection is intact skin and mucous membranes covering body cavities.

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? No action is needed. Don another pair of sterile gloves. Complete a sentinel event report. Notify the primary care provider.

Don another pair of sterile gloves. Explanation: If the nurse realizes that the sterile field is broken, the most appropriate response is to stop and don another pair of sterile gloves. A sentinel event has not occurred, and calling the PCP is unnecessary. Doing nothing and moving forward with foley insertion places the client at greater risk of infection and is not an appropriate action. Reference:

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply. Nurses need only apply clean gloves when performing or assisting with invasive client procedures. During some care activities for an individual client, nurses may need to change gloves more than once. Nurses may use a waterproof gown more than one time. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse.

During some care activities for an individual client, nurses may need to change gloves more than once. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. Explanation: Several examples represent the proper use of personal protective equipment in a health care agency. First, during some care activities for an individual client, nurses may need to change gloves more than once. Nurses should remove PPE at the doorway or in an anteroom except, for the respirator. The nurse should remove a gown by unfastening ties, if at the neck and back, and allow the gown to fall away from the shoulders. The nurse would apply clean gloves for most care activities, not just when assisting or performing an invasive client procedure. A waterproof gown is to be used only once. Nurses cannot wear a mask around the neck when not being worn nor can it be brought back over the nose and mouth for reuse.

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

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. Explanation: 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.

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

Fungi Explanation: Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes.

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 Localized heat Purulent or malodorous drainage Inside edges of the ulcer appear to be drawing together Scabs forming over the ulcer

Pain with redness and swelling Localized heat Purulent or malodorous drainage Explanation: Signs of infection of the client's foot ulcer that the nurse includes in discharge teaching include redness, swelling, and pain; localized heat; and purulent or malodorous drainage. If the inside edges of the ulcer appear to be drawing together and/or if scabs are forming over the ulcer, the ulcer is likely to be healing.

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

Perform hand hygiene Explanation: 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.

The nurse prepares for a sterile procedure. What action does the nurse perform first? Put on personal protective equipment, if required. Perform hand hygiene with alcohol-based hand rub. Identify the client the procedure is prescribed for. Place all the necessary supplies in the room.

Perform hand hygiene with alcohol-based hand rub.

The nurse is caring for a client with full-thickness (third-degree) burns. What aseptic intervention(s) would the nurse implement for this client when admitted to the general medical unit? Select all that apply. Place the client in a private room with protective isolation. Instruct all staff, the client, and family members to practice strict and meticulous hand washing. Restrict visitors to family members who are not ill. Permit flowers only if the containers have plastic wrapping around the base. Allow the client to only ingest fresh fruits or vegetables, no canned or prepackaged food products.

Place the client in a private room with protective isolation. Instruct all staff, the client, and family members to practice strict and meticulous hand washing. Restrict visitors to family members who are not ill. Explanation: Clients with extensive burns are at high risk for infection. Such clients are placed in private rooms on protective isolation. To reduce the risk of infection, everyone practices strict and meticulous hand washing, including the client and his or her family. Visitors should be only family members who are not ill. Flowers, either in water or soil, are not permitted because soil harbors fungus and standing water supports the growth of microorganisms. All of these measures help to ensure that the client's environment stays as free from pathogens as possible, thereby decreasing the chance of infection. No fresh fruits or vegetables are allowed, only canned and cooked food.

Which interventions will be most effective in preventing the spread of infection in the health care setting? Sterilizing all client supplies Frequent room air exchanges Proper handwashing Donning gloves for all client care

Proper handwashing Explanation: The most effective means of preventing the spread of infection in the health care setting is through proper handwashing. Sterilizing all client supplies is not possible nor would it omit bacterial transmission on the hands of health care workers. Frequent room air exchanges are important if a client has an illness, such as influenza or tuberculosis. Donning gloves for all client care helps to protect the nurse and client from contaminants but is not the most effective means of preventing the spread of illness. Reference:

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply. The nurse's back is facing the sterile field. The nurse keeps hands above waist level while donning sterile gloves. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. The nurse disposes of an opened container of sterile saline after half is used.

The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. Explanation: Principles of surgical asepsis include never turning one's back on a sterile field. The nurse should avoid talking, coughing, or sneezing over the field and keep sterile objects above waist level. Sterile objects may only be touched by other sterile objects. All opened bottles of liquid should be discarded after use.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? Use a private room with the door closed at all times. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. Place client in a private room that has monitored negative air pressure. Ensure that hard surfaces in the room are disinfected at least once per day.

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. Explanation: The nurse should wear PPE upon entry into the room for all interactions that may involve contact with the client. The nurse should use a private room, if available, and the door may remain open. Placing a client in a private room that has monitored negative air pressure is appropriate for airborne infections. Frequent disinfecting is not indicated.

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

droplet Explanation: Influenza is transmitted through droplets; therefore droplet contact precautions are appropriate.

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply. infectious disease communicable disease noncommunicable disease contagious disease health care-associated infection (HCAI)

infectious disease communicable disease contagious disease Explanation: Infections disease, communicable disease, and contagious disease describe this type of illness. A noncommunicable disease is caused by food or environmental toxin. Health care-associated infections are acquired within a healthcare facility.

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action? to protect the integrity of the nurse's immune system to prevent the nurse from developing disease to eliminate disease-producing organisms from the nurse's skin to sterilize the nurse's hands to prevent infection

to eliminate disease-producing organisms from the nurse's skin Explanation: The purpose of hand hygiene is to protect clients from infection by removing microorganisms from the skin. This action directly addresses client safety but is not directly related to effectiveness of care. Hand hygiene protects the nurse from infection but the primary purpose is to protect clients. Hand hygiene greatly reduces the number of microorganisms on the skin but does not result in sterile skin surfaces.

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? wash the area with soap and water fill out a risk management form find out who left the scalpel blade on the procedure tray go to employee health for testing

wash the area with soap and water Explanation: 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 immediate first aid care. 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.