Chapter 24 - Asepsis and Infection Control

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. 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 the door open.

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

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?' a 12-year-old girl an 80-year-old woman a 2-year-old toddler an 18-month-old infant

an 80-year-old woman Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerable to infection, so the 80-year-old woman is the client most at risk for infection. A neonate is defined as a child less than 4 weeks of age. An adolescent is a child aged 9 to 12 years. A toddler is a child who is 12 to 36 months or 1 to 3 years of age.

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 change to standard precautions change to contact precautions continue with droplet precautions

change to airborne precautions Tuberculosis is transmitted via the air, so airborne precautions are required. The other answers are incorrect.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? wear a mask and gown in the client's room perform hand hygiene before and after entering the client's room avoid direct contact with the client wear gloves when touching the client

perform hand hygiene before and after entering the client's room Hand hygiene is the most important way to prevent transmission of infection.

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? "I can leave my room any time I want as long as I wear a mask." "Any staff who enters my room will be wearing personal protective equipment (PPE)." "My personal belongings should remain in the room until I am discharged." "I will tell my visitors to keep their distance from me."

"I can leave my room any time I want as long as I wear a mask." The client on droplet precautions should only leave the room when necessary and wear a mask. The nurse should limit the client's movement outside the room. Visitors should remain 3 feet (1 meter) from the client. Anything that enters the isolation room should remain until discharge. Any staff who enters the room will wear PPE.

A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection? 18,000 cells/mm 8,000 cells/mm 5,000 cells/mm 10,000 cells/mm

18,000 cells/mm The leukocyte count of 18,000 cells/mm indicates infection in the client. A rise in circulating white blood cells (WBCs) above the normal adult range of 5,000 to 10,000 cells/mm is called leukocytosis. A count of 8,000 cells/mm, 5,000 cells/mm, and 10,000 cells/mm would be considered normal.

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? Avoid touching the outer surfaces of the gown. Perform hand hygiene before removing the gown. Remove the gown before removing gloves. Remove the gown immediately after exiting the room.

Avoid touching the outer surfaces of the gown. When removing a gown, it is important to touch only the inside of the gown. The gown should be removed inside the room and after removing gloves. Hand hygiene should be performed after removal.

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

Client with a urinary catheter 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.

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

Don another pair of sterile gloves. 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.

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

Fungi 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.

What is the second line of defense in microbial invasion? Infection Inflammation Disability Disease

Inflammation The inflammatory response makes up the second line of defense to microbial invasion.

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client? Vancomycin-resistant enterococci and urinary tract infection Coronary artery bypass grafting MRSA in the wound Clostridium difficile and colitis

MRSA in the wound In many situations, clients with like infections can be placed together. The presence of similar causative microorganisms negates the risks of cross-contamination. Each of the other listed clients would encounter a risk for MRSA.

A nurse at the health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action(s) is appropriate by the nurse when using masks? Select all that apply. Avoid touching the mask once it is in place. Discard used masks into a regular wastebasket. Touch only the strings of the mask during removal. Position the mask so that it covers the nose and mouth. Change the mask if it becomes damp.

Position the mask so that it covers the nose and mouth. Avoid touching the mask once it is in place. Change the mask if it becomes damp. Touch only the strings of the mask during removal. The nurse should avoid touching the mask once it is in place because touching the mask transfers microorganisms to the hands. The mask should be changed every 20 to 30 minutes or when it becomes damp, to preserve its effectiveness. The nurse should touch only the strings of the mask during removal to prevent transfer of microorganisms to the hands. The mask should be positioned over the nose and the mouth to provide a barrier to nasal and oral ports of entry. The nurse should discard used masks into a lined or waterproof waste container and not a regular wastebasket.

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? Allow many family members to visit at once. No special precautions are required. Deliver flowers and balloons to the room. Remove fresh fruit from the room.

Remove fresh fruit from the room. Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.

What is an accurate guideline for the use of PPE? Substitute personal glasses for protective eyewear, if desired. Replace gloves if they are visibly soiled. When wearing gloves, work from "dirty" areas to "clean" ones. Put on PPE after entering the client's room.

Replace gloves if they are visibly soiled. If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas.

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 normal flora proliferated because of a nutritional deficit The resident microorganisms mutated and became virulent The client's immune system became further weakened The client's normal flora began producing spores

The client's immune system became further weakened Unless the supporting host becomes weakened, normal flora remains controlled. If the host's defenses are weakened, as in cases of HIV/AIDS, even benign microorganisms can cause opportunistic infections. This phenomenon is not due to mutations, spore production or the direct effects of a nutritional deficit.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement? Restrict visitors to public places. Culture all residents and staff. Review the current infection control protocols. All new residents are prescribed antibiotics.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement? The nurse manager that notes an increase in infection rates should first review the current infection control protocols. Reviewing the protocols can identify if the protocols are appropriate and being implemented by the staff. Prescribing antibiotics to all new residents will not decrease infections rates, but may increase the rate of antibiotic resistant bacteria. Culturing all residents and staff would identify infection, but not decrease the rates. Restricting visitors would not decrease rates.

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

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

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? The client reports nausea and vomiting. Urine culture is positive for vancomycin-resistant enterococci (VRE). The nurse notes the client's urine is dark yellow with sediment. The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C)

Urine culture is positive for vancomycin-resistant enterococci (VRE). 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.

A nurse instructs a new mother on immunizations. An immunization produces: antigen immunity humoral immunity active immunity passive immunity

active immunity Active immunity can be produced by vaccination. Vaccination is the process of injecting weakened or killed organisms into a person, stimulating antibody production.

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

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

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

be sure that there are gloves of various sizes and gowns for use 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 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? droplet airborne contact vehicle

contact Contact may be either direct or indirect.

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: increased effectiveness of phagocytosis. decreased cellular immunity. decreased susceptibility to infection. increased humoral immunity response.

decreased cellular immunity. As a person ages, there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to infection.

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

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

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control? handwashing sterile gloves clean environment sterile gauze

handwashing A person's defenses may be compromised when exposed to the health care system, for a multitude of reasons. Healthcare-associated infections (HAIs) often result from poor hand hygiene and invasive procedures occurring within the health care system. HAIs occur frequently in skilled nursing facilities (SNF), jails, and other residential facilities where auxiliary staff have varied levels of training to care for high-risk individuals.

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply. fever absence of pain increased respiratory rate lymph node enlargement decreased pulse rate

increased respiratory rate lymph node enlargement fever Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, and lymph node enlargement.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? with a client with a myocardial infarction with a client with pneumonia into a private room with another client with a draining wound

into a private room The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

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? providing gentle oral care encourage wearing a mask when out of the room avoiding razors with blades obtaining rectal temperatures

obtaining rectal temperatures Rectal temperatures should be avoided to prevent trauma and subsequent infection. The nurse should encourage the client to wear a mask to prevent airborne infection. Providing gentle oral care and avoiding razors helps to keep the membranes intact and prevent infection.

Any microorganism capable of disrupting normal physiologic body processes is a: virus. bacterium. pathogen. fomite.

pathogen Microorganisms that are capable of harming people are called pathogens or pathogenic.

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the: prodromal period acute period convalescent period incubation period

prodromal period The prodromal period is characterized by nonspecific symptoms such as nausea, fever, general weakness, or aches and pains.

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? applies a mask with face shield performs hand hygiene before donning gloves asks the client to state name and date of birth removes gloves and walks out of the room

removes gloves and walks out of the room The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used as barriers to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients. Asking the client to state his or her name and date of birth is important to make sure the specimen is collected with the correct laboratory label. To protect the UAP from direct contact with the urine, a face mask is indicated.

A nurse provides care for an adolescent who is diagnosed with mononucleosis. Which crucial information does the nurse include in client education about the condition? Select all that apply. - The Epstein-Barr virus (EBV) causes mononucleosis. - Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. - Mononucleosis is called the "kissing disease" so refrain from kissing. - Cover coughs or sneezes to reduce the risk of spreading infection. - It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact.

- It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. - Mononucleosis is called the "kissing disease" so refrain from kissing. - Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. - Cover coughs or sneezes to reduce the risk of spreading infection. - The Epstein-Barr virus (EBV) causes mononucleosis. The Epstein-Barr virus (EBV), along with cytomegalovirus (CMV), causes a form mononucleosis that spreads through bodily fluids, with the most common way being through saliva. Mononucleosis can be spread by sharing food, drinks, or silverware with a person who has it, or if an infected person coughs or sneezes near others. EBV can be spread through various body fluids including saliva, blood, and semen so it can be spread by kissing and sexual contact.

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? - 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. - 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. When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

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. - Pour the liquid into the cap of the bottle and dip the gauze as needed. - Pour the liquid onto gauze on the sterile field until the gauze is moist. - Pour the liquid into the palm of a sterile gloved hand for use.

Pour the liquid into a sterile container within the sterile field. The solution container should be held outside the edge of the sterile field and poured steadily from a height of 4 to 6 inches into a sterile container previously added to the sterile field and positioned at the side of the sterile field. This assures minimal splashing, as moisture contaminates the sterile field, and maintains sterility of the bottle and solution.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. microbial precautions body fluid precautions airborne precautions respiratory precautions droplet precautions contact precautions

airborne precautions droplet precautions contact precautions The CDC has three general precautions: contact, droplet, and airborne. Use contact precautions for clients with known or suspected infections that represent an increased risk for contact transmission. Use droplet precautions for clients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a client who is coughing, sneezing, or talking. Use airborne precautions for clients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster). Respiratory, microbial, and body fluid precautions are embedded in the three 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: increased humoral immunity response. decreased susceptibility to infection. decreased cellular immunity. increased effectiveness of phagocytosis.

decreased cellular immunity. As a person ages, there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to 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? vehicle droplet contact airborne

contact Contact may be either direct or indirect.

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

contact precautions 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.