NURS 3111 Exam 3 Ch 24

a) Hold sterile objects above waist level to prevent inadvertent contamination Pg. 618 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. (2.5 cm) 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.

1. A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique? a) Hold sterile objects above waist level to prevent inadvertent contamination b) Consider the outside of the sterile package to be sterile c) Consider the outer 3-in. (8-cm) edge of a sterile field to be contaminated d) Open sterile packages so that the first edge of the wrapper is directed toward the nurse

b) Avoid contact with mosquitoes Pg. 598 Other Reservoirs Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate.

10. About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? a) Self-quarantine yourself for 2 weeks if you feel ill b) Avoid contact with mosquitoes c) Use a face mask when in crowds d) Use hand sanitizer after touching any public surface

a) True Pg. 611 PPE protects both the health care worker and clients from infection. It use interrupts the chain of infection.

14. Personal protective equipment (PPE) is used in health care facilities to protect the staff from potentially infected clients. a) True b) False

d) Cover exposed wrist skin Pg. 626 Gloves are intended to protect hands and wrists from exposure to microorganisms. This is best accomplished by extending the gloves up the arm to cover the cuffs of the gown. While the proper application of the gloves does anchor the cuffs, the primary purpose is directed at the risk management of microorganism expose to the wrists. This application has no value to adjusting for glove size or to prevent tearing of the glove.

21. What is the primary purpose for the demonstrated glove application? a) Help adjust for glove size b) Anchor gown sleeves c) Minimize risk of a glove tear d) Cover exposed wrist skin

a) Ambulation Ambulation helps to prevent the stasis of secretions. Invasive devices, breaks in skin integrity, and inadequate nutrition are all risk factors for infection.

4. A nurse is working with an 82-year-old man following gallbladder surgery. He is NPO. and has IV access in his hand. He also has a Foley catheter in place. He is able to ambulate with the aid of a walker. What does not lower this client's immunity? a) Ambulation b) Foley catheter c) Surgical incision d) IV access

b) Escherichia coli in the intestinal tract Pg. 598 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.

11. Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? a) Escherichia coli in the urinary tract b) Escherichia coli in the intestinal tract c) Shigella in the urinary tract d) Shigella in the intestinal tract

a) The nurse discards a sterile field when a portion of it becomes contaminated d) The nurse calls for help when realizing a supply is missing e) The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated Pg. 618 The nurse practitioner would follow several recommended guidelines when performing a biopsy on a client. First, the nurse would consider the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. The nurse would discard a sterile field when a portion of it became contaminated. The nurse would call for help when realizing a supply is missing. The nurse would not place the cap of an opened solution on the table with edges down. The nurse would not drop a sterile item on a sterile field from the height of 12 in (30 cm), rather 6 in (15 cm). The nurse would hold a wrapped item with the top flap opening away from the body.

12. A nurse is preparing a sterile field for the health care provider to perform a biopsy on a client. Which actions follow recommended guidelines for maintaining the sterile field for this procedure? Select all that apply. a) The nurse discards a sterile field when a portion of it becomes contaminated b) The nurse holds an agency-wrapped item with the top flap opening toward the body c) The nurse places the cap of an opened solution on the table with edges down d) The nurse calls for help when realizing a supply is missing e) The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated f) The nurse drops a sterile item on a sterile field from the height of 12 inches (30 cm)

d) Assess client's pain level and manage pain accordingly Encouraging clients to cough, breathe deeply, blow the nose, and move the body promotes clearance of respiratory secretions, which may become infected if allowed to pool in the lower respiratory tract. Retained secretions prevent adequate gas exchange at the alveolar level and reduce oxygen available to the tissues to combat infection, heal injured tissues, and meet metabolic needs. Secondary infections are commonly associated with impaired respiratory tract function. Timing is an important consideration when administering analgesics. To time analgesics appropriately, know the average duration of action for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense. For example, an analgesic would be offered before ambulating a patient postoperatively.

13. The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first? a) Inform the client that these exercises must be done at regular intervals b) Educate the client of the importance of infection prevention c) Inform the physician of the client's noncompliance d) Assess client's pain level and manage pain accordingly

b) "The way you are doing it helps to minimize contamination of the non-waterproof side" Pg. 618; 628-633 The sterile drape is to be positioned with the drape on work surface with the moisture-proof side down. It is important that only a sterile object touch another sterile object. Unsterile touching results in contamination of the sterile field. If this occurs, the procedure should be started again with new supplies. It is not okay to turn the drape on the other, non-waterproof side. This action will increase the risk for contamination.

15. 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? a) "Using either side of the drape is okay, as long as you do not contaminate the sterile supplies on the field" b) "The way you are doing it helps to minimize contamination of the non-waterproof side" c) "I use my whole hand to touch the non-waterproof surface before placing the sterile equipment on it" d) "It is okay to turn the drape on the other side"

c) Hand hygiene Pg. 603 Performing 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.

16. The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection? a) Avoid crowded areas and people who have the flu b) Good nutrition and getting enough rest c) Hand hygiene d) How to properly wear a mask during flu season

b) Prodromal Pg. 600 Stages of Infection Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature.

17. A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing? a) Resolution b) Prodromal c) Stationary d) Invasion

d) "As we age, our immune system does not function as well" Pg. 563 Neuroendocrine and Immunity Theories The nurse should explain that during the aging process, the immune system decreases in function and the older adult client is at greater risk for becoming infected. Other risk factors for the older adult client include poor nutrition and fluid intake. Although washing hands is an important part of the prevention of infection, there are other methods such as airborne and droplet transmission that may be unavoidable. When it comes to visitation, the only limitation that should be set is that those who are ill or possibly infected should refrain from visiting the client. Informing the client that nothing can be done is not accurate, as there are preventative measures that may be taken to avoid exposure.

18. An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond? a) "There are a lot of infectious processes around and there is nothing that can be done" b) "You will have to limit who comes to visit since they may be exposing you" c) "It is possible that you are not washing your hands well enough" d) "As we age, our immune system does not function as well"

d) Indwelling catheter Pg. 601 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.

19. 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? a) Bath blanket b) Face shields c) Specimen containers d) Indwelling catheter

a) Bacteria Pg. 610 Bacteria may be transmitted through air, food, water, soil, vectors, or sexual activity.

2. A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an): a) Bacteria b) Fungi c) Protozoa d) Virus

d) Exposure to the pathogen c) Nonspecific symptoms b) Positive laboratory tests a) Return of appetite During the communicable period, a person is exposed to the pathogen (incubation period), then develops nonspecific symptoms (prodromal period), then specific symptoms with positive laboratory test results (acute phase), and finally, a return to normal with appetite and energy returning (convalescent period).

20. A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period. a) Return of appetite b) Positive laboratory tests c) Nonspecific symptoms d) Exposure to the pathogen

a) Contact precautions Pg. 615 Contact precautions should always be used when coming into contact with contaminated body fluids. Gown and gloves should be worn and protective eyewear if splashing may occur. Droplet precautions are used there is a risk of transmitting pathogens within a 3-foot (1-meter) radius of the client when sneezing, coughing, etc. Neutropenic precautions are for the protection of the client due to immunosuppression. Airborne precautions should be instituted when exposure to microorganisms are transmitted by airborne route may occur.

22. 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? a) Contact precautions b) Neutropenic precautions c) Airborne precautions d) Droplet precautions

c) Bacterial infection If the infection is severe or prolonged, the body cannot manufacture neutrophils quickly enough, resulting in the release of immature granulocytes into the blood. This increase in the number of immature cells is called a shift to the left or leftward shift in the granulocyte differential count.

23. The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from: a) Hepatitis b) Viral infection c) Bacterial infection d) Chickenpox

b) "Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding" The immune system does not become fully operational until a baby reaches about 6 months of age (Shaw, Thalapial, Shaw, & Malla, 2007). Before then, the infant's resistance to infection comes from the antibodies passed by way of the placenta and breast milk. Newborns have difficulty localizing infections (preventing the spread of organisms from the site of contact). Their phagocytes have difficulty trapping microbes, and they do not produce enough antibodies. Newborns have immature thermoregulatory mechanisms and do not become febrile.

24. The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate? a) "Infections in newborns are rare because they have little difficulty localizing infections" b) "Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding" c) "It usually takes about a month or two until the baby's immune system to become completely functional" d) "If you notice that the newborn has a fever, then you need to have him seen by the doctor fairly quickly"

b) "Help me understand your perspective about vaccinating" Pg. 603 Seeking to understand the parent's perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. Vaccines have not been connected to autism; asking the parent "why" reflects demanding an answer; and vaccines are one of numerous ways to halt disease transmission.

25. The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response? a) "Vaccinations have been shown to contribute to autism" b) "Help me understand your perspective about vaccinating" c) "Vaccines are the only way to halt disease" d) "Why do you not want to vaccinate your child?"

a) The nurse places the client in a private room with monitored negative air pressure Pg. 615 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.

3. 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? a) The nurse places the client in a private room with monitored negative air pressure b) The nurse keeps visitors 3 feet away from the infected person c) The nurse uses droplet precautions when providing care for the client d) The nurse places the client in a private room with the door open

c) Removes gloves and walks out of the room Pg. 608 The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used as barriers to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients. Asking the client to state his or her name and date of birth is important to make sure the specimen is collected with the correct laboratory label. To protect the UAP from direct contact with the urine, a face mask is indicated.

5. 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? a) Performs hand hygiene before donning gloves b) Applies a mask with face shield c) Removes gloves and walks out of the room d) Asks the client to state name and date of birth

a) Review the current infection control protocols Pg. 608-610 The nurse manager that notes an increase in infection rates should first review the current infection control protocols. Reviewing the protocols can identify if the protocols are appropriate and being implemented by the staff. Prescribing antibiotics to all new residents will not decrease infections rates, but may increase the rate of antibiotic resistant bacteria. Culturing all residents and staff would identify infection, but not decrease the rates. Restricting visitors would not decrease rates.

6. The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement? a) Review the current infection control protocols b) Culture all residents and staff c) Restrict visitors to public places d) All new residents are prescribed antibiotics

b) Use a sterile cotton-tipped applicator to apply the prescription to the site Pg. 604; 618 Applying the ointment with the gloved finger contaminates the prescription ointment. Sterile cotton-tipped applicators are used to apply ointments or solutions to the wound bed to avoid contaminating the wound. A 4 × 4 gauze pad should not be applied until the wound is cleansed properly with sterile supplies. Soiled dressing supplies should be placed in a biohazardous trash bag or container.

7. 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? a) Apply a 1-in (2.5-cm) layer of the ointment to the site using the index finger b) Use a sterile cotton-tipped applicator to apply the prescription to the site c) Place sterile 4 × 4 gauze on the wound and secure the dressing with dressing with paper tape d) Put soiled dressing change supplies in the client's bathroom garbage and double bag

b) To protect both the staff and clients from becoming infected by one another Pg. 624-627

8. Personal protective equipment (PPE) is used in health care facilities for primarily which reason? a) To protect the hospital from legal liability b) To protect both the staff and clients from becoming infected by one another c) To protect clients from becoming infected by staff members d) To protect staff members from becoming infected by clients

b) "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" Pg. 612 Masks 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.

9. 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? a) "If you wash your hands before coming in contact with your friend you will prevent infection during your visit" b) "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" c) "You should not visit your friend if you have an infection of any kind because your friend may also get sick" d) "As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend"

a) Applying a new dressing with the gloves that were used to remove the old dressing Pg. 617 Gloves should be changed after removing the old dressing prior to putting on a sterile dressing, because the microorganisms from the old dressing can be transferred to the new dressing. The nurse should explain the procedure to the client before beginning and not during. The nurse should avoid talking over a sterile field as well as turning his or her back on sterile field to discuss the procedure with the client. The nurse should check that the packages are intact, ensure that the surface is dry, and open all packages before donning sterile gloves.

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection? a) Applying a new dressing with the gloves that were used to remove the old dressing b) Describing each step verbally to the client before performing the dressing change c) Checking that the sterile dressing packages are intact before opening d) Ensuring that the surface where the sterile field will be set up is dry