spread of infection & vital signs

Which response indicates a nurse has a correct understanding about the components of a vital sign assessment? "Oxygen saturation is the measurable intake of oxygen and release of carbon dioxide." "Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart." "Respiration is the measurable amount of oxygen available to the tissues." "Blood pressure is the measurable pressure of blood within the systemic veins."

"Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart."

Which statement is correct regarding hand hygiene in the health care setting? -Soap and water effectively reduce microorganisms on visibly dirty hands -Infectious agents are killed by soap and water when washing hands. -Washing hands with very hot water helps eliminate a greater number of bacteria. -Non-alcohol-based hand sanitizers inhibit microorganism growth on hands.

-Soap and water effectively reduce microorganisms on visibly dirty hands

Match the precaution with its corresponding description. 1. Separates sick and contagious people from others 2. Separates people exposed to a contagious disease 3. Separates people with weak immune systems Protective isolation Isolation Quarantine

1. Isolation 2. Quarantine 3. Protective isolation

A nurse caring for a patient with an infection would anticipate a temperature less than ________°F when the infection has resolved.

100.4

Which vital sign measurements of adult patients would require the nurse to immediately notify the health care provider?Select all that apply. 158 pulse rate 8 respirations 99.5°F (37.5°C) temperature 98% oxygen saturation 50/30 blood pressure

158 pulse rate 8 respirations 50/30 blood pressure

A microorganism is considered to be resistant if it cannot be stopped by the use of __?__ or more antibiotics.

2

An effective alcohol-based hand scrub must contain at least ________ percent alcohol

60

Which vital sign measurements are unexpected?Select all that apply. 99.5°F (37.5°C) temperature for a newborn 60 pulse rate for a 1-year-old 35 respirations for a 6-year-old SpO2 90% for a 15-year-old 110/68 blood pressure for an older adult

60 pulse rate for a 1-year-old 35 respirations for a 6-year-old SpO2 90% for a 15-year-old

What is the expected pulse range for an adult patient? Record your answer as whole numbers separated by a hyphen.

60-100

Which patient is considered to be a susceptible host in the chain of infection? A. 22-year-old undergoing noninvasive treatment for back pain B. 30-year-old receiving an immunization for hepatitis C. 70-year-old with diabetes learning about insulin therapy D. 45-year-old being discharged after minor knee therapy

70-year-old with diabetes learning about insulin therapy The 70-year-old patient is a susceptible host because diabetes is a chronic disease. Also, the patient is of older age, which is a risk factor for infection.

By which means are pathogens transmitted through droplets, requiring infected patients to be placed on protective precautions? Coughing Sneezing Suctioning Talking Eating

Coughing Sneezing Suctioning Talking

Which actions are strictly a nurse's responsibility?Select all that apply. Assess patients to determine if medically stable. Interpret vital sign measurements. Report significant vital sign findings to the health care provider. Reassess any unexpected vital sign values. Measure vital signs for stable patients.

Assess patients to determine if medically stable. Interpret vital sign measurements. Report significant vital sign findings to the health care provider. Reassess any unexpected vital sign values.

Which medical asepsis interventions by the nurse directly protect the patient from infection? -Cleaning patient bedside equipment routinely -Disposing of used needles in sharps containers -Placing items wet from body fluids in biohazard bags -Providing leak-proof receptacles at bedside for tissues -Preventing contamination of intravenous sites and ports -Removing excess linens from the patient's room

Cleaning patient bedside equipment routinely Disposing of used needles in sharps containers Providing leak-proof receptacles at bedside for tissues Preventing contamination of intravenous sites and ports

Which action would the nurse take before notifying the health care provider about a patient's vital signs? Compare the findings to the patient's baseline Follow only the expected ranges for the patient Observe for slight changes in results Review for just increases in measurements

Compare the findings to the patient's baseline

Which rationale explains why antibiotic use in animals contributes to human antimicrobial resistance? A. Creates a reservoir of potentially resistant bacteria. B. Allows for greater exposure to multiple pathogens. C. Promotes new vectors as sources of transmission D. Lack of hygiene and sanitation in animal holding areas

Creates a reservoir of potentially resistant bacteria.

Which factor is most likely to contribute to the development of a health care-associated respiratory infection in an ambulatory diabetic patient receiving an intravenous antibiotic? A. Excessive activity B. Decreased oxygenation C. Current comorbidity D. Incorrect antibiotic

Current comorbidity Diabetes mellitus places the patient at increased risk for development of a health care-associated infection.

Which entries would the nurse include when documenting vital signs?Select all that apply. Date of assessment Time of assessment Names of visitors in the room Numeric results of the assessment Expected values for vital signs

Date of assessment Time of assessment Numeric results of the assessment

Match the infectious agent to its description. Different sizes, shapes, and growth patterns =? Cannot be killed by antibiotics =? Found in air, soil, and water =? Transmitted by insects and domestic animals =? A. Fungi B. Bacteria C. Parasite D. Viruses

Different sizes, shapes, and growth patterns: Bacteria(B) Cannot be killed by antibiotics: Viruses (D) Found in air, soil, and water: Fungi (A) Transmitted by insects and domestic animals: Parasites(C)

Which actions are required for proper documentation of vital signs?Select all that apply. Recording duplicate entries Documenting in a standardized format Documenting at the end of the day Recording on a specified form Recording just expected values

Documenting in a standardized format Recording on a specified form

Which action can communities engage in to help reduce infections among their citizens?

Encouraging and facilitating immunization programs

Which actions are responsibilities of the nurse when assigning vital signs to the unlicensed assistive personnel (UAP)?Select all that apply. Ensure that the UAP uses the proper technique for measuring vital signs. Validate that the UAP knows what values need to be reported immediately for each patient. Determine that the UAP knows to report unexpected values to the health care provider. Ensure that the UAP is competent to perform vital sign assessments. Validate that the UAP uses appropriate equipment.

Ensure that the UAP uses the proper technique for measuring vital signs. Validate that the UAP knows what values need to be reported immediately for each patient. Ensure that the UAP is competent to perform vital sign assessments. Validate that the UAP uses appropriate equipment.

How frequently would the nurse take vital sign measurements for a stable hospitalized patient? Every 5 minutes Every 15 to 60 minutes Every hour Every 4 to 8 hours

Every 4 to 8 hours

How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94?

Every 5 minutes

Which type of infection would a nurse suspect when caring for a patient who has a prescription for a Clostridium difficile test? Respiratory tract infection Urinary tract infection Gastrointestinal infection Cellulitis

Gastrointestinal infection

Place the personal protective equipment (PPE) in the order in which the nurse would remove them: Gown Shoe covers Mask Gloves Eyewear

Gloves Eyewear Gown Mask Shoe covers

Which step is first in the sequence for donning personal protective equipment (PPE)?

Hand hygiene

Match the situation to the type of personal protective equipment required Surgery or labor and delivery Sprays from respiratory droplets Direct contact with body fluids Patient on transmission precautions Head cover Goggles Gloves Gown

Head cover Surgery or labor and delivery Goggles Sprays from respiratory droplets Gloves Direct contact with body fluids Gown Patient on transmission precautions

Which action would the nurse recognize as a breach in surgical asepsis that contaminated the sterile field? Health care provider touched sterile field one-half inch from edge Health care provider reached over sterile field to pick up a towel Masked assistant talked over the sterile field Sterile packages opened facing away from body

Health care provider reached over sterile field to pick up a towel

Which infection would prompt the nurse to implement contact precautions? Hepatitis A Streptococcal pneumonia Influenza Chickenpox

Hepatitis A

Which microorganisms are blood-borne pathogens that can be transmitted by needlesticks? Select all that apply. A. Hepatitis B virus (HBV) B. Human immunodeficiency virus (HIV) C. Mycobacterium tuberculosis (TB) D. Neisseria gonorrhoeae (gonorrhea) E. Vancomycin-resistant Enterococcus (VRE)

Hepatitis B virus (HBV) Human immunodeficiency virus (HIV)

Match the type of transmission-based precaution with the infection for which it is implemented. Herpes simplex virus (HSV) Rubella Rubeola Droplet Contact Airborne

Herpes simplex virus (HSV) Contact Rubella Droplet Rubeola Airborne

Which situations require vital sign assessment?Select all that apply. After discharge In ongoing care During an inpatient stay Before and after surgery As part of a physical assessment

In ongoing care During an inpatient stay Before and after surgery As part of a physical assessment

Which actions are required by the nurse when preparing for a sterile procedure? Keeping sterile surfaces dry Setting up the sterile field Leaving the room for supplies Checking packaging integrity Monitoring activities of others Delegating preparations to unlicensed assistive personnel (UAP)

Keeping sterile surfaces dry Setting up the sterile field Checking packaging integrity Monitoring activities of others

Which personal protective equipment (PPE) would the nurse don before observing a sterile procedure in the operating room?

Mask

Which tasks would the nurse delegate to the unlicensed assistive personnel (UAP)?Select all that apply. Interpret vital sign data collected. Record vital signs for any patient. Report vital signs for a stable patient. Measure vital signs for a stable patient. Measure vital signs before the nurse has assessed the patient.

Measure vital signs for a stable patient. Report vital signs for a stable patient.

Which infectious agents have acquired drug resistance within health care settings? Select all that apply. A. Streptococcus pneumoniae (pneumococcus) B. Methicillin-resistant Staphylococcus aureus C. Vancomycin-resistant Staphylococcus aureus (VRSA) D. Vancomycin-resistant Enterococcus (VRE) E. Clostridium difficile (C. diff) F. Staphylococcus aureus (Staph infection)

Methicillin-resistant Staphylococcus aureus Vancomycin-resistant Staphylococcus aureus (VRSA) Vancomycin-resistant Enterococcus (VRE) Clostridium difficile (C. diff)

Which factors influence the interpretation of a patient's vital signs?Select all that apply. Patient status Length of time the nurse is on duty Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition

Patient status Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition

Which finding takes precedence when interpreting a patient's vital sign values? Expected result Normal result Patient's averaged result Patient's baseline result

Patient's baseline result

Which group(s) does the Centers for Disease Control and Prevention (CDC) apply the term quarantine to? People Animals Cargo Buildings Institutions

People Animals Cargo Buildings

Which type of action is the nurse taking to reduce the spread of infections by not going to work when sick?

Personal

Which component of the chain of infection involves the infectious agent leaving the reservoir? A. Source B. Portal of entry C. Portal of exit D. Mode of transmission

Portal of exit

Which phrases describe the purpose of hand hygiene?

Prevents the spread of infection Breaks the chain of infection Interrupts organism transmission

Which phrase describes medical asepsis? -Absence of all infectious agents -Procedure known as clean technique -Requires use of sterile gloves -Prevents microbial entry into body

Procedure known as clean technique

Which measurements are included as cardinal vital signs?Select all that apply. Pain Pulse Respirations Blood pressure Oxygen saturation

Pulse Respirations Blood pressure

Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient's pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)? Advise the UAP to wait 1 hour and repeat vital signs. Compare the findings to the expected values. Reassess the patient. Tell the UAP to give fluids to the patient.

Reassess the patient.

Which finding is unexpected for a 15-year-old patient? Pain level 0 Pulse rate 88 Respirations 30 O2 sat 97%

Respirations 30

Which vital sign finding indicates the adult patient is improving? Blood pressure changes from 120/78 to 80/60. Pulse rate increases from 85 to 110. Oxygen saturation changes from 90% to 85%. Respiratory rate decreases from 36 to 20.

Respiratory rate decreases from 36 to 20.

Which behavior indicates the need for additional teaching after educating a patient about respiratory etiquette?

Reusing tissues for a productive cough

Which precaution would be implemented for a patient admitted for suspected West Nile virus? A. Contact B. Droplet C. Airborne D. Standard

Standard Standard precautions would be implemented for this patient because West Nile virus is transmitted by a vector, specifically mosquitos. There are no other precautions required for vector-transmitted pathogens.

Which procedure is necessary for equipment being used to enter a sterile body cavity? Sanitization Disinfection Sterilization Decontamination

Sterilization

Which pathogen cannot be treated with antibiotics because it has a protective envelope? A. Bacterium B. Virus C. Fungus D. Parasite

Virus

Which information about prescribed antibiotics would the nurse teach a patient prior to discharge to help prevent antimicrobial resistance? A. Take all antibiotics for the full time prescribed. B. Do not share antibiotics with family members. C. Call if you do not understand how to take your antibiotics. D. If you miss an antibiotic dose, take it with the next dose.

Take all antibiotics for the full time prescribed.

Which action would the nurse take for a stable patient who is scheduled for a transfer to the rehabilitation unit later in the afternoon? Take vital signs before the transfer. Require every 2-hour monitoring until the transfer. Monitor the pulse rate once a day after the transfer. Delay vital signs monitoring since the patient is being transferred.

Take vital signs before the transfer.

In which situation is it permissible for the nurse to use an alcohol-based hand sanitizer?

When hands are not visibly soiled

Which infection would require a nurse to don a fitted N95 respiratory mask?

Tuberculosis

Which infections are considered health care-associated infections (HAIs)? Select all that apply. A. Urinary tract infection related to an indwelling catheter B. Pneumonia related to the presence of a ventilator C. Wound infection related to surgical incision D. Respiratory infection related to influenza E. Skin infection related to traumatic injury

Urinary tract infection related to an indwelling catheter Pneumonia related to the presence of a ventilator Wound infection related to surgical incision

Which infection would require a patient to be admitted to the airborne infection isolation room?

Varicella zoster