Chapter 24 Asepsis

The nurse is caring for a client that requires a dressing change. When applying the principles of asepsis, what aspect of care should the nurse include?

Blood and body fluids are major reservoirs for microorganisms.

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.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?

Exogenous healthcare-associated

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

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

The nurse is caring for a client with a cough and copious secretions. Before providing care, the nurse observes the licensed practical nurse (LPN) standing outside the client's room and donning personal protective equipment as shown above. How should the nurse best interpret the LPN's actions?

The LPN is donning personal protective equipment appropriately.

Which should be documented by the nurse?

The fact that sterile technique was used for a given procedure

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 monitored negative air pressure.

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.

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?

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

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)?

airborne precautions droplet precautions contact precautions

Standard precautions apply to...

blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

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

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?

one that remains in the clients room

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?

place the specimens into plastic biohazard bags

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

Which client would the nurse consider the most infectious?

A client who is in the prodromal stage

Which practice is a correct application of infection control practices?

A nurse performs hand washing each time the nurse removes a pair of gloves.

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

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

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.

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?

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

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

client with urinary catheter

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?

contact precautions

The nurse is caring for an older adult with influenza. Which precautions will the nurse begin?

droplet

Which piece of personal protective equipment (PPE) should be removed first?

gloves

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

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

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 client care and interaction

A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health?

Hepatitis B Hepatitis C HIV

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

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?

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

The nurse suspecting that a client has an infected surgical wound should assess for which sign?

Redness Swelling Pain Exudate

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 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?

Obtain a urine specimen, as ordered, because the client may have developed a urinary tract

The nurse prepares for a sterile procedure. What action does the nurse perform first?

Perform hand hygiene with alcohol-based hand rub.

The nurse is preparing to provide wound care for a client who is on droplet precautions. Place the following steps in the correct order that the nurse should take.

Perform hand hygiene. Put on gown, with the opening in the back and tie gown securely at neck and waist. Apply mask with face shield, secure ties at the middle of the head and neck. Put on clean disposable gloves.

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?

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.

After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste?

Used syringe with attached needle Used fingerstick lancet

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

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?

intact skin and mucous membranes

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

keeping sterile field above waist level