Ch. 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?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism? 17

"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.

-"If someone is exposed to my blood, I may transmit the virus to him or her." -"I may transmit the virus to my child during pregnancy and childbirth." -"I may transmit the virus if I share needles with another person."

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply.

-The nurse is going from one room to another to introduce themself at the start of the shift. -The nurse has entered the client's room to adjust settings on the intravenous pump. -The nurse has just completed documentation and is entering another client's room.

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.

-fever -increased respiratory rate -lymph node enlargement

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

1. Carefully open inner package 2. With the thumb and forefinger 3. Place the fingers of the gloves hands 4. Adjust gloves on both hands

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

1.Turn on faucet 2. Wet the hand 3.Apply soap 4.Wash palms 20sec 5.Pat Dry 6.Turn off faucet w/ paper towel

A nurse is reviewing the laboratory test results of a client who is at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis?

3.2 mmol/L

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?

A= Assessment

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?

Airborne

The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?

Assess client's pain level and manage pain accordingly.

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?

Cleanse and disinfect the sphygmomanometer.

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

Client receiving chemotherapy

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?

Client with a urinary catheter

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

Create an area for sterile field and opening packages

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub.

Which mask should the nurse don when caring for a client with tuberculosis?

Filtered respirator

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

Fungi

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

Hand hygiene is needed after contact with objects near the client.

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection?

Healthcare-associated infection (HAI)

The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?

Perform hand hygiene.

The nurse is assigned to clean a client's wound before applying a sterile dressing. Which action by the nurse demonstrates maintaining a sterile field?

Pouring the sterile solution slowly from 6 in (15 cm) above the container.

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

Which of the following are considered the building blocks of the immune system?

T lymphocytes

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 client's immune system became further weakened

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

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles?

The nurse removes her gown and then removes her gloves.

Surgical asepsis is defined as:

absence of all microorganisms.

Personal protective equipment for use with standard precautions includes which items? Select all that apply.

face mask disposable gloves eye protection fluid-repellent gown

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?

hand washing

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?

intravenous antibiotic administration

The physician orders a serum trough drug level for a client who is receiving antibiotic therapy. The client is receiving the drug every 6 hours: at midnight, 6 a.m., noon and 6 p.m. The nurse anticipates that the specimen would be obtained:

just before the 6 a.m. dose.

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen

The most common infection in children is:

respiratory.

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?

virus

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

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:

within normal limits

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?

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

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?

"This antibiotic is the best choice since the causative organism is not known."

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?

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

A nurse is reviewing a client's complete white blood cell (WBC) count and differential. The nurse determines that the client is experiencing neutropenia based on which absolute neutrophil count?

800 cells/mm3

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?

Don another pair of sterile gloves.

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.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract

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?

Incentivizing health care workers to utilize hand hygiene

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

An operating room (OR) nurse on the facility's infection control team notices that a coworker in the OR is wearing artificial nails. What is the appropriate action/response by the nurse?

Remind coworker that artificial nails increase infections

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from the room.

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

When hands are visibly soiled

Which client would require a negative flow room?

an 81-year-old man with active tuberculosis and a productive cough

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

an older adult client with a history of heart failure

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?

changing the soiled dressing

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?

contact precautions

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:

decreased cellular immunity.

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?

inserting an arm within each sleeve while touching the outer surface of the gown

A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client?

obtaining rectal temperatures

A group of students is reviewing information about cellular and humoral immunity. The group demonstrates understanding of these concepts when they identify what as a function of cellular immunity?

reactivate if the same antigen reappears

Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care?

skin is dry and intact

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 who is 48-hours postsurgical procedure

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

Greater than 40.5°C

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne

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 airborne precautions