Taylor chapter 23 review questions. Asepsis and Infection Control

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? A. Wear a protective gown and gloves with any direct contact. B. Have the client wear a mask during care. C. Wear a mask with face shield during invasive procedures. D. Apply a non-particulate (N-95) respirator when entering the room.

Apply a non-particulate (N-95) respirator when entering the room. Explanation: TB is an airborne infection and the nurse should wear a non-particulate mask (N-95) respirator. Gown and gloves would be indicted for infections that are transmitted via direct contact. A mask with a face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care.

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. A. contagious disease B. infectious disease C. health care-associated infection (HCAI) D. noncommunicable disease E. communicable disease

B. infectious disease E. communicable disease A. contagious disease Explanation: Infections diseases, 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.

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action? A. Change to airborne precautions. B. Leave in droplet precautions. C. Change to contact precautions. D. Change to standard precautions.

Change to airborne precautions. Explanation: Tuberculosis is transmitted via the air, thus airborne precautions are required. Other answers are incorrect.

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate? A. Do nothing; it can be used again immediately. B. Sterilize it by placing it in the autoclave. C. Disinfect it with alcohol swabs. D. Discard it in the waste can.

Disinfect it with alcohol swabs. Explanation: Equipment such as stethoscopes, sphygmomanometers, and other assessment tools that are used for clients on contact precautions should be cleaned and disinfected before using them for other clients. Other answers are incorrect.

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

Removing respirator after leaving client's room Explanation: 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.

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? A. The new nurse touches 1.5 in (4 cm) from the outer edges. B. The top flap of the package is opened away from the new nurse's body. C. The sterile field is set up at waist level. D. Direct visualization of the sterile field is maintained.

The new nurse touches 1.5 in (4 cm) from the outer edges. Explanation: The outer 1 in (2.5 cm) of the sterile package is safe to touch. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body.

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor? A. stretches the glove over the hand without touching the unsterile area B. washes hands for 20 seconds with soap and water C. reaches down to the bed to pick up a sterile drape D. picks up the glove at the folded edge with the thumb and forefinger

reaches down to the bed to pick up a sterile drape Explanation: The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully.

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement? A. providing alcohol-based hand sanitizer to all clients B. having any visitor with a cough or cold wear a mask C. staff education on utilizing hand hygiene D. restricting visitors to those older than 12 years of age

staff education on utilizing hand hygiene Explanation: Hand hygiene is the most effective way to decrease the transmission of infections or pathogens in the health care setting. Educating staff on hand hygiene would be the best intervention to implement. Providing alcohol-based hand sanitizer to all clients will encourage hand hygiene, but will not decrease transmission from health care providers. Restricting visitors to those older than 12 years of age will not decrease transmission. Having visitors with a cough or cold wear a mask will decrease transmission to the clients, but will not decrease health care associated infections.

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? A. "We only wash our hands when they are visibly soiled." B. "Alcohol based hand rub provides the greatest reduction in microbial counts on the skin." C. "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." D. "Washing the hands with soap and water is not necessary."

"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin." Explanation: By explaining that alcohol based hand rubs are effective in preventing the spread of microbes, the nurse directly addresses the client's concern. While washing with soap and water may not be necessary, it doesn't address the client's concern. Alcohol hand rub is an appropriate method for hand hygiene even when you plan to touch the client.

A home health nurse is completing a health history for a client. What is one question that is important to ask to identify a latex allergy for this client? A. "When you were a child, did you have frequent infections?" B. "Have you ever had an allergic reaction to shellfish or iodine?" C. "Have you had any unusual symptoms after blowing up balloons?" D. "Tell me what you use to wash your hands after toileting."

"Have you had any unusual symptoms after blowing up balloons?" Explanation: Awareness of a latex allergy is important for safe home care. Nurses need to ask whether clients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning.

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response? A. "Transmission of certain diseases is halted with vaccination." B. "Vaccinations prevent disease." C. "Help me understand your thoughts about vaccinations." D. "Has your child received any previous vaccinations?"

"Help me understand your thoughts about vaccinations." Explanation: Seeking to understand the caregiver's perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. The nurse could then collect assessment data regarding past vaccines and provide appropriate teaching.

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? A. "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." B. "Drug resistance can develop when the wrong antibiotic is used for pneumonia." C. "This antibiotic is the best choice since the causative organism is not known." D. "Pneumonia is usually caused by multiple organisms."

"This antibiotic is the best choice since the causative organism is not known." Explanation: Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness. The side effects of all antibiotics are similar. The antibiotic can cause resistance when used excessively in the absence of infection. Pneumonia may or may not be caused by multiple organisms; however, this isn't the best answer regarding the medication.

The nurse is caring for a client who has an infection spread by respiratory droplets and has droplet precautions isolation. The client asks, "Can my spouse visit me?" Which response is correct? A. "No, the supplies used for this type of infection are too expensive to provide to family members." B. "Yes, as long as your spouse wears a mask and stays at least 3 feet (1 meter) away from you." C. "Yes, but only if your spouse stays outside of the room and speaks to you from the doorway." D. "No, the chance of spreading your infection to the community is too great."

"Yes, as long as your spouse wears a mask and stays at least 3 feet (1 meter) away from you." Explanation: The client's family can visit and must use personal protective equipment (PPE). PPE should be worn when entering the room for all interactions that may involve contact droplet precautions with the client and potentially contaminated areas in the client's environment. Keep visitors 3 feet (1 meter) from the infected person. The client is not going to infect the community because the interaction is occurring in the health care setting. The spouse can visit using PPE as long as the spouse stays 3 feet (1 meter) from the client. PPE are provided to protect anyone visiting including hospital personnel.

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds: A. "A cesarean section will prevent a herpes outbreak." B. "You may have infection in your birth canal that you are unaware of." C. "You will likely have an outbreak due to the stress of labor and delivery." D. "Have you discussed this with your physician?"

"You may have infection in your birth canal that you are unaware of." Explanation: Viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.

Which client would the nurse consider the most infectious? A. A client who is in the full stage of illness b. A client who is in the convalescent period c. A client who is in the incubation period d. A client who is in the prodromal stage

A client who is in the prodromal stage Explanation: The client is most infectious during the prodromal stage of the illness. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the client often is unaware of being contagious. As a result, the infection spreads. The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the client's general condition. The signs and symptoms disappear, and the person returns to a healthy state.

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? A. Sterility may not be preserved even when one sterile item touches another sterile item. B. Any partially uncovered sterile package need not be considered contaminated. C. A commercially packaged surgical item is not considered sterile if past expiration date. D. When a sterile item touches something that is not sterile, it may not be contaminated.

A commercially packaged surgical item is not considered sterile if past expiration date. Explanation: When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

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 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft C. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior D. A client with renal failure who receives hemodialysis three times weekly

An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Explanation: Two common factors that increase a persons risk of becoming infected with C difficle 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.

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the the education provided was effective? Select all that apply. A. "I may transmit the virus to my child during pregnancy and childbirth." B. "If someone is exposed to my blood, I may transmit the virus to him or her." C. "If someone uses the bathroom after I have been on the toilet, he or she can catch the virus." D. "If I sweat at the gym and someone touches me, he or she can contract the virus." E. "I may transmit the virus if I share needles with another person."

B. "If someone is exposed to my blood, I may transmit the virus to him or her." A. "I may transmit the virus to my child during pregnancy and childbirth." E. "I may transmit the virus if I share needles with another person." Explanation: The client has demonstrated that an understanding of the transmission of the virus may occur through exposure to blood, during pregnancy and childbirth, and through sharing needles. Transmission of the virus does not occur through sweat or by exposure on a toilet seat. The virus is fragile and does not live on inanimate objects.

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse? A. Send the sphygmomanometer for sterilization. B. Cleanse and disinfect the sphygmomanometer. C. Use the sphygmomanometer. D. Discard the sphygmomanometer in the trash.

Cleanse and disinfect the sphygmomanometer. Explanation: The nurse should cleanse and disinfect the sphygmomanometer. A sphygmomanometer is another name for a blood pressure cuff. As this equipment is used on the outside of the arm versus entering a sterile body part, there is no need to have the equipment sterilized. It would be inappropriate for the nurse to use the visibly soiled blood pressure cuff or to throw it in the trash.

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? A. Clint with an intravenous catheter B. Client with a surgical wound C. Client with a urinary catheter D. Client with a diabetic foot ulcer

Client with a urinary catheter Explanation: While all of the clients are at risk for infection, the client at the greatest risk is the one with a urinary catheter. This is because catheter-associated urinary tract infections are the most common type of hospital-acquired infections, accounting for more than 30% of HAIs in acute care hospitals. Most hospitalized clients receive an intravenous catheter. Clients go to the hospital for surgery so a surgical incision is expected. Clients with a diabetic foot ulcer may be admitted to the hospital for intravenous antibiotics.

A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control? A. Airborne precautions B. Protective isolation C. Droplet precautions D. Contact precautions

Contact precautions Explanation: Contact precautions are used with organisms that can be transmitted by hand- or skin-to-skin contact (e.g., during client care activities or when touching the client's environmental surfaces or care items) such as with a client with impetigo. Airborne precautions are used to protect against microorganisms transmitted by small-particle droplets that can remain suspended and become widely dispersed by air currents, such as tuberculosis or measles. Droplet precautions are used for microorganisms transmitted by larger-particle droplets which disperse into air currents, such as H. influenzae or M. pneumoniae. Protective isolation is used to prevent infection for people whose body defenses are known to be compromised, such as those who are neutropenic secondary to chemotherapy.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? A. Don a second pair of sterile gloves over the first pair. B. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. C. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. D. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field.

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. Explanation: The nurse should continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. It is appropriate to adjust the gloves by touching sterile surface to sterile surface which is what is occurring. Leaving the both the thumb and finger in the thumb hole and performing the procedure can cause contamination. Donning the second pair of sterile gloves does not address the thumb and finger that are in the thumb hole. The nurse cannot complete the procedure with only one sterile glove.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? A. sending a VRE-positive client to the radiology department for a chest X-ray without a face mask B. delivering a meal tray to a VRE-positive client without first donning gloves and a gown C. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing D. Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. Explanation: Direct client contact between a VRE-positive client and another client without handwashing carries a significant risk of infection, especially when contact includes body fluids. Handwashing is necessary before a procedure such as staple removal, but foregoing this infection control measure is less likely to spread VRE unless the nurse failed to handwash after the procedure. VRE does not normally require droplet or airborne precautions. Delivering an item to a client without gloves or a gown is less of a risk than failing to wash the hands after such contact.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? A. Shigella in the intestinal tract B. Escherichia coli in the urinary tract C. Shigella in the urinary tract D. Escherichia coli in the intestinal tract

Escherichia coli in the intestinal tract Explanation: 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.

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. Antibiotic-resistant B. Endogenous healthcare-associated C. Iatrogenic D. Exogenous healthcare-associated

Exogenous healthcare-associated Explanation: 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 lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? A. Make contact between two clean surfaces. B. Handwashing before leaving the client's room. C. Remove the garments that are most contaminated. D. Make contact between two contaminated surfaces.

Handwashing before leaving the client's room. Explanation: The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath.

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. Consider the outside of the sterile package to be sterile. B. Open sterile packages so that the first edge of the wrapper is directed toward the nurse. C. Hold sterile objects above waist level to prevent inadvertent contamination. D. Consider the outer 3-in (8-cm) edge of a sterile field to be contaminated.

Hold sterile objects above waist level to prevent inadvertent contamination. Explanation: 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.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? A. Release of histamine B. Production of antibodies C. Constriction of the small blood vessels near the wound D. Migration of leukocytes to the area of the wound

Migration of leukocytes to the area of the wound Explanation: During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation. Antibody production is characteristic of the immune response to infection.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? A. Limiting visitors to family members over the age of 18 B. Encouraging visitors to adhere to isolation precautions C. Revising the facility's infection control protocols D. Incentivizing health care workers to utilize hand hygiene

Incentivizing health care workers to utilize hand hygiene Explanation: Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. Revising the agency's infection control protocols is not nursing centered. Encouraging visitors to adhere to isolation precautions is important but does not affect the immediate surroundings and personal space that can cause a contaminated work environment. Limiting visitors to family members over the age of 18 is not client-centered care and will not decrease transmission of pathogens.

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. Specimen containers B. Bath blanket C. Face shields D. Indwelling catheter

Indwelling catheter Explanation: 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.

A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter? A. Use an alcohol-based hand rub to decontaminate hands. B. Remove all jewelry, including wedding bands before hand washing. C.Keep hands lower than elbows to allow water to flow toward fingertips. D. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips.

Keep hands lower than elbows to allow water to flow toward fingertips. Explanation: Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms. When drying, pat dry with a paper towel beginning with the fingertips and stopping at the hands.

The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate? A. Notify the CT department in advance so other clients and staff can be removed from the area. B. Place a surgical mask on the client and transport to the CT department at the specified time. C. Request that the examination be done at the bedside. D. Question the need for the examination because the client must remain in Airborne Precautions.

Place a surgical mask on the client and transport to the CT department at the specified time. Explanation: Transport clients in Airborne Precautions out of the room only when necessary and place a surgical mask on the client, if possible. Use Airborne Precautions for patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster). The nurse should not question the need for the examination or request that the examination be done at the bedside. It is not necessary to notify the CT department and allow for all patients and staff to be removed from the area.

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?

Remind the student that a fitted N95 respirator is required. Explanation: A fitted N95 respirator must be worn in addition to other precautions when caring for clients with pulmonary tuberculosis. Other answers do not recommend the appropriate precautions that must be used for this type of infection.

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? A. No special precautions are required. B. Deliver flowers and balloons to the room. C. Remove fresh fruit from the room. D. Allow many family members to visit at once.

Remove fresh fruit from the room. Explanation: Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.

The student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains: A. Stress causes the body to release cortisol, which can increase the risk of infection. B. Stress is not considered a risk for infection. C. Stress causes the body to increase insulin production and the resulting hypoglycemia predisposes the patient to infection. D. Cortisol decreases the level of serum glucose, leading to infection.

Stress causes the body to release cortisol, which can increase the risk of infection. Explanation: Physical or emotional stress causes the body to release cortisol, which can increase the risk of infection by suppressing the immune response. Cortisol increases the level of serum glucose, providing a good medium for bacterial growth.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? A. Increased vitamin C B. Surgical asepsis C. Increased T cells D. Decreased antibiotics

Surgical asepsis Explanation: Clients are at risk for healthcare-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? A. Surgical asepsis technique B. Medical asepsis technique C. Droplet precautions D. Strict reverse isolation

Surgical asepsis technique Explanation: Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others.

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 hand hygiene instead of gloves when in contact with blood. B. The nurse keeps fingernails less than 1/4 in (0.63 cm) long. C. The nurse uses gloves in place of hand hygiene. D. The nurse refrains from using hand moisturizer following hand hygiene.

The nurse keeps fingernails less than 1/4 in (0.63 cm) long. Explanation: 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.

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure? A. The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. B. The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands. C. The nurse uses soap and cold water to wash hands. D. The nurse rinses thoroughly with water flowing away from the fingertips.

The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. Explanation: The nurse must wash at last 1 in (2.5 cm) above the area of contamination to properly performed hand hygiene. The nurse should use warm to hot water to wash hands. The amount of liquid soap varies depending on the concentration of the soap. The nurse rinses with water flowing toward the fingertips.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection? A. The client reports nausea and vomiting. B. The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C) C. Urine culture is positive for vancomycin-resistant enterococci (VRE). D. The nurse notes the client's urine is dark yellow with sediment.

Urine culture is positive for vancomycin-resistant enterococci (VRE). Explanation: Infections result from pathogens that produce illness after invading body tissues and organs. The client with the indwelling urethral catheter is at risk for developing an infection. The finding that would most likely indicate an infection would be a positive result. Nausea and vomiting, a fever, and dark yellow urine with sediment are possible signs of an infection, but each of these findings alone does not confirm an infection.

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism? A. Droplet B. Airborne C. Direct contact D. Vehicle

Vehicle Explanation: Vehicle transmission involves the transfer of microorganisms by way of vehicles or contaminated items that transmit pathogens; for example, food can carry Salmonella. Direct contact transmission involves body surface-to-body surface contact causing the physical transfer of organisms between an infected or colonized person and an infected host. Droplet transmission occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. Airborne transmission occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens.

A nurse who has finished cleansing and dressing the wound of a young client now needs to change the dressings of a client in the burn unit. Which action should the nurse perform, keeping in mind the importance of asepsis and client comfort? A. Wash hands thoroughly and then wear sterile gloves. B. Avoid washing hands with an antiseptic cleansing agent. C. Wear gloves made of polyvinyl chloride. D. Avoid using alcohol-based hand sanitizers to protect skin integrity.

Wash hands thoroughly and then wear sterile gloves. Explanation: To prevent the spread of infection and follow strict asepsis, the nurse should wash hands and wear sterile gloves between contacts with different clients, or before performing any invasive procedure on a client. When entering a high-risk area such as a burn unit, the nurse should use antiseptic cleansing agents, nail files, and antiseptic-impregnated scrub brushes. Alcohol-based hand sanitizers are a better idea, as they are less abrasive and less irritating on skin than washing with soap and water. The nurse should wear latex gloves instead of polyvinyl chloride when examining the client, as latex is more flexible and durable. Latex gloves are preferred when lengthy exposure is anticipated or fine motor skills are required.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? A. Use respiratory protection when entering the room of client with known or suspected diphtheria. B. Wear PPE when entering the room for all interactions that may involve contact with the client. C. Place client in private room that has monitored negative air pressure. D. Use a private room with the door closed.

Wear PPE when entering the room for all interactions that may involve contact with the client. Explanation: The nurse should wear PPE upon entry into the room for all interactions that may involve contact with the client. The nurse should use a private room, if available, and the door may remain open. Placing a client in a private room that has monitored negative air pressure is appropriate for airborne infections. The nurse should use respiratory protection when entering the room of the client with known or suspected tuberculosis (airborne infection).

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

Wear gloves whenever entering the client's room. Explanation: Contact precautions are used for clients who are infected or colonized by a microorganism that spreads by direct or indirect contact, such as MRSA, VRE, or 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 feet away from the client is a droplet precaution.

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? A. When hands are visibly soiled B. Before direct contact with clients C. After completing a wound dressing D. After direct contact with clients

When hands are visibly soiled Explanation: Alcohol-based hand rubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, except when the health care worker's hands are visibly soiled.

The nurse determines that which client is at greatest risk for a wound infection?

You Selected: An older adult client with dry skin Correct response: A two-day postoperative client Explanation: The client at greatest risk for a wound infection is the two-day postoperative client, as the surgery disrupted the integrity of the skin, thereby increasing the risk for wound infection. Although older adult clients are at greater risk for infection, this client's skin is dry (versus having an open or surgical wound); thus, this client is at less risk than the postoperative client. An infant with intact skin is not at risk for a wound infection. A client with a urinary catheter is at risk for a urinary tract infection versus a wound infection.

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

You Selected: remove gloves, wash hands, remove gown Correct response: remove gloves, remove gown, wash hands Explanation: The nurse will remove and dispose of the most contaminated items first, then dispose of other items, and then wash hands. Gloves should be first removed, then the gown. Then, hands are washed. Other answers are incorrect.

For which clients would the nurse be required to use droplet precautions? Select all that apply. A. a client with mumps B. a client with tuberculosis C. a client with severe acute respiratory distress syndrome (SARS) D. a client with rubella E. a client with diphtheria prioritization F.. a client with metihicillin resistant staphylococcus aureus (MRSA)

a client with rubella a client with mumps a client with diphtheria prioritization Explanation: Droplet precautions would be used for clients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. For tuberculosis and SARS, airborne precautions would be used. Contact precautions would be the primary method of precautions with MRSA.

Surgical asepsis is defined as: A. absence of all microorganisms. B. slowed growth of microorganisms. C. use of hand washing, gowning, and gloving. D. absence of all virulent microorganisms.

absence of all microorganisms. Explanation: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? A. an adolescent who has a right radial fracture B. a school-age child who is current with immunizations C. a middle-aged adult who takes prescribed medication to control blood pressure D. an older adult client with a history of heart failure

an older adult client with a history of heart failure Explanation: Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have pre-existing illnesses, appear to be more vulnerable to infection. School-age children are exposed to potential infections, but immunizations protect the child. An adolescent with a fracture or middle-aged adult taking medication to control blood pressure could develop an infection, but these clients are not at the highest risk.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? A. applying a face mask with shield B. wearing clean unsterile gloves when changing the dressing C. changing the soiled dressing D. isolating the client's belongings

changing the soiled dressing Explanation: A reservoir is a place where microbes grow and reproduce. A soiled dressing can be a reservoir for microbes to breed. Changing the soiled dressing reduces the microbes at the wound. Wearing gloves, isolating client's belongings, and applying a face mask decrease the transmission of infection.

The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin? A. none B. contact C. airborne D. droplet

contact Explanation: Acute vital conjunctivitis is transmitted through contact; therefore, contact precautions are appropriate.

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? A. airborne precautions B. droplet precautions C. contact precautions D. standard precautions

contact precautions Explanation: VRE is transmitted via contact. The nurse caring for a client with VRE should implement contact precautions which is wearing a gown and gloves while in the client's room. Droplet precautions include wearing a surgical mask while in the room. Special masks for airborne precautions are used for, but are not limited to: measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis. Standard precautions are used with all clients.

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative? A. prophylactic antibiotic therapy for MRSA-negative clients B. reduced length of stay for MRSA-positive clients C. constant use of gloves when on the unit D. diligent handwashing practices

diligent handwashing practices Explanation: As with all forms of infection, thorough handwashing is the most important infection-control measure. It is inappropriate to reduce clients' length of stay based on their MRSA status, and prophylaxis is not normally used. It is unnecessary to wear gloves at all times on the unit.

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? A. contact B. droplet C. none D. airborne

droplet Explanation: Streptococcal pneumonia is transmitted through droplets; therefore, droplet contact precautions are appropriate. The other options are inappropriate.

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? A. none B. contact C. droplet D. airborne

droplet Explanation: Whooping cough is transmitted through droplets; therefore, droplet precautions are appropriate.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene? A. has manicured nails that are 1-in (2.5-cm) long B. drains hands lower than the wrist C. washes hands for 15 seconds D. has wedding band on ring finger

has manicured nails that are 1-in (2.5-cm) long Explanation: Fingernails should be less than ¼-in (0.625-cm) long, as this reduces the reservoir for flora to accumulate, and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. A flat wedding band is acceptable. Allowing the hands to drain lower than the wrist promotes gravity drainage.

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition? A. community acquired infection B. infectious disease C. health care-associated infection (HCAI) D. contagious disease

health care-associated infection (HCAI) Explanation: HCAI, the most common adverse event in hospitals, are acquired within healthcare facilities. Community acquired infections occur in the community. Infectious and contagious can be acquired in any setting.

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority iintervention can the nurse include that is a first line of defense? A. staying home when sick. B. early intervention with antibiotics. C. low levels of flora. the cell-mediated immune response. D. intact skin and mucous membranes.

intact skin and mucous membranes. Explanation: The first line of defense against infection is intact skin and mucous membranes covering body cavities.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? A. with a client with pneumonia B. with a client with a myocardial infarction C. with another client with a draining wound D. into a private room

into a private room Explanation: The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

The nurse observes an unlicensed assistive personal (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? A. applies a mask with face shield B. asks the client to state name and date of birth C. removes gloves and walks out of the room D. performs hand hygiene before donning gloves

removes gloves and walks out of the room Explanation: 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.

A client has a systemic infection that resulted from an untreated urinary tract infection. The client has malaise and is confused. The client is: A. toxic. B. lethargic. C. contagious. D. septic.

septic. Explanation: Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? A. the client admitted with diarrhea who tested positive for Escherichia coli (E. coli) B. the client admitted with a rash who reports recent exposure to measles C. the client placed in contact isolation who was admitted with a draining abdominal wound D. the client who is 48-hours postsurgical procedure

the client who is 48-hours postsurgical procedure Explanation: Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between clients, the nurse should see clients from the "clean" to "dirty." The nurse should see the client who has no signs of infection first. Among these clients, the nurse should should begin withe the client who is postoperative, then see the other clients who have symptoms of infections. Reference:

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action? A. to protect the integrity of the nurse's immune system B. to sterilize the nurse's hands to prevent infection C. to eliminate disease-producing organisms from the nurse's skin D. to prevent the nurse from developing disease

to eliminate disease-producing organisms from the nurse's skin Explanation: The purpose of hand hygiene is to protect clients from infection by removing microorganisms from the skin. This action directly addresses client safety but is not directly related to effectiveness of care. Hand hygiene protects the nurse from infection but the primary purpose is to protect clients. Hand hygiene greatly reduces the number of microorganisms on the skin but does not result in sterile skin surfaces.

For which clients would the nurse be required to use droplet precautions? Select all that apply.

you selected a client with tuberculosis a client with diphtheria prioritization a client with severe acute respiratory distress syndrome (SARS) Correct response: a client with rubella a client with mumps a client with diphtheria prioritization Explanation: Droplet precautions would be used for clients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. For tuberculosis and SARS, airborne precautions would be used. Contact precautions would be the primary method of precautions with MRSA.

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? A. wearing a face mask when entering and staying at a distance from the client B. wearing a particulate respirator for all client care and interaction C. wearing protective eye wear for all client contact D. placing the client in a regular, private room

wearing a particulate respirator for all client care and interaction Explanation: To prevent the transmission of TB, the National Institute for Occupational Safety and Health recommends the use of a particulate air filter respirator that fits snugly to the face for all client care and interaction. A face mask does not block small TB particles effectively. Protective eyewear is only needed if contact with bodily fluids is expected. The client would be place in a negative pressure room to prevent the potential spread of TB.

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. stable C. elevated D. within normal limits

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