PrepU ch.24 asepsis &infection control

A client is placed on neutropenic precautions. What would be appropriate for the nurse to do? Select all that apply. -Place the client in a room with another client with neutropenia. -Keep the door closed. -Allow open visitation from family and friends. -Provide gentle oral care. -Remove any fresh flowers from the client's room.

-Keep the door closed. -Provide gentle oral care. -Remove any fresh flowers from the client's room. When neutropenic precautions are indicated, the client is placed in a private room; visitors are limited, especially children and people with signs of infection; the door is kept closed to limit airborne exposure; measures are taken to prevent any breaks in mucous membranes, including performing gentle oral care; and any sources of pathogens, such as fresh flowers or stagnant water, are removed from the client's room.

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply. -Sterile gloves -Nonsterile gloves -Mask -Gown -Hand hygiene

-Nonsterile gloves -Hand hygiene When taking vital signs on a client after surgery, the nurse should practice hand hygiene. There is no need to use a gown or mask unless the client is diagnosed or suspected to have a transmittable infection. Since it is an aseptic versus sterile procedure, the nurse should use nonsterile gloves.

Which client presents the most significant risk factors for the development of Clostridium difficile infection? a.An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis b.A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior c.A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft d.A client with renal failure who receives hemodialysis three times weekly

a. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Two common factors that increase a persons risk of becoming infected with C difficile are age greater than 65 and current or recent use of antibiotics. In this scenario, old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection? a.Exogenous healthcare-associated b.Endogenous healthcare-associated c.Iatrogenic d.Antibiotic-resistant

a. Exogenous healthcare-associated The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? a.Fungi b.Rickettsiae c.Protozoans d.Helminths

a. Fungi Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes.

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? a."I can't transmit the virus other people if I shake their hands." b."I probably got the virus when I sat on the toilet seat in a dirty bathroom." c."I received a blood transfusion in 1989, which could be a factor in contracting the disease." d."I may have gotten the virus when I got a tattoo while I was in prison."

b. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992. The virus cannot be contracted or spread through a toilet seat.

The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as: a.fungus. b.parasite. c.virus. d.bacteria.

b. parasite. Lyme disease is spread through the bite of an infected tick, an arthropod, which is classified as a parasite. The bacteria Borrelia burgdorferi causes Lyme disease in humans. Viruses cause numerous infections but are not associated with Lyme disease. Fungi also cause disease in humans but are not associated with Lyme disease.

A nurse is preparing to obtain a specimen for an anaerobic wound culture. The nurse would obtain the specimen from which area? a.Edge of the wound b.Area of active drainage c.Deep into the cavity d.Drainage on the dressing

c. Deep into the cavity The specimen for an anaerobic culture is obtained from deep in the cavity to identify organisms that may grow where oxygen is not present. When obtaining a specimen for an aerobic wound culture, the nurse would obtain the specimen from deep in an area of active drainage. Cultures are not taken from the edges of the wound or from the soiled dressing.

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: a.decreased b.elevated c.within normal limits d.stable

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

A nurse is caring for a client, age 4 months, following surgical repair of a tracheoesophageal fistula. When collecting the client's vital signs, the nurse notes her rectal temperature to be 103.1°F (39.5°C). The nurse knows what to be true of fever in young children? a.Young children who have temperatures this high will almost always have febrile seizures. b.Young children rarely mount a fever to an invading organism; this must be an error. d.Young children typically mount a fever after a surgical procedure and it should go away. d.Young children often have a vigorous immune response to infection and thus high fevers.

d. Young children often have a vigorous immune response to infection and thus high fevers. Children can frequently have fevers over 104°F (40°C). Young children are more prone to febrile seizures than adults. However, the overall percentage of children who have a febrile seizure is still relatively low. Young children frequently mount a high fever to an invading organism. A fever of 103.1°F (39.5°C) is not typical of a postoperative temperature elevation.

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply. -infectious disease -communicable disease -noncommunicable disease -contagious disease -health care-associated infection (HAI)

-infectious disease -communicable disease -contagious disease Infections disease, communicable disease, and contagious disease describe this type of illness. A noncommunicable disease is caused by food or environmental toxin. Health care-associated infections are acquired within a healthcare facility. Reference: Chapter 24: Asepsis and Infection Control - Page 595

The nurse of a local university is examining a student who has swollen glands and small painful lesions of the mouth. The nurse expects to palpate swelling in the neck area because: a.lymphedema has been caused by lymphatic obstruction. b.lymphocytes and macrophages invade the lymph nodes. c.there will be tumor formation in the lymph nodes. d.the tonsils are the likely source of infection.

b. lymphocytes and macrophages invade the lymph nodes. The swelling indicates that lymphocytes and macrophages in the lymph nodes are fighting the infection and trying to limit its spread.

A nurse is applying the principles of standard precautions on a hospital unit. In which instances should the nurse perform hand hygiene? Select all that apply. -Before touching a surface in a common area -Immediately after touching a client -Before performing a clean procedure -Between each phase of a client's assessment -After touching a client's surroundings

-Immediately after touching a client -Before performing a clean procedure -After touching a client's surroundings Hand hygiene is necessary immediately after touching a client, before performing a clean procedure, and after touching a client's surroundings. It is not normally necessary to perform hand hygiene before touching a common area or between each individual phase of a client's assessment. Reference: Chapter 24: Asepsis and Infection Control - Page 622-623

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

-Pain with redness and swelling -Localized heat -Purulent or malodorous drainage Signs of infection of the client's foot ulcer that the nurse includes in discharge teaching include redness, swelling, and pain; localized heat; and purulent or malodorous drainage. If the inside edges of the ulcer appear to be drawing together and/or if scabs are forming over the ulcer, the ulcer is likely to be healing.

A nurse at the health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action(s) is appropriate by the nurse when using masks? Select all that apply. -Position the mask so that it covers the nose and mouth. -Avoid touching the mask once it is in place. -Change the mask if it becomes damp. -Discard used masks into a regular wastebasket. -Touch only the strings of the mask during removal.

-Position the mask so that it covers the nose and mouth. -Avoid touching the mask once it is in place. -Change the mask if it becomes damp. -Touch only the strings of the mask during removal. The nurse should avoid touching the mask once it is in place because touching the mask transfers microorganisms to the hands. The mask should be changed every 20 to 30 minutes or when it becomes damp, to preserve its effectiveness. The nurse should touch only the strings of the mask during removal to prevent transfer of microorganisms to the hands. The mask should be positioned over the nose and the mouth to provide a barrier to nasal and oral ports of entry. The nurse should discard used masks into a lined or waterproof waste container and not a regular wastebasket. Reference: Chapter 24: Asepsis and Infection Control - Page 612

After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply. -Used syringe with attached needle -Used fingerstick lancet -Blood-soiled dressings -Cotton-tipped applicator used for wound cleaning -Chemotherapy solution container

-Used syringe with attached needle -Used fingerstick lancet Injurious wastes include needles, scalpel blades, lancets, broken glass, pipettes and aerosol cans. Blood-soiled dressings or contaminated cotton-tipped applicators would be considered infectious waste. Chemotherapy solution containers would be considered hazardous waste.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene? a.The nurse uses gloves in place of hand hygiene. b.The nurse keeps fingernails less than 1/4 in (0.63 cm) long. c.The nurse uses hand hygiene instead of gloves when in contact with blood. d.The nurse refrains from using hand moisturizer following hand hygiene.

b. 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.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? a.Perform hand hygiene b.Don a new pair of gloves to dispose of materials c.Wrap all used materials together and discard in biohazard container d.Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

a. Perform hand hygiene Inverting the gloves into each other encloses the soiled surface and blocks a potential exit route for microorganisms. After removing gloves, the next step would be to perform hand hygiene which should be conducted before touching the loved one. Used materials are not always disposed of in biohazard containers. Donning new gloves should not be necessary as materials should have already been disposed of prior to removing the gloves. Lotions that work in conjunction with soaps and lotions should be used when applying lotion after performing hand hygiene but this is not the next step.

Which action is the best example of a nurse donning/removing protective equipment properly? a.Removing respirator after leaving client's room b.Removing gown after leaving client's room c.Donning gown after entering client's room d.Donning respirator inside of client's room

a. Removing respirator after leaving client's room The best example of proper utilization of protective equipment is the removal of a respirator after leaving the client's room, as doing so prevents contact with airborne microorganisms. Gowns should be removed before leaving the client's room. Gowns and respirators should be donned prior to entering the client's room.

Which should be documented by the nurse? a.The fact that sterile technique was used for a given procedure b.The fact that the nurse donned gloves two different times during a procedure c.The fact that the nurse washed her hands before a procedure d.The specific items that the nurse transferred into a sterile field

a. The fact that sterile technique was used for a given procedure The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

A nurse instructs a new mother on immunizations. An immunization produces: a.active immunity b.humoral immunity c.passive immunity d.antigen immunity

a. active immunity n:Active immunity can be produced by vaccination. Vaccination is the process of injecting weakened or killed organisms into a person, stimulating antibody production.

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? a.fold soiled side to the inside and roll with inner surface exposed b.fold soiled side to the outside and roll with outer surface exposed c.fold soiled side to the inside and roll with outer surface exposed d.fold soiled side to the outside and roll with inner surface exposed

a. fold soiled side to the inside and roll with inner surface exposed To dispose of the gown, the nurse will fold the soiled side to the inside and roll with the inner surface exposed. The other answers are incorrect.

A nurse is caring for four clients. Which client has the highest risk of infection? a.older male with an enlarged prostate b.toddler with a benign heart murmur c.woman in second trimester of pregnancy d.young woman with a history of scoliosis

a. older male with an enlarged prostate An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on infection.

The nurse is creating a care plan for a client. Risk for Infection is the identified problem. Which situation supports this problem? a.the client with a urinary catheter inserted at the emergency department b.the client who is on contact precaution for Clostridium difficile c.a cancer client who is in remission for the past year d.a client whose wound has exudate drainage

a. the client with a urinary catheter inserted at the emergency department In the diagnosis Risk For Infection, the client is vulnerable to invasion and multiplication of pathogenic organisms which may compromise health. Risk for Infection relates to a foreseen problem that can cause infection if prevention is not initiated, followed, and maintained.

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: a.droplet precautions. b.universal precautions. c.reverse precautions. d.body-substance isolation.

b. universal precautions. Universal precautions protect health care workers from the blood and certain body fluids of clients who may be carrying HIV, hepatitis B virus, or other bloodborne pathogens. Reference: Chapter 24: Asepsis and Infection Control - Page 617

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into? a.S= Situation b.B= Background c.A= Assessment d.R= Recommendation

c. A= Assessment Drug therapy can cause defects in the host's response to infection. Steroids, chemotherapy, antimetabolites, and inappropriate or prolonged use of antibiotics can increase the risk of infection. Superinfection can and often does occur in these situations. For example, if the course of antibiotic administration is prolonged, prematurely stopped, or an incorrect antibiotic is chosen, bacterial growth may be stimulated as normal flora in the gut, mouth, and skin are destroyed. Invading organisms can take advantage of the alteration in the normal flora, leading to serious infection in the host. SBAR: Situation, Background, Assessment, and Recommendations (SBAR) is a shared mental model for improving communication between and among clinicians. Note that situation, background, and assessment are all based on the collection of complete and accurate assessment data. The last piece, recommendations, encompasses the nurse's suggestions for the next interventions. Situations: What is happening at the present time? Background: What are the circumstances leading up to this situation? Assessment: What do I think the problem is? Recommendations: What should we do to correct the problem?

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student? a.The use of gloves eliminates the need for hand hygiene. b.The use of hand hygiene eliminates the need for gloves. c.Hand hygiene is needed after contact with objects near the client. d.Hand lotions should not be used after hand hygiene.

c. Hand hygiene is needed after contact with objects near the client. Hand hygiene must be performed when moving from a contaminated body site to a clean body site during client care and after contact with inanimate objects near the client. Using gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still be used after hand hygiene. Lotions may be used to prevent irritation. Reference: Chapter 24: Asepsis and Infection Control - Page 622

A nurse has put on personal protective equipment (PPE) to perform the dressing change of a client's surgical wound. While the nurse is cleansing the incision, the client begins bleeding and blood hits the nurse's wrist, running down under the cuff of her glove. What is the nurse's best action? a.Perform thorough hand hygiene immediately after completing the dressing change. b.Rinse the infected hand with hydrogen peroxide after applying a sterile bandage to the client's wound. c.Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol. d.Remove the contaminated gloves and apply a clean pair of gloves.

c. Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol. If the nurse is accidentally exposed to blood, it is necessary to stop the task and immediately follow facility protocol for exposure, including reporting the exposure. It would be unsafe to proceed with the dressing change before addressing the exposure. Applying new gloves does not eliminate the exposure. Reference: Chapter 24: Asepsis and Infection Control - Page 624-627

The charge nurse observes the licensed practical nurse (LPN) removing personal protective equipment (PPE). Which action by the LPN warrants intervention from the charge nurse? a.The LPN removes gloves by grasping the outside of one glove without touching the wrist with the gloved hand. b.The LPN removes goggles while only touching the ear pieces. c.The LPN removes the mask by untying the top of the mask first. d.The LPN removes the gown by rolling it into an inside out ball.

c. The LPN removes the mask by untying the top of the mask first. The face mask should be untied at the bottom first. This helps to prevent the top of the mask from flopping forward and potentially exposing the nurses face to the dirty side of the mask. To remove PPE goggles appropriately, the nurse should handle them by the earpieces to lift away from the face. Gloves should be removed without touching the hand to prevent contaminating the skin. Gowns should be rolled into an inside out ball when removed to prevent exposure from contaminated surfaces of the gown. Reference: Chapter 24: Asepsis and Infection Control - Page 627

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? a.remind others to use a mask when caring for this client b.recognize that this type of infection requires droplet precautions c.be sure that there are gloves of various sizes and gowns for use d.include a N95 respirator mask for health care staff entering the room

c. 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.

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile? a.goggles and gloves b.respirator mask and gown c.gown and gloves d.mask and shoe covers

c. 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.

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens? a.wear gloves and a gown when transporting the specimen b.place each of the three sealed specimens in a separate paper bag c.place the specimens into plastic biohazard bags d.swab the outside of each specimen container with alcohol prior to transport

c. place the specimens into plastic biohazard bags Specimens should be placed in sealed plastic bags to prevent them from becoming contaminated or causing the transmission of infective microorganisms. Paper bags are not used for this purpose, and it is not customary to swab the outsides of specimen containers. Standard precautions should be implemented, but this does not necessitate the use of a gown in all cases.

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? a.very hot coffee b.recent bed bath c.respiratory infection d.loose stool

c. respiratory infection Assess vital signs frequently to detect infection or to monitor its progress. The accuracy of such assessment is important in determining if infection is present. In client with an infection, look for elevations in temperature (above 38.4°C [101°F]), pulse rate, and respiratory rate.

Which term describes foreign particles that enter a host and stimulate the body's immune response? a.Macrophage b.Phagocyte c.Antibody d.Antigen

d. Antigen Antigens are foreign particles, such as microbes, that enter a host.

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client? a.Place the client in a private room that has monitored negative air pressure. b.Keep visitors 3 feet (1 m) from the client. c.Use respiratory protection when entering the room. d.Wear gloves whenever entering the client's room.

d. Wear gloves whenever entering the client's room. Contact precautions are used for clients who are infected or colonized by a microorganism that spreads by direct or indirect contact, such as MRSA, vancomycin-resistant enterococci (VRE), or vancomycin-intermediate Staphylococcus aureus (VISA). Gloves should be worn when entering the client's room. Use of negative air pressure and respiratory protection are appropriate with airborne precautions. Keeping visitors 3 ft (1 m) away from the client is a droplet precaution.

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique? a.picking up the gown at the sterile neckline b.holding the gown away from the body and other unsterile objects c.unfolding the gown while avoiding contact with the floor d.inserting an arm within each sleeve while touching the outer surface of the gown

d. inserting an arm within each sleeve while touching the outer surface of the gown To maintain sterile technique while donning the sterile gown, the gown should be picked up at the sterile neckline to preserve the sterility of the outer gown surface. Holding the gown away from the body and any unsterile surfaces or objects prevents contamination of the sterile gown. Allowing the gown to unfold and not touch the floor in the process will prevent contamination. The nurse should intervene and supply a new gown when observing the surgical technician touching the outer surface of the gown.