Chapter 23 Prep U

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

airborne

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

airborne

The nurse is caring for a client who developed a urinary tract infection while hospitalized. How will the nurse document this condition? infectious disease contagious disease community acquired infection healthcare associated infection (HCAI)

healthcare associated infection (HCAI)

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart? stethoscope belonging to the nurse stethoscope that remains in the client's room stethoscope that hangs outside the client's room stethoscope that has been purchased by the client

stethoscope that remains in the client's room

The nurse is preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply. -Place a mask on the client. -Refuse to transport the client. -Cover the client with a sheet during transport. -Communicate about precautions with the health care team. -Prepare the transport stretcher with a clean sheet.

-Place a mask on the client. -Cover the client with a sheet during transport. -Communicate about precautions with the health care team. -Prepare the transport stretcher with a clean sheet.

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps, in the correct order, that the nurse should take when donning sterile gloves. All options must be used.

1. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4.Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

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

When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission? Airborne Contact Vector Vehicle

Contact

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing? With the double-bag technique In the client's trash container In a bag marked "biohazards" In the sharps container

In a bag marked "biohazards"

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

Incentivizing health care workers to utilize hand hygiene

A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection? Adult Child Older adult Pregnant

Older Adult

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention? Offer the student a mask. Do nothing, as precautions observed are appropriate. Teach that a gown and shoe coverings must be worn in addition to gloves. Remind the student that a fitted N95 respirator is required.

Remind the student that a fitted N95 respirator is required.

A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is: semen. blood. wound drainage. sputum.

Semen

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse? Stop and obtain appropriate PPE Complete the task, then obtain PPE Ask a colleague to perform the task Leave PPE in the room

Stop and obtain appropriate PPE

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

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

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

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? The nurse places the client in a private room with the door open. The nurse uses droplet precautions when providing care for the client. The nurse keeps visitors 3 feet away from the infected person. The nurse places the client in a private room with monitored negative air pressure.

The nurse places the client in a private room with monitored negative air pressure.

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 handrub is appropriate in which of the following situations? After completing a wound dressing Before direct contact with clients After direct contact with clients When hands are visibly soiled

When hands are visibly soiled

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? Discard the sphygmomanometer in the trash Cleanse and disinfect the sphygmomanometer Send the sphygmomanometer for sterilization Use the sphygmomanometer

Cleanse and disinfect the sphygmomanometer

To eliminate needlesticks as potential hazards to nurses, the nurse should: Place the uncapped needle on a tray and carry it to the medicine room for disposal. Immediately deposit uncapped needles into puncture-proof plastic container. Stick the uncapped needle into a Styrofoam block and deposit in a plastic container. Slide the needle into the cap and deposit it in a puncture-proof plastic container.

Immediately deposit uncapped needles into puncture-proof plastic container.

An elderly female client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate? Standard Airborne Droplet Contact

Standard

Which client would require a negative flow room? a 21-year-old man with latent tuberculosis who is postoperative following repair of a femoral fracture a 4-year-old boy with meningitis an 81-year-old man with active tuberculosis and a productive cough a 3-year-old with influenza A and a productive cough

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

The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response? "Vaccinations have been shown to contribute to autism." "Help me understand your perspective about vaccinating." "Why do you not want to vaccinate your child?" "Vaccines are the only way to halt disease."

"Help me understand your perspective about vaccinating."

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. Any partially uncovered sterile package need not be considered contaminated. A commercially packaged surgical item is not considered sterile if past expiration date. 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.

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.

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 sterile technique putting on gloves signs of healing

Hand washing

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? Surgical asepsis Increased T cells Decreased antibiotics Increased vitamin C

Surgical asepsis

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

use of one gown per person per shift

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.

The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders 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. Notify the CT department in advance so other clients and staff can be removed from the area. Question the need for the examination because the client must remain in Airborne Precautions. Request that the examination be done at the bedside.

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