Chapter 24 Prep U (TTE)

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact Wound infectious agents are transmitted through contact; therefore contact precautions are appropriate.

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

"All visitors who enter the room must wear N95/surgical masks." Tuberculosis is an airborne respiratory disease, which requires a HEPA-style respirator or N95 mask when visitors or staff enter the room of a client with known or suspected disease. Gowning and gloving do not prevent airborne transmission. Visitors are permitted and there is no firm prohibition against touching the client.

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?

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.

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?

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.

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 care and interaction with this client To prevent the transmission of TB, the National Institute for Occupational Safety and Health recommends the use of a particulate air filter respirator that fits snugly to the face for all client care and interaction. A face mask does not block small TB particles effectively. Protective eyewear is only needed if contact with bodily fluids is expected. The client would be placed in a negative pressure room to prevent the potential spread of TB.

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact Fluids from a draining abscess can transmit infection through contact; therefore contact precautions are appropriate.

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?

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

The school nurse is educating a group of teenagers about ways in which human immunodeficiency virus (HIV) can be transmitted. Which methods of infection transmission will the nurse educate the group about? Select all that apply.

contact with blood via sexual contact contact with wound openings via mucous membranes via syringes shared between the client and others All of these (with the exception of sweat) can transmit HIV.

A home health nurse is completing a health history for a client. What is one question that is important to ask to identify a latex allergy for this client?

"Have you had any unusual symptoms after blowing up balloons?" Awareness of a latex allergy is important for safe home care. Nurses need to ask whether clients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning.

The nurse is teaching a community group about transmission of HIV. Which client statement by a community member demonstrates that further teaching is needed?

"I can catch HIV by swimming in pools." HIV is not transmitted through swimming pools; further teaching is needed to clarify this point. The other client statements appropriately reflect how HIV is transmitted and do not require further teaching.

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?

"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.

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:

"You may have infection in your birth canal that you are unaware of." Viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract Escherichia coli resides in the intestinal tract, is normal flora, and does not cause harm or infection in the client. Shigellosis is an infectious disease caused by a group of bacteria called Shigella, closely related to E. coli. Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria.

The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection?

Hand hygiene Hand hygiene is the most effective way to control the spread of microorganisms. While it is true that the client may be less susceptible to illness when well rested, exposure to a pathogen can still result in influenza. Avoiding those with the flu is also appropriate; however, hand washing remains the best answer for prevention. Wearing a mask all season may or may not prevent the flu and is not the most reasonable choice.

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?

Hold sterile objects above waist level to prevent accidental 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 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 student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains

Stress causes the body to release cortisol, which can increase the risk of infection. Physical or emotional stress causes the body to release cortisol, which can increase the risk of infection by suppressing the immune response. Cortisol increases the level of serum glucose, providing a good medium for bacterial growth.

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:

Survival adaptation 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.

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?

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.

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne Tuberculosis is transmitted via the air. Therefore, airborne precautions are required. Standard, droplet, and contact precautions will not be selected by the nurse for a client who has tuberculosis.

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gown and gloves A client with Clostridium difficile requires contact isolation. Gown and gloves are the most appropriate options for this client; more so than goggles and gloves, respirator masks and gowns, and masks and shoe covers.

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift A new gown should be used by the nurse each time the nurse enters the room.

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

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

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. 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.

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?

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.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients 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) Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together. C. difficile requires contact isolation and is contagious. Diabetic ketoacidosis is considered a medical diagnosis and requires standard precautions. A surgical incision from an appendectomy is considered clean. A draining leg ulcer can transmit an infection to a client with a clean surgical incision. In both of these cases, rooming these clients together violates infection control standards. Tuberculosis requires airborne precautions and pneumonia requires standard precautions. Based on the mode of transmission of tuberculosis, these clients cannot room together.

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

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

What is an accurate guideline for the use of PPE?

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

The nurse is caring for a client with a surgical wound who is postoperative day 3. Which image best demonstrates the method for preparing a sterile field?

The nurse is expected to consider the edge (outer 1 inch or 2.5 centimeters) of a sterile field to be contaminated. Answer option C is the only image that adheres to this guideline when preparing a sterile field.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?

The nurse keeps fingernails less than 1/4 in (0.63 cm) long. 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.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason?

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

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?

remind the student that a fitted N95 respirator is required A fitted N95 respirator must be worn in addition to other precautions when caring for clients with pulmonary tuberculosis. The other answers do not recommend the appropriate precautions that must be used for this type of infection.

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.

"If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus to my child during pregnancy and childbirth." "I may transmit the virus if I share needles with another person." The client has demonstrated that an understanding of the transmission of the virus may occur through exposure to blood, during pregnancy and childbirth, and through sharing of needles. Transmission of the virus does not occur through sweat or by exposure on a toilet seat. The virus is fragile and does not live on inanimate objects.

The nurse is reviewing discharge instructions for a client who was prescribed amoxicillin to be taken twice a day. Which statement by the client would require further teaching?

"Once I start feeling better, I should stop taking the antibiotic." Causes of antibiotic drug resistant bacteria include prescribing antibiotics for viruses or self-limiting bacterial infections, not completing the full course of prescribed therapy, taking someone else's antibiotics, and sharing antibiotics with others. The nurse should instruct the client to continue taking the prescribed antibiotic even when feeling better. The client does not need additional instruction if he or she recognizes the need to call the health care provider if a rash develops or knows to store the antibiotic capsules at room temperature away from excessive heat and moisture. Taking an antibiotic on an empty stomach is not necessarily an indicator of the need for additional teaching. Some antibiotics can be taken or are required to be taken on an empty stomach. Not all antibiotics need to be taken with food or after eating.

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?

"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.

The nurse is discussing antiviral medication with a client diagnosed with human immunodeficiency virus (HIV). Which client statement indicates a need for further teaching?

"The antiviral medication will cure the virus from my body." The discovery and use of antiviral medications has turned once deadly viral infections, such as HIV, into chronic diseases. The antiviral will not cure the virus, however, it will decrease the viral load and limit multiplication of the virus. The antiviral medication will need to be taken daily for life.

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?

"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." 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.

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

"These barriers help prevent the transmission of infection to you or other people." Contact precautions block transmission of pathogens by direct or indirect contact Wearing a gown and gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing or even to others the visitors may come in contact with. While wearing gloves and gown may prevent sharing additional microorganisms with the client, that is not the reason for contact precautions. Agreeing that wearing the gown and gloves is not pleasant doesn't educate the family member.

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.

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 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 preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas. The correct order of putting on sterile gloves is as follows. First, the nurse should open the package, taking care not to touch the inner surface of the package or gloves. Then, the nurse should pick up the glove at the folded cuff with the thumb and forefinger and insert fingers while pulling the glove over the hand. Next, the nurse should place the finger of the gloved hand inside the cuff of the remaining glove, taking care not to touch outside of the folded cuff. Once both gloves are on, the nurse adjusts the gloves touching only sterile areas. If gloves are donned not following this order, there is an increased risk for contamination of the sterile gloves

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. 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.

The nurse is assessing older adult clients at a community health center. Which client is identified as being at the highest risk for developing an infection?

Client with immobility, incontinence, and dysphagia following a stroke Of the nurse's clients, the older adult with immobility, incontinence, and dysphagia following a stroke is at the highest risk for infection because immobility can result in skin breakdown, incontinence can result in a urinary tract infection and dysphagia can increase risk of aspiration and pneumonia. Uncontrolled diabetes and heart failure can result in hyperglycemia and decreased oxygenation. A history of tuberculosis may result in a reactivation of the disease if the client's immune system is decreased or compromised. Alcohol and substance use disorders increase the risks for stroke and for poor nutrition. However, the three clients with these conditions are at lower risk of infection than the client who suffered a stroke.

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?

Contact precautions 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.

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?

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.

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?

Disinfect it with alcohol swabs. 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.

What is the primary goal of the observable action associated with the removal of contaminated gloves?

Prevent contamination of ungloved hand The outside of gloves are considered contaminated and care must be take to prevent contamination of the ungloved hand during the glove removal process. Sliding fingers of the ungloved hand under the remaining glove at the wrist helps avoid contact with the contaminated outer surface of the remaining glove. While proper removal of the contaminated glove does preserve the cleanliness of the ungloved hand, contamination and not general cleanliness, is the primary focus of the ungloving process. Neither speed nor tearing is the focus of this process.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

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.

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. 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 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. 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.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

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

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

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

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?

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

Which clients are at a heightened risk for infection? Select all that apply.

client with gastric tube feeding client with an indwelling catheter client with an IV catheter 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.

Which nursing action is a component of medical asepsis?

handwashing after removing gloves 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).

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 most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath.

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?

health care-associated infection (HAI) HCAI, the most common adverse event in hospitals, are acquired within healthcare facilities. Community-acquired infections occur in the community. Infectious and contagious can be acquired in any setting.

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?

indwelling catheter 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.

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

urinary catheter Urinary catheters account for the highest percentage (26%) of hospital-associated infections. The four most common types of HAIs are related to invasive devices or surgical procedures: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated events (VAEs). A peripherally inserted catheter is an invasive line. Nasogastric tubes and endotracheal tubes are not associated with HAIs.