Saftety and Infection Control

When suctioning a client with a tracheostomy, what is the most important safety measure the nurse must remember? 1. Use a new sterile catheter with each insertion. 2. Initiate suction only as the catheter is being withdrawn. 3. Insert the catheter until the cough reflex is stimulated. 4. Remove the inner cannula before inserting the suction catheter.

2. Initiate suction only as the catheter is being withdrawn. Rationale: Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection and the catheter should only be inserted approximately 1 to 2 cm past the end of the trach tube to prevent tissue trauma.

A client who is HIV positive is admitted with a diagnosis of Kaposi's sarcoma. The nurse should institute appropriate precautions knowing that HIV is highly transmitted through: {Select all that apply.) 1. feces. 2. blood. 3. semen. 4. urine. 5. sweat. 6. tears.

2. blood. 3. semen. Rationale: HIV, which is the virus that causes AIDS, is transmitted through infected blood and semen. Although the virus may be found in other body secretions, the amount of virus is thought not to be sufficient enough to be transmitted.

Which physical assessment finding is most indicative of a systemic infection? 1. Nasal drainage 2. Bilateral 3+ pitting pedal edema 3. Oral temperature of 101.1° F 4. Pale skin and nailbed color

3. Oral temperature of 101.1° F Rationale: An elevated temperature is most indicative of a systemic infection. Pale skin and nailbeds and nasal drainage may be related to an infectious process but not necessarily. Pedal edema is generally not related to an infectious process.

A client had a liver biopsy performed. The nursing action of highest priority to prevent postprocedure hemorrhage would be to place the client: 1. supine and flat in bed. 2. in a sitting position on the edge of the bed. 3. on the right side. 4. on the left side.

3. on the right side. Rationale: Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation.

An education program is being conducted on standard precautions. The nurse understands that a primary purpose of standard precautions with all clients is: 1. to prevent nosocomial infections. 2. to protect clients from AIDS. 3. to protect employees from HIV and HBV. 4. to replace other isolation requirements.

3. to protect employees from HIV and HBV. Rationale: Standard precautions are a combination of universal precautions and body substance isolation. They are designed for the care of all clients in health care facilities regardless of their diagnosis or presumed infection status. Standard precautions apply to nonintact skin, mucous membranes, blood, and all body fluids, secretions, and excretions except sweat. A major benefit of adhering to standard precautions for health care personnel is protection from pathogens such as HIV and HBV.

A client who had a cardiac catheterization through the femoral artery is found to have a large amount of blood under his buttocks. Which of the following actions should the nurse take first? 1. Call the physician. 2. Obtain vital signs. 3. Change the client's gown and bed linens. 4. Apply gloves and assess the catheterization site.

4. Apply gloves and assess the catheterization site. Rationale: Observing standard precautions is the first priority when dealing with any body fluid. Assessment of the catheterization site is the second priority. This action establishes the source of the blood and determines how much blood has been lost. The priority goal is to stop the bleeding and ensure stability of the client by monitoring the vital signs. The physician should be notified after interventions are initiated to control the bleeding.

A client is being admitted to a medical unit with a diagnosis of tuberculosis. Which type of room should this client be assigned by the nurse? 1. Private room 2. Semiprivate room 3. Room with windows that can be opened 4. Negative airflow room

4. Negative airflow room Rationale: Tuberculosis is an airborne contagious disease that is best contained in a negative airflow room. Negative airflow rooms are always private. Opening windows would present a possible safety hazard in a client's room.

A client is diagnosed with AIDS. The nurse recognizes that an opportunistic infection is present when the oral cavity is examined and white plaques are discovered on the mucosa. What does this finding mostly likely represent? 1. Cytomegalovirus 2. Histoplasmosis 3. Candida albicans 4. Human papillomavirus

3. Candida albicans Rationale: White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike fungal infection. This condition is also known as "thrush."

The partial thromboplastin time, or PTT, is a test used to measure blood coagulation. Which drug would directly prompt the nurse to monitor the PTT? 1. Aspirin 2. Warfarin (Coumadin) 3. Heparin 4. Phytonadione (vitamin K)

3. Heparin Rationale: Heparin directly affects fibrin clot formation by prolonging the process. Warfarin (Coumadin) prolongs prothrombin time (PT). aspirin decreases platelet aggregation, and phytonadione (vitamin K) is necessary for prothrombin formation and is used as an antidote for warfarin.

A nurse discusses the procedure for protective isolation with the husband of a client who is receiving chemotherapy and has been hospitalized for neutropenia. Which statement made by the husband indicates the teaching was effective? 1. "Protective isolation helps prevent the spread of infection to my wife from the outside environment." 2. "Protective isolation helps prevent the spread of infection from my wife to health care personnel and visitors." 3. "Protective isolation helps prevent the spread of infection from my wife by using special techniques to destroy infectious fluids and secretions." 4. "Protective isolation helps prevent the spread of infection to my wife by using special sterilization techniques for her linens and personal items before use."

1. "Protective isolation helps prevent the spread of infection to my wife from the outside environment." Rationale: Protective isolation implies the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective isolation is also referred to as reverse isolation.

A client is determined to have an impending anaphylactic reaction secondary to a drug hypersensitivity. What should be the first action for the nurse to perform? 1. Administer oxygen. 2. Insert an IV catheter. 3. Take the vital signs. 4. Obtain an arterial blood gas analysis.

1. Administer oxygen. Rationale: Giving oxygen should be the first action of the nurse for this client. With anaphylaxis there is bronchial constriction and subsequent vascular collapse. The airway is of primary concern. The vital signs should then be checked and the physician notified immediately. At this point it would be appropriate to insert an IV catheter and possibly obtain an arterial blood gas to determine oxygenation status. The IV is initiated in order to administer required medications.

A nurse administering immunizations is preventing infection by which of the following mechanisms? 1. Enhancing the defenses of the host 2. Eliminating the mode of transmission 3. Introducing a weak secondary infection 4. Blocking the immune response of the host

1. Enhancing the defenses of the host Rationale: Immunizations and vaccines enhance the immunological defenses of the host by stimulating the production of protective antibodies (active immunization) or by the actual administration of antibodies for specific diseases (passive immunization).

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Select all that apply.) 1. Oral temperature 98.2° F 2. Apical pulse 88 beats per minute and regular 3. Respiratory rate of 30 per minute 4. Blood pressure 116/78 mm Hg while in a sitting position 5. Oxygen saturation of 92%

1. Oral temperature 98.2° F 2. Apical pulse 88 beats per minute and regular 4. Blood pressure 116/78 mm Hg while in a sitting position Rationale: The client's temperature, pulse, and blood pressure are within normal ranges; however, the respirations are mildly elevated and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age-group would be 12 to 20 per minute and oxygen saturation level should be >95%.

A nurse is teaching a new nursing assistant about ways to prevent the spread of infection. Included in the instruction would be that the cycle of the infectious process must be broken, which may be accomplished primarily through: 1. handwashing before and between providing client care. 2. thoroughly cleaning the environment. 3. wearing infection control-approved protective equipment when providing client care. 4. using medical and surgical aseptic techniques at all times.

1. handwashing before and between providing client care. Rationale: Handwashing is the single most effective means of preventing the spread of infection by breaking the cycle of infection.

A nurse receives reports on the following clients. Which client should the nurse assess first? 1. 25-year-old male with a hemoglobin of 15.9 2. 56-year-old female client on warfarin (Coumadin) with a PT of 35.6 seconds 3. 38-year-old female client with a serum calcium level of 9.4 4. 45-year-old male client with a BUN of 20 and a creatinine of 1.1

2. 56-year-old female client on warfarin (Coumadin) with a PT of 35.6 seconds Rationale: The 56-year-old client on warfarin (Coumadin) with a PT of 35.6 should be assessed first by the nurse because this is an elevated result. Normal is considered between 12 and 15 seconds. It may be considered therapeutic because the client is on warfarin-, however, the nurse should still assess for bleeding and stability. The nurse should consult with a physician to determine whether the PT is considered within the desired therapeutic range, and bleeding precautions should be implemented. The other results are within normal ranges.

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1. Skin breakdown 2. Aspiration pneumonia 3. Retention ileus 4. Profuse diarrhea

2. Aspiration pneumonia Rationale: The potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying semi-Fowler's or higher.

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? 1. Pull the fire alarm on the unit. 2. Assist in removing any clients in immediate danger. 3. Obtain a fire extinguisher and report to the fire area. 4. Close all windows and fire doors and await further instructions.

2. Assist in removing any clients in immediate danger. Rationale: The nurse is following the standard fire safety procedure RACE: R represents removing any clients from immediate danger, A represents alarming or activating the fire alarm. C represents containing the fire source, and E represents extinguishing and/or evacuating.

A 62-year-old male client is being discharged home from the hospital. During his stay, he acquired a nosocomial infection, Clostridium difficile. In preparing a teaching plan for the client and caretaker, which priority point would the nurse include? 1. Report any constipation to your physician immediately. 2. C. difficile causes diarrhea accompanied by flatus and abdominal discomfort. 3. The client should consume a diet high in fiber and low in fat. 4. No special cleaning or disinfection will be required in the home.

2. C. difficile causes diarrhea accompanied by flatus and abdominal discomfort. Rationale: The main clinical manifestation of Clostridium difficile is diarrhea accompanied by excessive flatus and abdominal discomfort. Constipation is not associated with this infectious disease. Clients should follow a nutritionally balanced diet with no specific restrictions. Cleaning and disinfection of items in the home is key to preventing spread of the infection because the C. difficile spore is relatively resistant.

An adult client has a nosebleed. After applying pressure, which action should the nurse take next? 1. Assess for trauma 2. Check the blood pressure 3. Instruct not to pick the nose 4. Check the pulse

2. Check the blood pressure Rationale: Of the choices provided, the first action of the nurse should be to check the client's blood pressure. Nosebleeds can be indicative of high blood pressure in an adult.

Which of the following would be an inappropriate use of a restraint device? 1. Preventing a confused client from pulling out an IV 2. Keeping an older adult client from getting up at night because of not being able to sleep 3. Keeping a client's leg immobilized to prevent dislodging a skin graft 4. Preventing an older adult client from falling out of bed

2. Keeping an older adult client from getting up at night because of not being able to sleep Rationale: Restraints are indicated for client protection from injury and to maintain essential medical therapies. Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for being unable to sleep and for safety needs before consideration of any restraint device.

A client with hyperthyroidism has been treated with radioactive iodine (l3ll) to destroy overactive thyroid gland cells. Which intervention is best for the nurse to use to reduce radiation exposure? 1. Wear a lead-shield apron. 2. Limit time spent with the client and limit distance. 3. Wear a radiation meter to measure exposure. 4. Remain at least 6 feet away from the client at all times.

2. Limit time spent with the client and limit distance. Rationale: When caring for clients who are radioactive, the three most important concepts for reducing radiation exposure are to limit exposure time, increase distance, and use shielding. In this situation, time and distance provide the best reduction in radiation exposure.

A nurse observes a colleague preparing a medication for IV bolus administration. Which medication being prepared should prompt the nurse to immediately intervene? 1. Saline flush 2. Potassium chloride 3. Naloxone (Narcan) 4. Adenosine (Adenocard)

2. Potassium chloride Rationale: Potassium chloride given as an IV bolus can cause cardiac arrest. It should never be administered IV without being diluted and infused slowly through an IV infusion pump. Saline flush, naloxone (Narcan), and adenosine (Adenocard) are appropriate to be given IV bolus undiluted.

A client is to begin IV antibiotic therapy for a pulmonary infection. What should be completed before the first dose of antibiotic is administered? 1. Urinalysis 2. Sputum culture 3. Chest x-ray 4. Red blood cell count

2. Sputum culture Rationale: A sputum specimen is obtained for culture to determine the causative organism, then a broad-spectrum antibiotic may be given. After the organism is identified, an organism-specific antibiotic can be prescribed. Cultures are always obtained before antibiotics are administered.

A client is receiving a unit of packed red blood cells. The client experiences tingling in the fingers and headache. What is the nurse's priority action? 1. Call the physician. 2. Stop the transfusion. 3. Slow the infusion rate. 4. Assess the IV site for infiltration.

2. Stop the transfusion. Rationale: Tingling in the fingers and headache may be an indication of an adverse reaction to the transfusion. The infusion should be stopped, and normal saline should be used to KVO. The client should be assessed—including vital signs—then the physician should be notified.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1. Lay the client down on the left side. 2. Lay the client down on the right side. 3. Apply a petroleum gauze dressing over the site. 4. Prepare to reinsert a new chest tube.

3. Apply a petroleum gauze dressing over the site. Rationale: A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. A petroleum gauze dressing will also allow for excessive air to escape, preventing a tension pneumothorax. The physician should be notified and the client assessed for signs of respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment. Positioning the client on either the left or right side will not make a difference in outcome.

A client is ordered to receive morphine via patient controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? 1. Temperature 2. Neurological status 3. Respirations 4. Urinary output

3. Respirations Rationale: The nurse must be especially alert to any changes in respirations because morphine decreases the respiratory center function in the brain. An order for morphine should be questioned if the baseline respirations are less than 12 per minute.

Which activity would be best in preventing septic shock in the hospitalized client? 1. Maintaining the client in a normothermic state 2. Administering blood products to replace fluid losses 3. Using aseptic technique during all invasive procedures 4. Keeping the critically ill client immobilized to reduce metabolic demands

3. Using aseptic technique during all invasive procedures Rationale: Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures.

When preparing to administer an antibiotic to a client, the nurse understands it will be effective in the treatment of an infectious disease process primarily because antibiotics: 1. reduce the inflammatory response. 2. enhance the body's natural immune function. 3. block growth of essential components of the bacterial cell. 4. immobilize bacteria and allow them to be eliminated from the body.

3. block growth of essential components of the bacterial cell. Rationale: Antibiotics block the growth of essential components of an organism by inhibiting or interfering with protein synthesis, thus leading to cell death or dysfunction, rendering it unable to reproduce.

A surgical client develops a wound infection during hospitalization. How is this type of infection classified? 1. Primary 2. Secondary 3. Superimposed 4. Nosocomial

4. Nosocomial Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as failure to wash hands between clients.

A client has a nursing diagnosis of Risk for infection. What would be the most desirable expected outcome for this client? 1. All nursing functions will be completed by discharge. 2. All invasive intravenous lines will remain patent. 3. The client will remain awake, alert, and oriented at all times. 4. The client will be free of signs and symptoms of infection by discharge.

4. The client will be free of signs and symptoms of infection by discharge. Rationale: Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by time of discharge.