Chapter 25 - PrepU

Surgical asepsis technique

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

an infectious disease.

A client presents with a sore throat, malaise, and loss of appetite. The nurse assesses the client and identifies white-yellow exudates in the back of the throat and a fever. The nurse should ensure the primary care provider assesses the client for:

Inform the health care provider about this finding.

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?

"Stress leads to increased secretion of cortisol, which suppresses your immune response."

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?

stimulation of T lymphocytes

A client with an intact immune system has been exposed to Mycobacterium tuberculosis, initiating a cellular immune response. This response will begin with what physiological process?

WBC of 25,000 mcL

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

Heart rate 110 beats/minute Respiratory rate of 26/minute Chills

A nurse is assessing a client with an infection and suspects that the client may be developing systemic inflammatory response syndrome. What would support the nurse's suspicions? Select all that apply. Temperature of 37.4°C Heart rate 110 beats/minute Respiratory rate of 26/minute Chills Polyuria

perform hand hygiene before and after entering the client's room

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?

Basophils Neutrophils Eosinophils (Explanation: Granulocytes include neutrophils, eosinophils, and basophils. T-lymphocytes and monocytes are agranulocytes.)

A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply. Basophils T-Lymphocytes Monocytes Neutrophils Eosinophils

ear infections

The nurse is assessing a 3-year-old child and is aware that the child's eustachian tubes are shorter and straighter than those of an adult. The nurse will consequently prioritize assessment for what health problem?

Palpate the side of the client's neck with three fingertips.

The nurse is assessing a client who has symptoms consistent with an infection. When palpating the client's lymph nodes, what action should the nurse perform?

"Because of the tuberculosis, I need to follow airborne precautions for protection."

The nurse is caring for a client admitted with tuberculosis. The client asks why the nurse wears a respirator, gown, and gloves whenever they are in the room. How should the nurse respond?

Standard precautions such as gloves and hand hygiene Move client to a private room for safety precautions Transmission-based precautions including proper disinfecting of equipment

The nurse is caring for a client who developed a urinary tract infection while hospitalized. What intervention(s) will the nurse initiate to care for this health care-associated infection? Select all that apply. Standard precautions such as gloves and hand hygiene Wear mask, eye protection, and gown for all client contact Move client to an airborne infection isolation room Move client to a private room for safety precautions Transmission-based precautions including proper disinfecting of equipment

Place a surgical mask on the client and transport to the CT department at the specified time.

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?

Remove fresh fruit from the room.

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

House the client in a private room with a securely closing door.

The nurse is caring for a client who is on neutropenic precautions following a bone marrow transplant. When applying infection control principles to this client's care, the nurse will perform what action?

"The way you are doing it helps to minimize contamination of the non-waterproof side."

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. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?

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

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

The LPN is donning personal protective equipment appropriately.

The nurse is caring for a client with a cough and copious secretions. Before providing care, the nurse observes the licensed practical nurse (LPN) standing outside the client's room and donning personal protective equipment as shown above. How should the nurse best interpret the LPN's actions?

contact

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

droplet

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin?

The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room.

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 with soap and water? Select all that apply. The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room. The nurse is exiting a room after completed indwelling urinary catheter care. The nurse has assisted a client with changing and caring for a new colostomy.

81-year-old client with active tuberculosis and a productive cough

The nurse is caring for the following clients. Which client requires a negative air flow room?

"Has any one in the family recently been sick?" "Have you been frequently out in the community?" "Are you taking steroids?"

The nurse is conducting assessment on a client with cancer who is undergoing treatments. The client reports having the flu. Which question(s) should be asked? Select all that apply. "Has any one in the family recently been sick?" "Have you been frequently out in the community?" "Could the drugs used in your treatment be causing the flu?" "Have you recently received blood transfusion?" "Are you taking steroids?"

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

handwashing

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?

an older adult client with a history of heart failure

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

The new nurse touches 1.5 in (4 cm) from the outer edges. (Explanation: Only the outer 1 in (2.5 cm) of the sterile package is safe to touch.)

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?

MRSA in the wound

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?

Drop the item from 6 in (15 cm) above the sterile field.

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take?

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

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

wearing a particulate respirator for all care and interaction with this client

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

81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

Which client presents the most significant risk factors for the development of Clostridioides difficile infection?

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.

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

a client with a bladder outlet obstruction who has a urinary catheter in place

Which of the nurse's four clients would the nurse monitor most closely for infection?

Gloves (Explanation: The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.)

Which piece of personal protective equipment (PPE) should be removed first?

respiratory infection

The nurse notes that the client's temperature is 101.2°F (38.4°C) at 8 a.m. Elevated temperature may be due to several factors. What could be the reason for this?

Immediately deposit the uncapped needle into a puncture-proof plastic container.

A nurse is administering a client's prescribed insulin subcutaneously. To reduce the risk of a needlestick injury after administration, which action should the nurse perform?

removes gloves and walks out of the room

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

increased respiratory rate lymph node enlargement fever

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply. decreased pulse rate increased respiratory rate absence of pain lymph node enlargement fever

The nurse places the client in a private room with monitored negative air pressure.

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?

Fungi

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

A commercially packaged surgical item is not considered sterile if past expiration date.

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?

older adult

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?

Greater than 40.5°C

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

absence of all microorganisms.

Surgical asepsis is defined as:

Early infection treatment is needed to prevent the spread of infection.

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?

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

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

Airborne

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?

Survival adaptation

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:

"All visitors who enter the room must wear N95/surgical masks."

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

antigens

A client is fighting an infection because foreign particles have entered the client's body, stimulating an immune response. These foreign particles are described as what?

surgical asepsis

A client is scheduled for an inguinal hernia repair and is concerned about the possibility of developing a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

"I will obtain a mask from the staff and wash my hands before touching my family member."

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?

T-lymphocytes

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

helps to determine prescribed antibiotic therapy

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

Keep hands lower than elbows to allow water to flow toward fingertips.

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter?

Avoid touching the outer surfaces of the gown.

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?

The client will state how to safely take the prescribed antibiotic.

A nurse has identified the client's lack of knowledge regarding their prescribed antibiotic therapy. Which outcome is appropriate for the nurse to include in the client's care plan based on this nursing concern?

decreased cellular immunity.

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

an incontinent client in a nursing home who has diarrhea

For which client would the use of standard precautions alone be appropriate?

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

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?

"These results indicate that you are colonized with MRSA."

On a preoperative surgical unit, as a standard of care, all clients are swabbed for methicillin-resistant Staphylococcus aureus (MRSA). Prior to his surgery, a nurse notes that a specific client's results have come back positive. the client ask the nurse what this means. What is the nurse's best response?

within normal limits

The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

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

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?

White blood cells ingested and destroyed microorganisms.

The client was exposed to an infectious microorganism but did not develop a systemic infection because phagocytosis took place. What process took place during this response to microbes?

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

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?

Stop and obtain appropriate PPE.

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse?

an 80-year-old woman

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

When hands are visibly soiled

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?

"I do not need to wash my hands if I am using gloves."

The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states:

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

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?

Use a sterile cotton-tipped applicator to apply the prescription to the site

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

applying a new dressing with the gloves that were used to remove the old dressing

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?

Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.

Pain with redness and swelling Localized heat Purulent or malodorous drainage

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 Inside edges of the ulcer appear to be drawing together Scabs forming over the ulcer

"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."

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?

Explanation: 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 will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?

Incentivizing health care workers to utilize hand hygiene

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?

Incubation period Prodromal stage Full stage of illness Convalescent period

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. Incubation period Prodromal stage Full stage of illness Convalescent period

The client is experiencing inflammation.

What assessment finding most clearly suggests that a client is experiencing the second line of defense to microbial invasion?

Discard the bottle and get a new one because the saline has expired. (Explanation: Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening.)

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?

Removing respirator after leaving client's room

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

Filtered respirator

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