Ch. 23 Asepsis and Infection Control
A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?
1500
Which patient would the nurse consider the most infectious?
A patient who is in the prodromal stage
The nurse determines that which of the following clients is at greatest risk for a wound infection?
A two-day postoperative client
A nursing student is alarmed to learn that the patient whom she has been assigned to provide care is positive for HIV. What infection control strategy should the student apply when caring for this patient?
Apply routine precautions in the same manner as when caring for other patients.
Which of the following clients should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?
Client with a urinary catheter
The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?
Don another pair of sterile gloves.
Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.
During some care activities for an individual client, nurses may need to change gloves more than once. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.
Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?
Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair
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)?
Fold soiled side to the inside and roll with inner surface exposed.
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?
Fungi
A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. What is the appropriate nursing intervention?
Offer the family member a mask, explaining its use.
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?
Place a surgical mask on the client and transport to the CT department at the specified time.
Which of the following is the best example of a nurse donning/removing protective equipment properly?
Removing respirator after leaving client's room
The nurse is instructing a new mother on symptoms of infection in the newborn. Which of the following would the nurse include? Select all that apply.
Restlessness Poor feeding Lethargy
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?
Urine culture is positive for vancomycin-resistant enterococci (VRE).
Which of the following are names of the transmission-based precautions defined by the Centers for Disease Control (CDC)? Select all that apply.
airborne precautions droplet precautions contact precautions
Hepatitis is classified as a virus that
causes tissue damage
The nurse is caring for an older adult with pneumonia. Which assessment finding requires immediate nursing intervention?
client is more difficult to arouse
A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control?
contact precautions
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?
contact precautions
When preparing a sterile field, the nurse notes that bottle of sterile saline was opened 48 hours ago and is half full. What should the nurse do?
discard the bottle
The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin?
droplet
The nurse is caring for an older adult with influenza. Which precautions will the nurse begin?
droplet
Which piece of personal protective equipment (PPE) should be removed first?
gloves
A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?
has manicured nails that are 1-in (2.5-cm) long
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 contagious disease
A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as which of the following?
latrogenic
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)?
remove gloves, remove gown, wash hands
The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?
to eliminate disease-producing organisms from the nurse's skin
While assessing a client admitted with a transmissible spongiform encephalopathy, what finding might the nurse observe?
unsteady gait
What is the most common client site for development of healthcare-associated infections (HAI)?
urinary tract
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
vehicle
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?
"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin."
The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator?
"Wearing an N95 respirator is critical when I care for clients in droplet precautions."
A nursing student has caught a cold after experiencing a large amount of stress brought about by her busy school schedule, responsibilities at her part-time job, and family stressors. Increased stress likely caused which of the following physiological effects?
Increased release of cortisol
Unbeknown to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.
Incubation period Prodromal stage Full stage of illness Convalescent period
A patient has sought care because of a knee wound that appears to have become infected. Which of the following processes is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?
Migration of leukocytes to the area of the wound
The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution(s) should the nurse use? (Select ALL that apply.)
Non-sterile gloves Hand hygiene
A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply.
The nurse carries soiled items away from the body. The nurse moves soiled equipment away from the body when cleaning it. The nurse cleans least soiled areas first and then moves to more soiled ones.
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate
