Chapter 24: Asepsis/Infection Control

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

contact precautions

The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client?

droplet

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

droplet

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

go into a private room

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?

hand washing

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

handwashing before leaving the client's room

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.

infectious disease communicable disease contagious disease why? 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 is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense?

intact skin and mucous membranes

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

keeping sterile field above waist level

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

older adults

The nurse observes a member of the care team removing a gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?

teach the colleague to let the gown fall away rather than pulling on the sleeves

Which nursing action demonstrates safe injection practice?

use sterile single-use disposable syringes for each injection

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all client care and interaction

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."

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?

"Avoid touching the outside of your gown when removing it."

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?

"I have set up this sterile field for your procedure, so please do not touch anything around the tray."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

"This antibiotic is the best choice since the causative organism is not known."

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?

Don another pair of sterile gloves.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply.

Pain with redness and swelling Localized heat Purulent or malodorous drainage

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.

The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. why? 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. All opened bottles of liquid should be discarded after use.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection?

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

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client

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?

alcohol-based hand rub

Which client would the nurse consider the most infectious?

client in prodromal stage

Which mask should the nurse don when caring for a client with tuberculosis?

filtered respirator

A nurse is caring for four clients. Which client has the highest risk of infection?

older male with an enlarged prostate why? 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.

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

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

remove gloves, remove gown, wash hands

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

student has nails that are 1 in. long

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?

to eliminate disease-producing organisms from the nurse's skin

What is the most common client site for development of healthcare-associated infections (HAI)?

urinary tract

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?

"I probably got the virus when I sat on the toilet seat in a dirty bathroom." why? 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.

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

Client with urinary catheter

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

Hepatitis C HIV Hepatitis B

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?

contact