Chapter 24: Asepsis and Infection Control PrepU

The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room? a. gloves b. face shield c. goggles d. face mask

a. gloves 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.

The nurse is preparing to help mobilize a client with an abdominal wound that is colonized by methicillin-resistant Staphylococcus aureus (MRSA). Which of the shown actions should the nurse perform before assisting the client? a. gloves b. face mask c. goggles d. face shield

a. gloves Drug-resistant wounds normally require contact precautions. This necessitates the use of gloves and a gown but not a mask, goggles, or face shield.

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? a. "I can't transmit the virus other people if I shake their hands." b. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." c. "I received a blood transfusion in 1989, which could be a factor in contracting the disease." d. "I may have gotten the virus when I got a tattoo while I was in prison."

b. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992. The virus cannot be contracted or spread through a toilet seat.

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. Which response by the student nurse to the nurse is the most accurate understanding of this procedure? a. "It is okay to turn the drape on the other side." b. "I use my whole hand to touch the non-waterproof surface before placing the sterile equipment on it." c. "The way you are doing it helps to minimize contamination of the non-waterproof side." d. "Using either side of the drape is okay, as long as you do not contaminate the sterile supplies on the field."

c. "The way you are doing it helps to minimize contamination of the non-waterproof side." The sterile drape is to be positioned with the drape on work surface with the moisture-proof side down. It is important that only a sterile object touch another sterile object. Unsterile touching results in contamination of the sterile field. If this occurs, the procedure should be started again with new supplies. It is not okay to turn the drape on the other, non-waterproof side. This action will increase the risk for contamination.

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into? a. S= Situation b. B= Background c. A= Assessment d. R= Recommendation

c. A= Assessment SBAR: Situation, Background, Assessment, and Recommendations (SBAR) is a shared mental model for improving communication between and among clinicians. Note that situation, background, and assessment are all based on the collection of complete and accurate assessment data. The last piece, recommendations, encompasses the nurse's suggestions for the next interventions. Situations: What is happening at the present time? Background: What are the circumstances leading up to this situation? Assessment: What do I think the problem is? Recommendations: What should we do to correct the problem?

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? a. contact b. vehicle c. droplet d. airborne

a. contact Contact may be either direct or indirect.

Otitis media occurs in children because the: a. eustachian tube is long and twisted. b. eustachian tube has a downward turn. c. eustachian tube is shorter and straighter. d. eustachian tube is widened.

c. eustachian tube is shorter and straighter. The most common infections in early childhood are respiratory infections. In children, the eustachian tubes are shorter and straighter; middle ear infections (otitis media) are common because bacteria can easily pass from the nasopharynx to the ear canal.

A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is: a. Semen b. Blood c. Wound drainage d. Sputum

a. Semen Vehicle transmission involves the transfer of microorganisms by way of vehicles, or contaminated items that transmit pathogens. For example, food can carry Salmonella. In this case, semen can carry human immunodeficiency virus.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason? a. To protect both the staff and clients from becoming infected by one another b. To protect clients from becoming infected by staff members c. To protect staff members from becoming infected by clients d. To protect the hospital from legal liability

a. To protect both the staff and clients from becoming infected by one another

A nurse prefers to use an alcohol-based hand rub when providing care for clients. In which case is this practice contraindicated? a. The nurse is caring for a client with a C. difficile infection. b. The nurse performs routine care and is moving to another client. c. The nurse finishes cleaning a client's table. d. The nurse finishes client care and hands are not visibly soiled.

a. The nurse is caring for a client with a C. difficile infection. Controversy exists regarding the use of alcohol-based hand rubs when C. difficile organisms have been identified. Alcohol does not kill C. difficile spores.

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution will the nurse use? a. sterile gloves b. mask c. gown d. hand hygiene

d. hand hygiene When taking vital signs on a client after surgery, the nurse will perform hand hygiene. There is no need for the nurse to wear a gown or mask, unless the client is diagnosed or suspected to have a transmittable infection. Because vital signs is an aseptic versus sterile procedure, the nurse should use nonsterile gloves.

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? a. contagious disease b. infectious disease c. communicable disease d. noncommunicable disease

d. noncommunicable disease 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.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? a. Migration of leukocytes to the area of the wound b. Constriction of the small blood vessels near the wound c. Release of histamine d. Production of antibodies

a. Migration of leukocytes to the area of the wound During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation. Antibody production is characteristic of the immune response to infection.

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 Two common factors that increase a persons risk of becoming infected with C difficile are age greater than 65 and current or recent use of antibiotics. In this scenario, old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.

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? a. Avoid touching the outer surfaces of the gown. b. Remove the gown before removing gloves. c. Remove the gown immediately after exiting the room. d. Perform hand hygiene before removing the gown.

a. 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.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? a. changing the soiled dressing b. wearing clean unsterile gloves when changing the dressing c. isolating the client's belongings d. applying a face mask with shield

a. changing the soiled dressing 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.

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? a. the client who is 48-hours postsurgical procedure b. the client admitted with a rash who reports recent exposure to measles c. the client admitted with diarrhea who tested positive for Escherichia coli (E. coli) d. the client placed in contact isolation who was admitted with a draining abdominal wound

a. the client who is 48-hours postsurgical procedure Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between clients, the nurse should see clients from the "clean" to "dirty." The nurse should see the client who has no signs of infection first. Among these clients, the nurse should begin with the client who is postoperative, then see the other clients who have symptoms of infections.

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

b. "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 suspects that a client may be developing sepsis based on assessment findings. The practitioner orders a serum lactate level to be obtained. When reviewing the results, which serum lactate level would the nurse identify as indicative of sepsis? a. 1.3 mmol/L b. 2.4 mmol/L c. 3.5 mmol/L d. 4.6 mmol/L

d. 4.6 mmol/L Hyperlactatemia is often present in clients with severe sepsis. All clients with elevated lactate levels greater than 4 mmol/L need early, goal-directed therapy for severe sepsis resuscitation bundle, regardless of blood pressure. The actions included in the bundle help to promote better outcomes for the client.

When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. What is the appropriate action by the nurse? a. Report the incident to the supervisor immediately b. Have the client tested for HIV and hepatitis C c. Follow the agency's policy of exposure to communicable infections d. Perform hand hygiene after removing the glove

d. Perform hand hygiene after removing the glove Because the client's blood contaminated the nurse's glove versus the nurse's hand, no exposure occurred. The nurse should perform hand hygiene after removing the glove. There is no need for further action. The supervisor does not need to be contacted as the blood contaminated the nurse's gloved hand. The health care prescriber would need to order for HIV and hepatitis testing if the blood touched the nurse's ungloved hand. The agency would have a bloodborne pathogen exposure policy based on exposure to eyes and skin. However, the blood did not touch the nurse's ungloved hand so the policy does not need to be accessed.

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? a. After completing a wound dressing b. Before direct contact with clients c. After direct contact with clients d. When hands are visibly soiled

d. When hands are visibly soiled 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.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? a. Avoid contact with mosquitoes b. Use hand sanitizer after touching any public surface c. Self-quarantine yourself for 2 weeks if you feel ill d. Use a face mask when in crowds

a. Avoid contact with mosquitoes Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate.

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? a. Client receiving chemotherapy b. Client with a history of eczema c. Client on a short course of vancomycin d. Client in the ICU for one day

a. Client receiving chemotherapy The nurse should determine that the client receiving chemotherapy is the client at greatest risk for VRE infection due to having a compromised immune system from the chemotherapy. Other risk factors for VRE include recent surgery, presence of urinary or central IV catheter, prolonged antibiotic use (especially with vancomycin), and lengthy hospital stays (especially in an ICU).

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? a. Decontaminate hands using an alcohol-based hand rub. b. Do not wash hands; apply clean gloves. c. Wash hands with soap and hot water. d. Wash hands with soap and water, followed by an alcohol-based hand rub.

a. Decontaminate hands using an alcohol-based hand rub. Alcohol-based hand rubs can be used if hands are not visibly soiled. If the hands are visibly soiled, the nurse should wash hands with soap and hot water. The nurse should wash their hands. The nurse does not need to wash their hands AND use an alcohol-based hand rub.

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse? a. Discard the supplies and field and prepare a new sterile field. b. Educate the client on sterile fields and continue preparing for the procedure. c. Give the client the water pitcher and continue preparation. d. Remove the supplies from the field and replace with new supplies.

a. Discard the supplies and field and prepare a new sterile field. If sterile procedure is disrupted in any way, the nurse must discard all items (including the field) and begin preparing a new sterile field. Reaching over a sterile field would disrupt the sterility of the area. The nurse would not remove the supplies from the field and replace but rather start all over with a sterile field. Education of the client should have been performed prior to the procedure. The nurse should have asked if the client needs anything including a water pitcher prior to the procedure.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? a. 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. b. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing c. sending a VRE-positive client to the radiology department for a chest X-ray without a face mask d. delivering a meal tray to a VRE-positive client without first donning gloves and a gown

a. 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. Direct client contact between a VRE-positive client and another client without handwashing carries a significant risk of infection, especially when contact includes body fluids. Handwashing is necessary before a procedure such as staple removal, but foregoing this infection control measure is less likely to spread VRE unless the nurse failed to handwash after the procedure. VRE does not normally require droplet or airborne precautions. Delivering an item to a client without gloves or a gown is less of a risk than failing to wash the hands after such contact.

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? a. Exogenous healthcare-associated b. Endogenous healthcare-associated c. Iatrogenic d. Antibiotic-resistant

a. Exogenous healthcare-associated The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique? a. Hold sterile objects above waist level to prevent inadvertent contamination. b. Consider the outside of the sterile package to be sterile. c. Consider the outer 3-in. (8-cm) edge of a sterile field to be contaminated. d. Open sterile packages so that the first edge of the wrapper is directed toward the nurse.

a. Hold sterile objects above waist level to prevent inadvertent contamination. Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 in. (2.5 cm) of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse.

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? a. Incentivizing health care workers to utilize hand hygiene b. Revising the facility's infection control protocols c. Encouraging visitors to adhere to isolation precautions d. Limiting visitors to family members over the age of 18

a. Incentivizing health care workers to utilize hand hygiene 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.

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? a. Place a surgical mask on the client and transport to the CT department at the specified time. b. Notify the CT department in advance so other clients and staff can be removed from the area. c. Question the need for the examination, because the client must remain under airborne precautions. d. Request that the examination be done at the bedside.

a. Place a surgical mask on the client and transport to the CT department at the specified time. 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 patients 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 patients and staff to be removed from the area.

The nurse is caring for a client with full-thickness (third-degree) burns. What aseptic intervention(s) would the nurse implement for this client when admitted to the general medical unit? Select all that apply. a. Place the client in a private room with protective isolation. b. Instruct all staff, the client, and family members to practice strict and meticulous hand washing. c. Restrict visitors to family members who are not ill. d. Permit flowers only if the containers have plastic wrapping around the base. e. Allow the client to only ingest fresh fruits or vegetables, no canned or prepackaged food products.

a. Place the client in a private room with protective isolation. b. Instruct all staff, the client, and family members to practice strict and meticulous hand washing. c. Restrict visitors to family members who are not ill. Clients with extensive burns are at high risk for infection. Such clients are placed in private rooms on protective isolation. To reduce the risk of infection, everyone practices strict and meticulous hand washing, including the client and his or her family. Visitors should be only family members who are not ill. Flowers, either in water or soil, are not permitted because soil harbors fungus and standing water supports the growth of microorganisms. All of these measures help to ensure that the client's environment stays as free from pathogens as possible, thereby decreasing the chance of infection. No fresh fruits or vegetables are allowed, only canned and cooked food.

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. a. Redness b. Swelling c. Pain d. Coolness e. Exudate

a. Redness b. Swelling c. Pain e. Exudate 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.

Which action is the best example of a nurse donning/removing protective equipment properly? a. Removing respirator after leaving client's room b. Removing gown after leaving client's room c. Donning gown after entering client's room d. Donning respirator inside of client's room

a. Removing respirator after leaving client's room The best example of proper utilization of protective equipment is the removal of a respirator after leaving the client's room, as doing so prevents contact with airborne microorganisms. Gowns should be removed before leaving the client's room. Gowns and respirators should be donned prior to entering the client's room.

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? a. Surgical asepsis b. Increased T cells c. Decreased antibiotics d. Increased Vitamin C

a. Surgical asepsis 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.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? a. Surgical asepsis technique b. Medical asepsis technique c. Droplet precautions d. Strict reverse isolation

a. Surgical asepsis technique Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others.

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? a. The new nurse touches 1.5 in (4 cm) from the outer edges. b. The sterile field is set up at waist level. c. Direct visualization of the sterile field is maintained. d. The top flap of the package is opened away from the new nurse's body.

a. The new nurse touches 1.5 in (4 cm) from the outer edges. Only the outer 1 in (2.5 cm) of the sterile package is safe to touch. In this case, the nurse touches 1.5 in (4 cm), which is inside the sterile field. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands soap and water? Select all that apply. a. The nurse is going from one room to another to introduce self at the start of the shift. b. The nurse has entered the client room to adjust settings on the intravenous pump. c. The nurse has just completed documentation and is entering another client room. d. The nurse is exiting a room after completed indwelling urinary catheter care. e. The nurse has assisted a client with changing and caring for a new colostomy.

a. The nurse is going from one room to another to introduce self at the start of the shift. b. The nurse has entered the client room to adjust settings on the intravenous pump. c. The nurse has just completed documentation and is entering another client room. Alcohol-based handrub is preferred in situations when hands are not visibly soiled; before and after touching a client; before handling an invasive device for client care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; and after removing sterile or nonsterile gloves. Use of an alcohol-based handrub does not replace the need for gloves or for handwashing, however. After performing catheter care and assisting with changing a colostomy, gloves are worn and handwashing should take place.

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? Select all that apply. a. The nurse's back is facing the sterile field. b. The nurse keeps hands above waist level while donning sterile gloves. c. The nurse touches an unsterile object to the instrument tray. d. The nurse is talking with the scrub nurse over the sterile field. e. The nurse disposes of an opened container of sterile saline after 24 hours.

a. The nurse's back is facing the sterile field. c. The nurse touches an unsterile object to the instrument tray. d. The nurse is talking with the scrub nurse over the sterile field. Principles of surgical asepsis include never turning one's back on a sterile field. The nurse should avoid talking, coughing, or sneezing over the field and keep sterile objects above waist level. Sterile objects may only be touched by other sterile objects. Most solutions are considered sterile for 24 hours after they are opened.

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? a. Wash the area with soap and water b. Fill out a risk management form c. Find out who left the scalpel blade on the procedure tray d. Go to employee health for testing

a. Wash the area with soap and water 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 immediate first aid care. 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.

The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing intervention(s)? Select all that apply. a. facilitating interdepartmental coordination about the transport b. removing the client's mask for transport c. placing a clean sheet on the stretcher that the client will be transported upon d. ensuring that the client has a mask on e. reminding transporter to utilize droplet precautions

a. facilitating interdepartmental coordination about the transport c. placing a clean sheet on the stretcher that the client will be transported upon d. ensuring that the client has a mask on e. reminding transporter to utilize droplet precautions The nurse will provide interdepartmental coordination, use methods to prevent the spread of pathogens (such as lining the surface of the stretcher with a sheet to protect the surface from direct contact), and ensure that the client is wearing a mask before being transported. The nurse will not remove the client's mask for transport.

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? a. fold soiled side to the inside and roll with inner surface exposed b. fold soiled side to the outside and roll with outer surface exposed c. fold soiled side to the inside and roll with outer surface exposed d. fold soiled side to the outside and roll with inner surface exposed

a. fold soiled side to the inside and roll with inner surface exposed To dispose of the gown, the nurse will fold the soiled side to the inside and roll with the inner surface exposed. The other answers are incorrect.

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? a. hand washing b. sterile technique c. putting on gloves d. signs of healing

a. hand washing 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.

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply. a. infectious disease b. communicable disease c. noncommunicable disease d. contagious disease e. health care-associated infection (HAI)

a. infectious disease b. communicable disease d. contagious disease Infections disease, communicable disease, and contagious disease describe this type of illness. A noncommunicable disease is caused by food or environmental toxin. Health care-associated infections are acquired within a healthcare facility.

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? a. one that remains in the client's room b. one that is the nurse's personal stethoscope c. one that remains directly outside the client's room d. one that the client has personally purchased for use

a. one that remains in the client's room A dedicated stethoscope and blood pressure cuff should remain in the client's room. The other answers are incorrect.

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. a. place a mask on the client b. refuse to transport the client c. cover the client with a sheet during transport d. communicate about precautions with the health care team e. prepare the transport stretcher with a clean sheet

a. place a mask on the client c. cover the client with a sheet during transport d. communicate about precautions with the health care team e. prepare the transport stretcher with a clean sheet The nurse will provide interdepartmental coordination, use methods to prevent the spread of pathogens (such as placing a clean sheet on the stretcher and placing a sheet over the client during transport), and ensure that the client is wearing a mask before being transported. The nurse will not refuse to transport the client.

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? a. "Washing the hands with soap and water is not necessary." b. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." c. "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." d. "We only wash our hands when they are visibly soiled."

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

Which client would the nurse consider the most infectious? a. A client who is in the incubation period b. A client who is in the prodromal stage c. A client who is in the full stage of illness d. A client who is in the convalescent period

b. A client who is in the prodromal stage The client is most infectious during the prodromal stage of the illness. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the client often is unaware of being contagious. As a result, the infection spreads. The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the client's general condition. The signs and symptoms disappear, and the person returns to a healthy state.

An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate? a. Fomite b. Airborne c. Droplet d. Contact

b. Airborne The nurse should implement airborne precautions for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). Droplet precautions should be used for patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Contact precautions should be used for patients who are infected or colonized by a multidrug-resistant organism (MDRO).

When providing care to a incontinent client with a history of methicillin-resistant Staphylococcus aureus (MRSA), what is the priority goal for the nurse's observable intervention? a. Preventing the introduction of microorganisms to the client b. Avoiding the introduction of microorganisms to the nurse's uniform c. Maintaining the cleanliness of the nurse's uniform d. Providing a clean environment while providing client care

b. Avoiding the introduction of microorganisms to the nurse's uniform The use of personal protective equipment (PPE) interrupts the chain of infection. Gowns are examples of PPE used to cover/protect the nurse's uniform and thus protect the wearer from the spread of infection or illness when coming into contact with potentially infectious liquid and solid material. Methicillin-resistant Staphylococcus aureus (MRSA) is highly contagious and requires appropriate PPE use, including gown and gloves, when providing the care described. While the nurse should take steps to minimize the introduction of microorganisms to both the client and the general environment, the priority goal for this intervention in this situation is to minimize the risk of injury in the form of infection to the nurse.

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile? a. Since the bottle has been open, previously used, and unexpired, "lip" it by pouring a small amount into a waste container or waste cup. b. Discard the bottle and get a new one because the saline has expired. c. Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container. d. Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening.

b. Discard the bottle and get a new one because the saline has expired. Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening. Lipping the opening of the bottle and pouring the saline into a sterile container by holding it 6 in (15 cm) above the container would be appropriate, but contents in the bottle are expired. The nurse should discard the bottle and get a new one.

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. a. Nurses need only apply clean gloves when performing or assisting with invasive client procedures. b. During some care activities for an individual client, nurses may need to change gloves more than once. c. Nurses may use a waterproof gown more than one time. d. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. e. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. f. Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse.

b. During some care activities for an individual client, nurses may need to change gloves more than once. d. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. e. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. Several examples represent the proper use of personal protective equipment in a health care agency. First, 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. The nurse should remove a gown by unfastening ties, if at the neck and back, and allow the gown to fall away from the shoulders. The nurse would apply clean gloves for most care activities, not just when assisting or performing an invasive client procedure. A waterproof gown is to be used only once. Nurses cannot wear a mask around the neck when not being worn nor can it be brought back over the nose and mouth for reuse.

Which mask should the nurse don when caring for a client with tuberculosis? a. Low-efficiency particulate air (LEPA) b. Filtered respirator c. Surgical mask d. No mask is needed

b. Filtered respirator When caring for a client with tuberculosis, the nurse should don a filtered respirator mask to filter the inspired air. A surgical mask, also known as a procedure mask, is intended to be worn by health care professionals during surgery and during nursing to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose. Low-efficiency particulate air (LEPA) masks are not used in health care.

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

b. Review the current infection control protocols. 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.

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? a. airborne b. droplet c. contact d. none

b. droplet Streptococcal pneumonia is transmitted through droplets; therefore droplet contact precautions are appropriate. The other options are inappropriate.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene? a. washes hands for 15 seconds b. has manicured nails that are 1-in. (2.5-cm) long c. has wedding band on ring finger d. drains hands lower than the wrist

b. has manicured nails that are 1-in. (2.5-cm) long Fingernails should be less than ¼-in. (0.625-cm) long, as this reduces the reservoir for flora to accumulate and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. A flat wedding band is acceptable. Allowing the hands to drain lower than the wrist promotes gravity drainage.

To eliminate needlesticks as potential hazards to nurses, the nurse should: a. place the uncapped needle on a tray and carry it to the medicine room for disposal. b. immediately deposit uncapped needles into a puncture-proof plastic container. c. stick the uncapped needle into a Styrofoam block and deposit it in a plastic container. d. slide the needle into the cap and deposit it in a puncture-proof plastic container.

b. immediately deposit uncapped needles into a puncture-proof plastic container. All uncapped needles should be placed in a puncture-proof plastic unit immediately after use.

The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as: a. fungus. b. parasite. c. virus. d. bacteria.

b. parasite. Lyme disease is spread through the bite of an infected tick, an arthropod, which is classified as a parasite. The bacteria Borrelia burgdorferi causes Lyme disease in humans. Viruses cause numerous infections but are not associated with Lyme disease. Fungi also cause disease in humans but are not associated with Lyme disease.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? a. "I will not visit my family member in the first 3 days of my cold." b. "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." c. "I will obtain a mask from the staff and wash my hands before touching my family member." d. "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."

c. "I will obtain a mask from the staff and wash my hands before touching my family member." Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is elderly or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.

The charge nurse observes the licensed practical nurse (LPN) removing personal protective equipment (PPE). Which action by the LPN warrants intervention from the charge nurse? a. The LPN removes gloves by grasping the outside of one glove without touching the wrist with the gloved hand. b. The LPN removes goggles while only touching the ear pieces. c. The LPN removes the mask by untying the top of the mask first. d. The LPN removes the gown by rolling it into an inside out ball.

c. The LPN removes the mask by untying the top of the mask first. The face mask should be untied at the bottom first. This helps to prevent the top of the mask from flopping forward and potentially exposing the nurses face to the dirty side of the mask. To remove PPE goggles appropriately, the nurse should handle them by the earpieces to lift away from the face. Gloves should be removed without touching the hand to prevent contaminating the skin. Gowns should be rolled into an inside out ball when removed to prevent exposure from contaminated surfaces of the gown.

For which client would the use of standard precautions alone be appropriate? a. a client with diphtheria who needs p.m. care b. a client with TB who needs medications administered c. an incontinent client in a nursing home who has diarrhea d. a child with chickenpox who is treated in the emergency room

c. an incontinent client in a nursing home who has diarrhea 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.

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

c. 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 nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action? a. to protect the integrity of the nurse's immune system b. to prevent the nurse from developing disease c. to eliminate disease-producing organisms from the nurse's skin d. to sterilize the nurse's hands to prevent infection

c. to eliminate disease-producing organisms from the nurse's skin The purpose of hand hygiene is to protect clients from infection by removing microorganisms from the skin. This action directly addresses client safety but is not directly related to effectiveness of care. Hand hygiene protects the nurse from infection but the primary purpose is to protect clients. Hand hygiene greatly reduces the number of microorganisms on the skin but does not result in sterile skin surfaces.

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

d. 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.

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? a. Place the client in a private room that has monitored negative air pressure. b. Keep visitors 3 feet (1 m) from the client. c. Use respiratory protection when entering the room. d. Wear gloves whenever entering the client's room.

d. Wear gloves whenever entering the client's room. Contact precautions are used for clients who are infected or colonized by a microorganism that spreads by direct or indirect contact, such as MRSA, vancomycin-resistant enterococci (VRE), or vancomycin-intermediate Staphylococcus aureus (VISA). Gloves should be worn when entering the client's room. Use of negative air pressure and respiratory protection are appropriate with airborne precautions. Keeping visitors 3 ft (1 m) away from the client is a droplet precaution.

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: a. decreased b. elevated c. within normal limits d. stable

c. within normal limits A normal white blood cell count is 5,000 to 10,000 cells/mm3.

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? a. the cell-mediated immune response b. early intervention with antibiotics c. staying home when sick d. intact skin and mucous membranes e. low levels of flora

d. intact skin and mucous membranes The first line of defense against infection is intact skin and mucous membranes covering body cavities.

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

a. 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.

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

a. 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.

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? a. Alcohol-based hand rub b. Soap and water hand washing technique c. Scrubbing hands with soap, water, and brush d. Mixture of soap and alcohol-based hand rub techniques

a. Alcohol-based hand rub 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.

A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse? a. "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." b. "You cannot be admitted to the hospital with pneumonia without receiving some sort of antibiotics." c. "We give antibiotics to treat the virus that are causing you the pneumonia." d. "The antibiotics we are giving you will boost your immune system and help fight off whatever pathogen is present."

a. "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." Many bacteria are susceptible to broad-spectrum antibiotics and prior to the diagnosis of a specific bacteria, a broad-spectrum antibiotic will be prescribed to help eradicate the present bacteria until a culture result is returned. A client may be admitted to the hospital with pneumonia without receiving antibiotics, although it is likely that an antibiotic will be given at some point during hospitalization. Antibiotics do not boost the immune system and may destroy normal healthy flora. Antibiotics are used to treat bacterial infections, not viral infections; antibiotics do not kill viruses.

A nurse has finished giving care to a client who has a communicable respiratory infection. In which order should the personal protective equipment (PPE) be removed? 1. Gloves 2. Respirator 3. Gown 4. Goggles a. 1, 4, 3, 2 b. 4, 2, 3, 1 c. 1, 2, 4, 3 d. 4, 2, 1, 3

a. 1, 4, 3, 2 The order for removal of PPE is gloves, goggles, gown, and respirator.

The physician orders a serum trough drug level for a client who is receiving antibiotic therapy. The client is receiving the drug every 6 hours: at midnight, 6 a.m., noon and 6 p.m. The nurse anticipates that the specimen would be obtained: a. just before the 6 a.m. dose. b. immediately after the noon dose. c. at 7 a.m. d. at 6 p.m.

a. just before the 6 a.m. dose. Serum trough levels (or lowest drug level) should be obtained just before a dose is due to be administered, which would be just before any of the doses, or in this case just before the 6 a.m. dose. Peak levels or the highest level of drug concentration are obtained shortly after the drug is given.

A nurse is caring for four clients. Which client has the highest risk of infection? a. older male with an enlarged prostate b. toddler with a benign heart murmur c. woman in second trimester of pregnancy d. young woman with a history of scoliosis

a. older male with an enlarged prostate An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on infection.

The nurse is caring for an older adult with pneumonia. What action by the nurse will help the client prevent further pulmonary infections? a. Advise taking prophylactic antibiotics for the prevention of pneumonia b. Immunize the client with the pneumococcal vaccination once in a lifetime c. Discuss starting corticosteroids at low doses to prevent pulmonary infections d. Instruct client to limit fluids when coughing and congestion occurs

b. Immunize the client with the pneumococcal vaccination once in a lifetime Pneumococcal vaccination should occur once in a lifetime; influenza vaccination should occur annually. The client should not take prophylactic antibiotics, which can cause resistant bacterial strains and does not prevent pneumonia. Corticosteroids may lower the resistance and allow pathogens easier entrance from immunosuppression. Encourage fluid intake to thin secretions when coughing and congestion begins.

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

b. "Help me understand your perspective about vaccinating." Seeking to understand the parent's perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. Vaccines have not been connected to autism; asking the parent "why" reflects demanding an answer; and vaccines are one of numerous ways to halt disease transmission.

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation? a. "Do not touch this, or I will have to start over. " b. "Everything is ready, I will leave the tray here for the provider." c. "I have set up this sterile field for your procedure, so please do not touch anything around the tray." d. "It is alright if you want to look at the supplies. Just be careful not to touch them."

c. "I have set up this sterile field for your procedure, so please do not touch anything around the tray." If the client touches the sterile field, the nurse will need to discard the supplies and prepare a new sterile field. When any portion of the sterile field becomes contaminated, all portions of the sterile field must be discarded. The nurse should call for help if a supply is needed. The nurse should not leave the sterile field unobserved.

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. When a sterile item touches something that is not sterile, it may not be contaminated. b. Any partially uncovered sterile package need not be considered contaminated. c. A commercially packaged surgical item is not considered sterile if past expiration date. d. Sterility may not be preserved even when one sterile item touches another sterile item.

c. 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 is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? a. Change the sterile field, but reuse the sterile equipment. b. Proceed with the procedure since it was only touched by the client. c. Discard the sterile field and the supplies and start over. d. Call for help and ask for new supplies.

c. Discard the sterile field and the supplies and start over. The nurse's next appropriate action would be to discard the sterile field and the supplies and start over. The client touching the end of the sterile field contaminated the field and the items on the field. The nurse cannot reuse the sterile equipment because the items are no longer sterile. The nurse cannot proceed with the procedure since the items have been contaminated. Calling for help and asking for new supplies is not the best answer. The field has been contaminated also.

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely: a. Between 37.1°C and 38.2°C b. Above 38.2°C c. Greater than 40.5°C d. Between 35°C and 36.8°C

c. Greater than 40.5°C 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.

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care? a. Dip the IV catheter into an antiseptic before use. b. Clean the site with a disinfectant. c. Use a sterile intravenous catheter. d. Wear a mask and gown for the procedure.

c. Use a sterile intravenous catheter. Any item entering sterile tissues or the vasculature must be sterile. Therefore, an IV catheter must be sterile. It should not be dipped in an antiseptic before use. A chemical used on lifeless objects is called a disinfectant, whereas one used on living objects is an antiseptic. The nurse would clean the IV site with an antiseptic, not a disinfectant, before insertion. An IV insertion does not require the nurse to wear a mask and gown.

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? a. "You should not visit your friend if you have an infection of any kind because your friend may also get sick." b. "If you wash your hands before coming in contact with your friend you will prevent infection during your visit." c. "As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend." d. "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."

d. "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." 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.

Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur. a. Convalescent period b. Full stage of illness c. Prodromal period d. Incubation period

d. Incubation period c. Prodromal period b. Full stage of illness a. Convalescent period The correct sequence of the stages of infection are (1) incubation period, (2) prodromal stage, (3) full stage of illness, and (4) convalescent period.

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

d. 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.

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? a. wear gloves when touching the client b. wear a mask and gown in the client's room c. avoid direct contact with the client d. perform hand hygiene before and after entering the client's room

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

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

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

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator? a. "I will always wash my hands thoroughly and often." b. "It is important to refrain from recapping needles." c. "Masks, gloves, and gowns should be used to protect from infectious agents." d. "Wearing an N95 respirator is critical when I care for clients in droplet precautions."

d. "Wearing an N95 respirator is critical when I care for clients in droplet precautions." N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.