Foundations Ch. 24: Asepsis
A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?
"Antibiotics have no effect on viruses." Pg. 597
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?
"Wearing an N95 respirator is critical when I care for clients in droplet precautions." Pg. 613
The nurse suspecting that a client has an infected surgical wound should assess for which sign?
-Redness -Swelling -Pain -Exudate Pg. 600
Which nursing actions will be performed to assist in the prevention of health care-associated infections (HAIs)?
-Wash hands between caring for clients. -Recommend vaccinations to clients. -Educate clients regarding why antibiotics are not used for viral illnesses. Pg. 608
The nurse is preparing to provide wound care for a client who is on droplet precautions. Place the following steps in the correct order that the nurse should take. All options must be used.
1. Perform hand hygiene. 2. Put on gown, with the opening in the back and tie gown securely at neck and waist. 3. Apply mask with face shield, secure ties at the middle of the head and neck. 4. Put on clean disposable gloves. Pg. 615
The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.
1. Turn on the faucet and adjust force and temperature of the water. 2. Wet the hand and wrists. 3. Apply soap. 4. Wash the palms and backs of the hands for at least 20 seconds. 5. Pat the hands dry with a paper towel. 6. Turn the faucet off with a paper towel. Pg. 622-624
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. Pg. 613
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?
By the corners Image in Taylors Pg. 617; 629
Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?
Client with a urinary catheter Pg. 608
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?
Contact precautions Pg. 615
The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?
Contact precautions Pg. 615
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. Pg. 628
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?
Discard the sterile field and the supplies and start over. Pg. 640
The nurse is providing care for a client with varicella. What action should the nurse perform?
Ensure the client is housed in a negative pressure room Pg 615
An experienced nurse is educating a student nurse on the proper use of hand hygiene. What is an accurate guideline that should be discussed?
Hand hygiene must be performed after contact with inanimate objects near the client. Pg. 604- 605
A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step?
Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm). Pg. 632
The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?
In a bag marked "Biohazards" Pg. 614
The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?
Increases the risk of infection by contaminating the wound Pg. 1052
a disease state that results from the presence of pathogens (disease-producing microorganisms) in or on the body
Infection
A new nurse is caring for a client who has a prescription for a stool specimen analysis. As the nurse performs the procedure in the image, the charge nurse walks in to the client's bathroom and observes the new nurse obtaining the specimen. What is next priority action by the charge nurse?
Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids Pg 605;614
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 Pg. 600
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 Pg. 618
An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:
Recapping a needle Pg 616
A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. Which would be the appropriate action to take to maintain a sterile field?
Stop the procedure, remove damaged gloves, perform handwashing, and put on new sterile gloves. Pg 637
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?
Surgical asepsis Pg. 603
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?
The new nurse touches 1.5 in (4 cm) from the outer edges. Pg. 629
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. Pg. 615
The nurse is removing gloves after performing care for a client on droplet precautions. What action best adheres to principles of infection control?
Using 2 fingers to remove gloves while avoiding contact with the outside of the gloves Pg 626-627
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?
Wash area with soap and water Pg. 616
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 Pg. 606
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?
one that remains in the client's room Pg. 610