Chapter 24: Asepsis and Infection Control - ML4
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. The LPN should don personal protective equipment inside the client's room. Gloves should be worn while putting on a mask and goggles. The LPN should put on goggles prior to putting on the mask.
The LPN is donning personal protective equipment appropriately. Explanation: This nurse is applying PPE correctly; PPE should be donned before entering this client's room, and it is appropriate to put on the mask before the goggles. Gloves are donned after the mask and goggles. Reference: Chapter 24: Asepsis and Infection Control - Page 625
A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate? The client demonstrates the proper technique for hand hygiene. The client will state how to safely take the prescribed antibiotic. The client will verbalize measures appropriate to minimize infection transmission. The client will identify signs and symptoms of worsening infection.
The client will state how to safely take the prescribed antibiotic. Explanation: The client's knowledge deficit is related to antibiotic therapy. Therefore, the most appropriate outcome would be that the client states how to take the prescribed antibiotic. Identifying signs and symptoms of infection would relate to a nursing diagnosis of Deficient Knowledge related to infection. Verbalizing measures to minimize risk and demonstrating proper hand hygiene would be appropriate for a nursing diagnosis of Knowledge Deficit related to infection control or transmission, or possibly a nursing diagnosis of Risk for Infection.
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 normal flora began producing spores The client's immune system became further weakened
The client's immune system became further weakened Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 600
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? decreased antibiotics increased T cells increased vitamin C surgical asepsis
surgical asepsis Explanation: Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment. Reference: Chapter 24: Asepsis and Infection Control - Page 609
The nurse is creating a care plan for a client. Risk for Infection is the identified problem. Which situation supports this problem? the client who is on contact precaution for Clostridium difficile a client whose wound has exudate drainage a cancer client who is in remission for the past year the client with a urinary catheter inserted at the emergency department
the client with a urinary catheter inserted at the emergency department Explanation: In the diagnosis Risk For Infection, the client is vulnerable to invasion and multiplication of pathogenic organisms which may compromise health. Risk for Infection relates to a foreseen problem that can cause infection if prevention is not initiated, followed, and maintained. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Chapter 23: Asepsis and Infection Control, 2015: pp. 536-537. Chapter 24: Asepsis and Infection Control - Page 536-537
A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client? changing gloves after contact with the client's infective material wearing a mask when working within 3 feet (1 m) of the client washing hands with an antimicrobial agent or waterless antiseptic agent using a special high-filtration particulate respirator
wearing a mask when working within 3 feet (1 m) of the client Explanation: Rubella spreads through droplet transmission; therefore, the nurse should wear a mask when working within 3 feet of the rubella client as a precaution against droplet transmission. Changing gloves after contact with the client's infective material and washing hands with an antimicrobial agent or waterless antiseptic agent are contact precautions used for clients with diseases that spread through contact transmission. Using a special high-filtration particulate respirator is an airborne precaution followed in cases of clients with active tuberculosis. Reference: Chapter 24: Asepsis and Infection Control - Page 615
The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. Exudate Redness Coolness Swelling Pain
all exept: coolness Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 600
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? a 2-year-old toddler an 18-month-old infant an 80-year-old woman a 12-year-old girl
an 80-year-old woman Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 601
A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: 2 days. 5 days. 3 days. 4 days.
3 days. Explanation: Usually when a client is being screened for a parasitic infection, stool specimens are collected daily for 3 days. Parasites lay eggs in the GI tract that can be detected on examination. Moving organisms can easily be detected in fresh specimens.
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 continue with droplet precautions change to contact precautions change to standard precautions
change to airborne precautions Explanation: Tuberculosis is transmitted via the air, so airborne precautions are required. The other answers are incorrect. Reference: Chapter 24: Asepsis and Infection Control - Page 615
Which term describes foreign particles that enter a host and stimulate the body's immune response? Macrophage Antigen Antibody Phagocyte
Antigen Explanation: Antigens are foreign particles, such as microbes, that enter a host.
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." "Washing the hands with soap and water is not necessary." "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. Reference: Chapter 24: Asepsis and Infection Control - Page 605
The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team? "You should remove your mask before you remove your gown." "it's best to let me assist you with removal of your gown." "Whenever possible, remove your PPE outside the client's room." "Avoid touching the outside of your gown when removing it."
"Avoid touching the outside of your gown when removing it." Explanation: To prevent contamination, the outside of a gown should not be handled during removal. Gown removal should take place in the client's room, and the mask is not normally removed first. Assistance is not usually required with removal of a gown. Reference: Chapter 24: Asepsis and Infection Control - Page 627
The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor? "If you wash your hands before coming in contact with your friend you will prevent infection during your visit." "Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." "You should not visit your friend if you have an infection of any kind because your friend may also get sick." "As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend."
"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." Explanation: Visitors with respiratory infections need to wear a mask until their symptoms have subsided. The other options do not control transmission of airborne or droplet infections. Hand hygiene is appropriate and should be encouraged but used alone it won't prevent the spread of an airborne or droplet infection. Reference: Chapter 24: Asepsis and Infection Control - Page 612
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? "Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it." "Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." "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." "If you do not wear gloves you will also get the infection."
"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." Explanation: Contact precautions, which are not optional, block transmission of pathogens by direct or indirect contact. Explaining that the loved-one understands is not teaching information. Educating the visitor about drug-resistant infections is important but does not explain how to prevent transmission of the infection. Telling the visitor that he or she will get the infection if the visitor does not wear gloves is incorrect, the visitor is at a greater risk of getting and spreading the infection. Wearing gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing. Reference: Chapter 24: Asepsis and Infection Control - Page 615
The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate? "Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding." "If you notice that the newborn has a fever, then you need to have him seen by the doctor fairly quickly." "It usually takes about a month or two until the baby's immune system to become completely functional." "Infections in newborns are rare because they have little difficulty localizing infections"
"Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding." Explanation: The immune system does not become fully operational until an infant reaches about 6 months of age (Shaw, Thalapial, Shaw, & Malla, 2007). Before then, the infant's resistance to infection comes from the antibodies passed by way of the placenta and breast milk. Newborns have difficulty localizing infections (preventing the spread of organisms from the site of contact). Their phagocytes have difficulty trapping microbes, and they do not produce enough antibodies. Newborns have immature thermoregulatory mechanisms and do not become febrile
The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?
A draining abscess poses an infection control risk that is sufficiently addressed with contact precautions. Because there is no obvious risk of airborne or droplet transmission, masks, goggles, and face shields are not warranted. Reference: Chapter 24: Asepsis and Infection Control - Page 609
What is an accurate guideline for removing soiled gloves after client care? Use the nondominant hand to grasp the opposite glove, near the cuffed end on the outside exposed area. Remove the glove on the nondominant hand by pulling it straight off, keeping the contaminated area on the outside. After removing the first glove, slide the fingers of the ungloved hand between the remaining glove and the wrist and pull the glove straight off, with the contaminated area on the outside. After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.
After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. Explanation: When removing gloves, the dominant hand is used to grasp the opposite glove near the cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated area on the inside. The removed glove is held in the remaining gloved hand. Then, the fingers of the ungloved hand are slid between the remaining glove and the wrist, and the glove is pulled off and inverted. Reference: Chapter 24: Asepsis and Infection Control - Page 633
After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter? Mixture of soap and alcohol-based hand rub techniques Soap and water hand washing technique Alcohol-based hand rub Scrubbing hands with soap, water, and brush
Alcohol-based hand rub Explanation: Alcohol-based hand rubs 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. Indications for washing hands with soap and water include visibly dirty hands, hands visibly soiled with body fluids, or after using the toilet. Concomitant alcohol-based hand rub and soap and water use is not recommended. Surgical hand hygiene is reserved for sterile procedures. Reference: Chapter 24: Asepsis and Infection Control - Page 606
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? Apply a nonparticulate (N-95) respirator when entering the room. Wear a mask with face shield during invasive procedures. Wear a protective gown and gloves with any direct contact. Have the client wear a mask during care.
Apply a nonparticulate (N-95) respirator when entering the room. Explanation: TB is an airborne infection, and the nurse should wear a nonparticulate mask (N-95) respirator. Gown and gloves would be indicated for infections that are transmitted via direct contact. A mask with a face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care. Reference: Chapter 24: Asepsis and Infection Control - Page 613
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. Send the sphygmomanometer for sterilization. Discard the sphygmomanometer in the trash. Use the sphygmomanometer.
Cleanse and disinfect the sphygmomanometer. Explanation: The nurse should cleanse and disinfect the sphygmomanometer. A sphygmomanometer is another name for a blood pressure cuff. As this equipment is used on the outside of the arm versus entering a sterile body part, there is no need to have the equipment sterilized. It would be inappropriate for the nurse to use the visibly soiled blood pressure cuff or to throw it in the trash. Reference: Chapter 24: Asepsis and Infection Control - Page 607
A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which precautions are implemented by the nurse to prevent the spread of infection? Droplet precautions Airborne precautions Contact precautions Protective isolation precautions
Contact precautions Explanation: Contact precautions are used for clients who have incisional wound infections with organisms that can be transmitted by hand or skin-to-skin contact, such as during client care activities or when touching the client's environmental surfaces or care items. Droplet precautions are used for microorganisms transmitted by larger particle droplets, which disperse into air currents and are not applicable for clients with incisional infections. Airborne precautions are used to protect against microorganisms transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents and are not applicable to incisional infections. Protective isolation may still be used in high-risk situations to prevent infection for people whose body defenses are known to be compromised, which is not applicable to incisional infections. Reference: Chapter 24: Asepsis and Infection Control - Page 610
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? Discard it in the waste can. Do nothing; it can be used again immediately. Sterilize it by placing it in the autoclave. Disinfect it with alcohol swabs.
Disinfect it with alcohol swabs. Explanation: Equipment such as stethoscopes, sphygmomanometers, and other assessment tools that are used for clients on contact precautions should be cleaned and disinfected before use on other clients. The other answers are incorrect. Reference: Chapter 24: Asepsis and Infection Control - Page 610
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? Escherichia coli in the urinary tract Escherichia coli in the intestinal tract Shigella in the urinary tract Shigella in the intestinal tract
Escherichia coli in the intestinal tract Explanation: Escherichia coli residing in the intestinal tract is typical normal flora. Escherichia coli in the urinary tract is indicative of a urinary tract infection. Shigella germs are a common cause of severe diarrhea and are contagious. Shigella in the urinary tract is indicative of a urinary tract infection. Reference: Chapter 24: Asepsis and Infection Control - Page 598
Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely: Between 37.1°C and 38.2°C Between 35°C and 36.8°C Greater than 40.5°C Above 38.2°C
Greater than 40.5°C Explanation: A temperature greater than 40.5°C is referred to as hyperpyrexia. A low-grade fever is a temperature that is slightly elevated, 37.1°C to approximately 38.2°C. A temperature elevation above 38.2°C is considered a high-grade fever. A temperature between 35°C and 36.8°C is a subnormal temperature.
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 lotions should not be used after hand hygiene. Hand hygiene is needed after contact with objects near the client. The use of hand hygiene eliminates the need for gloves. The use of gloves eliminates the need for hand hygiene.
Hand hygiene is needed after contact with objects near the client. Explanation: Hand hygiene must be performed when moving from a contaminated body site to a clean body site during client care and after contact with inanimate objects near the client. Using gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still be used after hand hygiene. Lotions may be used to prevent irritation. Reference: Chapter 24: Asepsis and Infection Control - Page 622
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? Revising the facility's infection control protocols Limiting visitors to family members over the age of 18 Encouraging visitors to adhere to isolation precautions Incentivizing health care workers to utilize hand hygiene
Incentivizing health care workers to utilize hand hygiene Explanation: Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. Revising the agency's infection control protocols is not nursing centered. Encouraging visitors to adhere to isolation precautions is important but does not affect the immediate surroundings and personal space that can cause a contaminated work environment. Limiting visitors to family members over the age of 18 is not client-centered care and will not decrease transmission of pathogens. Reference: Chapter 24: Asepsis and Infection Control - Page 599
A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter? Use an alcohol-based hand rub to decontaminate the hands. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. Keep hands lower than elbows to allow water to flow toward fingertips. Remove all jewelry, including wedding bands, before hand washing.
Keep hands lower than elbows to allow water to flow toward fingertips. Explanation: Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms. Reference: Chapter 24: Asepsis and Infection Control - Page 622
A nursing instructor is preparing a class about the different types of white blood cells. Which of the following would the instructor include as agranulocytes? Select all that apply. Monocytes Eosinophils Basophils T lymphocytes Neutrophils
Neutrophils T lymphocytes Monocytes Explanation: Agranulocytes include T-lymphocytes, B-lymphocytes, and monocytes. Neutrophils, basophils, and eosinophils are granulocytes.
When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do? Obtain a new bottle of sterile saline. Shake the bottle to ensure contents are mixed. Continue to utilize the bottle. Switch to sterile water.
Obtain a new bottle of sterile saline. Explanation: The nurse should obtain a new bottle of sterile saline, as most solutions are considered sterile for 24 hours after they are opened. The nurse should not continue using the bottle. Shaking the bottle will not impact its sterility. Switching to sterile water is not indicated. Reference: Chapter 24: Asepsis and Infection Control - Page 618
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 Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps Don a new pair of gloves to dispose of materials Wrap all used materials together and discard in biohazard container
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. Reference: Chapter 24: Asepsis and Infection Control - Page 624
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? Question the need for the examination, because the client must remain under 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. Notify the CT department in advance so other clients and staff can be removed from the area.
Place a surgical mask on the client and transport to the CT department at the specified time. Explanation: Transport clients in airborne precautions out of the room only when necessary and place a surgical mask on the client if possible. 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). The nurse should not question the need for the examination or request that the examination be done at the bedside. It is not necessary to notify the CT department and allow for all clients and staff to be removed from the area. Reference: Chapter 24: Asepsis and Infection Control - Page 615
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 the cap of the bottle and dip the gauze as needed. Pour the liquid into a sterile container within the sterile field. Pour the liquid into the palm of a sterile gloved hand for use. Pour the liquid onto gauze on the sterile field until the gauze is moist.
Pour the liquid into a sterile container within the sterile field. Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 628-633
A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of: Spore production Aerobic activity Survival adaptation Means of transmission
Survival adaptation Explanation: An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae. Bacterial resistance is not demonstrated by aerobic activity. Spore production is another form of adaptation. Means of transmission is a component of the chain of infection, not an example of bacterial resistance. Reference: Chapter 24: Asepsis and Infection Control - Page 609
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene? The nurse uses gloves in place of hand hygiene. 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.
The nurse keeps fingernails less than 1/4 in (0.63 cm) long. Explanation: The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood. The nurse could use a hospital sanctioned hand moisturizer after hand hygiene, but this is not the best answer. Reference: Chapter 24: Asepsis and Infection Control - Page 604
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 places the client in a private room with the door open. 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. Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 615
The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. 1Apply soap. 2Wash the palms and backs of the hands for at least 20 seconds. 3Turn on the faucet and adjust force and temperature of the water. 4Pat the hands dry with a paper towel. 5Turn the faucet off with a paper towel. 6Wet the hand and wrists.
Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel. Explanation: The correct steps to hand washing are as follows. Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrist areas. Apply soap product. Wash the palms and back of the hands for at least 15 seconds. Pat hands dry with a paper towel. Finally, turn the faucet off with a paper towel. Reference: Chapter 24: Asepsis and Infection Control - Page 622-624
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take? Put soiled dressing change supplies in the client's bathroom garbage and double bag Use a sterile cotton-tipped applicator to apply the prescription to the site Apply a 1-in (2.5-cm) layer of the ointment to the site using the index finger Place sterile 4 × 4 gauze on the wound and secure the dressing with dressing with paper tape
Use a sterile cotton-tipped applicator to apply the prescription to the site Explanation: Applying the ointment with the gloved finger contaminates the prescription ointment. Sterile cotton-tipped applicators are used to apply ointments or solutions to the wound bed to avoid contaminating the wound. A 4 × 4 gauze pad should not be applied until the wound is cleansed properly with sterile supplies. Soiled dressing supplies should be placed in a biohazardous trash bag or container. Reference: Chapter 24: Asepsis and Infection Control - Page 604; 618
After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply. Chemotherapy solution container Cotton-tipped applicator used for wound cleaning Used fingerstick lancet Used syringe with attached needle Blood-soiled dressings
Used syringe with attached needle Used fingerstick lancet Explanation: Injurious wastes include needles, scalpel blades, lancets, broken glass, pipettes and aerosol cans. Blood-soiled dressings or contaminated cotton-tipped applicators would be considered infectious waste. Chemotherapy solution containers would be considered hazardous waste. Reference: Chapter 24: Asepsis and Infection Control - Page 615
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? After direct contact with clients When hands are visibly soiled After completing a wound dressing Before direct contact with clients
When hands are visibly soiled Explanation: Alcohol-based hand rubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, except when the health care worker's hands are visibly soiled. Reference: Chapter 24: Asepsis and Infection Control - Page 606
For which client would the use of standard precautions alone be appropriate? an incontinent client in a nursing home who has diarrhea a client with diphtheria who needs p.m. care a child with chickenpox who is treated in the emergency room a client with TB who needs medications administered
an incontinent client in a nursing home who has diarrhea Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 614-615
When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that: an infection was present and has dissipated. without an elevated temperature, infection is not present. an older adult can have an infection without a fever. the client's symptoms are typical of an older adult client.
an older adult can have an infection without a fever. Explanation: Older adults may not show a fever or may produce only a low-grade fever when an infection is present.
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? a school-age child who is current with immunizations an older adult client with a history of heart failure an adolescent who has a right radial fracture a middle-aged adult who takes prescribed medication to control blood pressure
an older adult client with a history of heart failure Explanation: Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have pre-existing illnesses, appear to be more vulnerable to infection. School-age children are exposed to potential infections, but immunizations protect the child. An adolescent with a fracture or middle-aged adult taking medication to control blood pressure could develop an infection, but these clients are not at the highest risk. Reference: Chapter 24: Asepsis and Infection Control - Page 601
The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? wearing clean unsterile gloves when changing the dressing applying a face mask with shield isolating the client's belongings changing the soiled dressing
changing the soiled dressing Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 617
A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess? productive cough clear mucus dyspnea abnormal breath sounds
clear mucus Explanation: Assessment findings associated with a respiratory infection include productive cough, dyspnea, and abnormal breath sounds. Sputum changes in color from clear to possibly yellow, brown, or green.
The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin? contact none airborne droplet
contact Explanation: Acute vital conjunctivitis is transmitted through contact; therefore, contact precautions are appropriate. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 23: Asepsis and Infection Control, p. 551. Chapter 24: Asepsis and Infection Control - Page 551
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 cellular immunity. decreased susceptibility to infection. increased effectiveness of phagocytosis.
decreased cellular immunity. Explanation: As a person ages, there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to infection
The process of phagocytosis involves: digestion of microbes by white blood cells. breakdown of proteins into amino acids. depletion of serotonin in the brain cells. secretion of a nonspecific chemical inhibitor.
digestion of microbes by white blood cells. Explanation: Many leukocytes function as phagocytes, digesting and destroying microbial invaders.
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 into a private room with another client with a draining wound with a client with pneumonia
into a private room Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 615
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? sterile technique putting on gloves signs of healing hand washing
hand washing Explanation: Hand washing technique is the single most important procedure in reducing the spread of microorganisms from either the client to the surroundings or the surroundings to the client. A client does not need to learn a sterile technique for the abdominal incision. Most client procedures are related to clean handing and do not need gloves to be added to a dressing change. The nurse should review signs of infection and healing of the abdominal incision. Reference: Chapter 24: Asepsis and Infection Control - Page 602
Which nursing action is a component of medical asepsis? insertion of an intravenous catheter handwashing after removing gloves insertion of an indwelling urinary catheter drawing blood from a central line
handwashing after removing gloves Explanation: Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood). Reference: Chapter 24: Asepsis and Infection Control - Page 603
A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason? permits selection of antibiotic concentration helps to determine prescribed antibiotic therapy helps in reducing proliferation of multidrug-resistant organisms narrows the therapeutic range to avoid prolonged use
helps to determine prescribed antibiotic therapy Explanation: Gram staining helps to order antibiotic therapy while waiting for specific culture results, whereas minimum inhibitory concentration permits selection of antibiotic concentration, helps in reducing proliferation of multidrug-resistant organisms, narrows the therapeutic range, and avoids prolonged use
A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients? specimen containers bath blanket face shields indwelling catheter
indwelling catheter Explanation: Infections are often transmitted to older adult clients through equipment reservoirs (e.g., indwelling urinary catheters, humidifiers, and oxygen equipment) or through incisional sites, such as those for intravenous tubing, parenteral nutrition, or tube feedings. Use of proper aseptic techniques is essential to prevent the introduction of microorganisms. Bath blankets, face shields, and specimen containers are not part of the equipment reservoir that transmits infection easily, because they are disposed of immediately after one-time use. Reference: Chapter 24: Asepsis and Infection Control - Page 601
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 hand hygiene measures signs and symptoms of infection vital sign monitoring
intravenous antibiotic administration Explanation: The discharge education plan would most likely include teaching the client and caregivers about the signs and symptoms of infection, hand hygiene measures, and vital sign monitoring. Because the client's infection has resolved, the client would probably not require intravenous antibiotic administration.
The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? putting on sterile gloves before opening sterile package opening the sterile package toward the nurse to prevent reaching over keeping sterile field above waist level maintaining a 3-in. (7.5-cm) border around the sterile field
keeping sterile field above waist level Explanation: When setting up a sterile field, the correct technique is to keep the sterile field above the waist level. A nurse would open the sterile package away from him- or herself first. The sterile gloves are applied after the sterile container is opened. The sterile field is maintained with a 1-in. (2.5-cm) border. Reference: Chapter 24: Asepsis and Infection Control - Page 618
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? contagious disease communicable disease infectious disease noncommunicable disease
noncommunicable disease Explanation: A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe an illness that is contracted after eating food. Reference: Chapter 24: Asepsis and Infection Control - Page 595
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 avoid direct contact with the client wear gloves when touching the client perform hand hygiene before and after entering the client's room
perform hand hygiene before and after entering the client's room Explanation: Hand hygiene is the most important way to prevent transmission of infection. Reference: Chapter 24: Asepsis and Infection Control - Page 639
A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing? resolution prodromal invasion stationary
prodromal Explanation: Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature. Reference: Chapter 24: Asepsis and Infection Control - Page 600
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? asks the client to state name and date of birth applies a mask with face shield removes gloves and walks out of the room performs hand hygiene before donning gloves
removes gloves and walks out of the room Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 608
The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? sterile gloves, removed from the outer wrapping, 4 in (10 cm) away from the edge of the sterile field sterile drape hanging off the work surface sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field sterile drape positioned with the moisture-proof side facing up
sterile drape positioned with the moisture-proof side facing up Explanation: If the sterile drape is placed with the moisture-proof side up, it will become contaminated if it gets wet. It is acceptable to place gloves away from the field and to place gauze on the field. The edges commonly overhang the end of the table slightly, and this is acceptable. Reference: Chapter 24: Asepsis and Infection Control - Page 629
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? find out who left the scalpel blade on the procedure tray wash the area with soap and water go to employee health for testing fill out a risk management form
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 first aid care is performed. 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. Reference: Chapter 24: Asepsis and Infection Control - Page 616
The client 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 decreased elevated stable
within normal limits Explanation: A normal white blood cell count is 5,000 to 10,000 cells/mm3. Reference: Chapter 24: Asepsis and Infection Control - Page 602
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. Any partially uncovered sterile package need not be considered contaminated. When a sterile item touches something that is not sterile, it may not be contaminated. A commercially packaged surgical item is not considered sterile if past expiration date.
A commercially packaged surgical item is not considered sterile if past expiration date. Explanation: 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. Reference: Chapter 24: Asepsis and Infection Control - Page 632
The most common infection in children is: gastrointestinal. respiratory. urinary. neurologic.
respiratory. Explanation: The most common infections in early childhood are respiratory infections.
A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins? T-lymphocytes Monocytes Neutrophils Eosinophils
T-lymphocytes Explanation: T-lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.
Which clients are at a heightened risk for infection? Select all that apply. client with an indwelling catheter client with an IV catheter client with hypothermia client with gastric tube feeding client with hypertension
client with gastric tube feeding client with an indwelling catheter client with an IV catheter Explanation: Clients with gastric tube feedings, indwelling catheters, and IV catheters are at a greater risk for infection than clients with hypothermia or hypertension. Pathogens can enter susceptible hosts through body orifices. Breaks in the skin or mucous membranes (from wounds or from abrasions) increase opportunities for organisms to enter hosts. Long-term IV or gastric feedings and drainage of body cavities further increase the number of potential routes of entry into the body, thus increasing the risk of infection. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 537. Chapter 24: Asepsis and Infection Control - Page 537
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 Explanation: Contact may be either direct or indirect. Reference: Chapter 24: Asepsis and Infection Control - Page 599
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 blanching over elbow area noted slight bleeding noted while old dressing is removed redness size over sacral area is with minimal increase
skin is dry and intact Explanation: The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Chapter 23: Asepsis and Infection Control, 2015: p. 536. Chapter 24: Asepsis and Infection Control - Page 536
