Chapter 24 Prep U

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 is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required?

"I can leave my room any time I want as long as I wear a mask."

Which practice is a correct application of infection control practices?

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

What is an accurate guideline for removing soiled gloves after client care?

After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.

A nurse is caring for a 7-year-old client with varicella. Which precautions will the nurse initiate?

Airborne

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.

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

Client receiving chemotherapy

The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin?

Droplet

The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing intervention?

Facilitating interdepartmental coordination about the transport. Placing a clean sheet onto the stretcher that the client will be transported upon. Ensuring that the client has a mask on. Reminding transporter to utilize droplet precautions.

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

Filtered respirator

A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to Don her PPE. Which would be appropriate?

Gloves Gown Mask with face shield

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

Hand hygiene is needed after contact with objects near the client.

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

Handwashing before leaving the client's room.

A nurse is inserting a male client's indwelling catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he had brought the wrong-sized catheter to the bedside. What is the nurse's best action?

Illuminate the client's call light and have a colleague bring the correct catheter to the bedside.

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?

Migration of leukocytes to the area of the wound

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today 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?

Perform hand hygiene before and after entering the client's room.

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse?

Pouring the sterile solution from a height of 5 in (13cm)

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Client's with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

The nurse observes an unlicensed assistive personal (UAP) collecting a urine specimen from a client with staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

Removes gloves and walks out of the room

Which action is the best example of a nurse donning/removing protective equipment properly?

Removing respirator after leaving client's room

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

Surgical asepsis

The nurse is preparing to enter a client's room who is on airborne precautions. Which technique should the nurse use when wearing a non-particulate respirator (N-95) mask?

The mask covers the nose and mouth. Replace the mask after 20-30 minutes. Tie the upper strings of mask snugly against back head.

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?

The nurse washes at least 1 in (2.5 cm) above the area of contamination if present

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct?

Touch the inside of the gown and pull it away from the torso

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is:

Universal precautions

A nurse is providing care to a client who has salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?

Vehicle

The nurse is monitoring a student who is performing surgical hand asepsis. Which student actions indicate the need for further education from the nurse?

Wearing a gold wedding band. Using at least 5 strokes for cleansing in each area. Dropping hands to side when wash is complete.