CH29 Exam 3

Which microorganism causes gas gangrene? 1 Escherichia coli 2 Neisseria gonorrheae Incorrect3 Staphylococcus aureus Correct4 Clostridium perfringens

Clostridium perfringens causes gas gangrene. Escherichia coli causes gastroenteritis and urinary tract infection. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus causes wound infection and pneumonia.

A patient is diagnosed with pulmonary tuberculosis. Which personal protection equipment (PPE) is most important to be worn whenever entering the patient's room? 1 Gown 2 Gloves 3 Head cap Correct4 Respirator

Patients with pulmonary tuberculosis require airborne precautions because the droplets are smaller than 5 microns and remain for longer periods in the air. Therefore, a respirator is the most appropriate personal protection equipment (PPE) that the nurse should use. Gowns and gloves are most important when a nurse performs a physical examination to avoid a contact infection. A head cap is applied when the nurse is in a surgical room.

Which disease requires contact precautions? Correct1 Scabies 2 Measles 3 Diphtheria 4 Pharyngitis

Scabies spreads through skin contact and the nurse should take contact precautions. Measles require airborne precautions. Diphtheria and pharyngitis require droplet precautions.

Which part of a sterile gown is actually considered sterile? 1 Collar of the gown 2 Area below the waist Incorrect3 Underside of the sleeves Correct4 Anterior surface of the sleeves

The anterior surface of the sleeves is considered sterile. The collar of the gown, the area below the waist, and the underside of the sleeves are not considered as sterile.

What noncritical item used requires a surface disinfection? 1 Endoscopes Correct2 Stethoscope 3 Intravascular catheter 4 Anesthesia equipment

A stethoscope is a noncritical item that requires disinfection. An endoscope is a semi-critical item that requires high-level disinfection. An intravascular catheter is a critical item that requires sterilization. Anesthesia equipment is a semi-critical item that requires high-level disinfection.

A nursing student uses a surgical mask to assist in a sterile surgical procedure. Which action made by the nursing student indicates a need for correction? 1 Dropping the used mask in a trash receptacle 2 Removing the mask when leaving the surgical room Correct3 Removing the mask by touching the outer surface of the mask Incorrect4 Tying the two lower ties snugly around the neck

After using a surgical mask, the mask should be removed by untying the bottom mask strings, followed by the top strings. The outer surface of the mask should never be touched while removing it. Used masks should be dropped in a trash receptacle. Surgical masks should be removed before leaving the surgical room to prevent infection. While using a surgical mask, the two lower ties of the mask should be tied around the neck.

The nurse is caring for a patient who has a respiratory infection. The nurse understands that an infection occurs in a cycle and involves several elements. What are the elements in the chain of infection? Select all that apply. Correct1 An infectious agent 2 A vaccine schedule Correct3 The source of pathogen growth 4 A clean surrounding Correct5 A susceptible host

An infectious agent is the main pathogen or infection-causing organism that spreads through the chain of infection . The source for pathogen growth is the reservoir where the pathogens can multiply, survive, and wait until they are transferred to a susceptible host. A susceptible host is the element in the chain of infection that receives the pathogens and is in a favorable condition for their growth and transmission. A vaccine schedule is the plan of immunization and is not an element in the chain of infection. A clean surrounding is an ideal situation to prevent the spread of pathogens and is not an element in the chain of infection.

The nurse is instructed to clean artery forceps contaminated with blood. Arrange the steps of cleaning in the appropriate order. Correct 1. Rinse the artery forceps with cold water. Correct 2. Wash the artery forceps with soap and water. Correct 3. Rinse the artery forceps with warm water. Correct 4. Dry the artery forceps.

Any object contaminated with organic material like blood should be rinsed with cold running water. If hot water is used in the beginning, the protein in the organic material would coagulate and stick to the object. This may make cleaning difficult. After rinsing with cold water, the object should be washed with soap and water. Next, the object should be rinsed in warm water, and finally dried for reuse.

Which equipment is used to sterilize surgical instruments? Correct1 Autoclave 2 Boiling water Incorrect3 Chemical sterilants 4 Ethylene oxide (ETO) gas

Autoclaves use moist heat to kill pathogens and spores on surgical instruments to prevent infections. Boiling water is used to clean urinary catheters, suction tubes, and drainage collection devices. Chemical sterilants are used to disinfect heat-sensitive instruments and equipment such as endoscopes and respiratory therapy equipment. Ethylene oxide (ETO) gas is used for medical materials.

Which normal flora of the human colon can cause an infection when it enters the bloodstream? 1 Escherichia coli 2 Candida albicans Correct3 Bacteroides fragilis 4 Plasmodium falciparum

Bacteroides fragilis is a part of the normal flora of the human colon. This microorganism can cause infections if it enters the blood stream or tissue during injury or surgery. Escherichia coli causes gastroenteritis in the colon. Candida albicans causes candidiasis, pneumonia, and sepsis. Plasmodium falciparum causes malaria.

A nursing student performs surgical hand asepsis after assisting a registered nurse in a surgical procedure. Which action made by the nursing student needs correction? Correct1 Keeping the hands below the waist level 2 Turning off the faucet using the knees 3 Using a continuous motion to rinse from the fingertips to the elbows 4 Using a rotary motion to move the towel from the fingers to the elbows

Because the area below the waist level is considered unsterile, the nurse should keep his or her hands above the waist. The faucet should be closed by using the knees to prevent contamination of the hands. The nurse should use a continuous motion to rinse from the fingertips to the elbows, allowing water to run off at the elbows. The nurse should use a rotary motion to move the towel from the fingers to the elbows during drying to dry the skin from the hands to the elbows.

Which type of medical equipment is cleaned outside the health care facilities? 1 Endoscopes Correct2 Drainage collection devices 3 Respiratory therapy equipment 4 Heat-tolerant surgical instruments

Boiling is done outside health care facilities for items such as drainage collection devices. Endoscopes and respiratory therapy equipment are cleaned by chemical disinfectants in health care settings. Heat-tolerant surgical instruments are cleaned by autoclaves in the health care facilities.

While preparing a sterile field, a nurse opens the outermost flap by stretching his or her arm away from the sterile field. What is the reason for this action? 1 To ensure sterility of the package 2 To prevent a break in the technique Correct3 To avoid contamination of the sterile field 4 To free the dominant hand for unwrapping

During the preparation of a sterile field, the nurse's arm should be stretched away from the sterile field to avoid contamination of the field. Placing the pack of sterile drapes on the work surface ensures the sterility of the package. Assembling the necessary equipment before starting the procedure prevents a break in the technique. Opening the sterile item by holding the outside wrapper in the nondominant hand helps to free the dominant hand to unwrap the outer wrapper.

Which vaccinations are recommended to reduce the risk of infectious diseases in older adults? Select all that apply. Correct1 Flu vaccination 2 DTaP vaccination 3 Rubella vaccination 4 Varicella vaccination Correct5 Pneumonia vaccination

Flu and pneumonia vaccinations are recommended for older adults to reduce the risk of infectious diseases. DTaP vaccinations are effective for preventing whooping cough in children. Children are vaccinated for rubella infections. Varicella vaccination is used to prevent chicken pox in children.

What major infections are caused by Escherichia coli? Select all that apply. 1 Hepatitis A 2 Pneumonia Correct3 Gastroenteritis 4 Food poisoning Correct5 Urinary tract infections

Gastroenteritis and urinary tract infections are major infections caused by Escherichia coli. The hepatitis A virus causes Hepatitis A. Pneumonia and food poisoning are major infections caused by Staphylococcus aureus.

The nurse is assessing a group of patients in a health screening program. A patient complains of itching and irritation under the right arm and the nurse suspects a localized infection. What assessments should be done on this patient? Select all that apply. 1 Examine for paleness of skin. Correct2 Palpate the area for tenderness. Correct3 Inquire about pain and tightness. Correct4 Inspect the area for redness and swelling. 5 Inquire about gastrointestinal disturbances.

Gentle palpation of the infected area may reveal some degree of local tenderness due to inflammation. Inquiring about pain and tightness is important, because they may be caused by edema. Infected areas generally appear red and swollen due to inflammation. Paleness of skin is not a manifestation of infection. Gastrointestinal disturbances are not related to localized infection and may sometimes be found in systemic infections.

The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? 1 Leave the gloves on to administer the medication. 2 Remove gloves and administer the medication. Correct3 Remove gloves and perform hand hygiene before administering the medication. 4 Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room.

Gloves need to be changed and hand hygiene performed to prevent transfer of microorganisms from one source (the wound) to another (the nurse's hands). Gloves are not a foolproof method of preventing contamination of the nurse's hands so it is necessary to perform hand hygiene according to approved protocol. Medications should never be left at the bedside. It is the nurse's responsibility to ensure that patients take their medications.

While performing hand hygiene, the nurse avoids wearing rings. What is the rationale behind this action? 1 To ensure complete antimicrobial action Correct2 To prevent a Staphylococcus aureus infection 3 To prevent an increase in the number of bacteria residing on the hands 4 To provide enough time for the antimicrobial solution to be effective

Gram-negative bacilli such as Enterobacter and Staphylococcus aureus are more common under rings; therefore, the nurse should not wear rings to avoid infections. The nurse rubs the hands together by covering all the surfaces of the hands and fingers with antiseptic to ensure complete antimicrobial action. The nurse's fingernails should be less than a quarter-inch long to decrease the number of bacteria residing on hands. The nurse rubs his or her hands together with an antiseptic for several seconds and allows his or her hands to dry before applying gloves to provide enough time for the antimicrobial solution to be effective.

Which is the most effective way to control the transmission of infection in health care facilities? 1 Vaccinations 2 Isolation precautions Correct3 Hand hygiene practices 4 Use of clean equipment

Hand hygiene practices are the most effective way to break the chain of infection and control the transmission of infection. Vaccinations are effective measures to prevent the occurrence of infection in an individual. Even if a patient is isolated, the nurse caring for the patient has a risk of infection. Therefore, the nurse should perform hand hygiene before and after providing patient care. The use of clean equipment without hand hygiene may spread infection.

In the hospital setting, what is the most likely means of transmitting infection between patients? 1 Exposure to another patient's cough 2 Sharing equipment among patients 3 Disposing of soiled linen in a shared linen bag Correct4 Contact with a healthcare worker's hands

Hands become contaminated through contact with the patient and the environment and serve as an effective vector of transmission. Exposure to another patient's cough and the sharing of equipment between patients can also lead to cross infection between patients, but proper hand hygiene by all healthcare workers is the most effective way to break the chain of infection.

Which is the most effective way to break the chain of infection? Correct1 Hand hygiene 2 Wearing gloves 3 Placing patients in isolation 4 Providing private rooms for patients

Hands become contaminated through contact with the patient's environment. Clean hands interrupt the transmission of microorganisms. Wearing gloves, placing patients in isolation and providing private rooms also can help break the chain of infection, but hand hygiene is the most effective method.

The nurse works in a medical-surgical unit. Which patient should the nurse evaluate as the highest risk for health care-associated infections (HAIs)? 1 A 20-year-old patient admitted with gastroenteritis 2 A 24-year-old patient admitted with a fracture of the leg 3 A 34-year-old patient admitted for appendectomy Correct4 A 53-year-old diabetic patient admitted for herniorraphy

Health care-associated infections (HAIs) are those that are acquired by patients in the hospital during their stays. People whose immunity is compromised are at risk of these infections. Those who are at greater risk include the elderly, the malnourished, or those who have some underlying conditions that compromise their immunity, such as diabetes or malignancies. Therefore, the 53-year-old diabetic patient is at increased risk of an HAI. Gastroenteritis, fracture, and appendectomy do not increase the risk of HAIs.

A community nurse is conducting an awareness program for sex workers and community members with substance abuse problems. What should the nurse tell the attendees about prevention of the spread of the hepatitis C virus? 1 A symptomatic patient cannot transmit hepatitis C. 2 Hepatitis C can be transmitted through the fecal-oral route. 3 Only symptomatic patients can transmit the virus. Correct4 Both symptomatic and asymptomatic patients can transmit the virus.

Hepatitis C is a communicable disease. A person with or without symptoms can transmit the virus. It is present in blood and body fluids. It can be spread through sexual contact but not through the fecal-oral route.

Which is a mode of transmission for the human immunodeficiency virus (HIV) infection? Incorrect1 Vectors 2 Droplet Correct3 Vehicles 4 Airborne

Human immunodeficiency virus (HIV) infections are transmitted through vehicles such as blood and body fluids. Vectors such as mosquitoes transmit malaria. Infections such as Ebola and tuberculosis are transmitted by droplet nuclei. Infections such as influenza, Ebola, and tuberculosis are airborne.

In which order does the chain of infection cycle occur chronologically? Correct 1. Infectious agent Correct 2. Reservoir Correct 3. Portal to exit Correct 4. Mode of transmission Correct 5. Portal to entry Correct 6. Host

Infection occurs in a cycle that depends on the presence infectious agents, reservoirs, portal to exit, mode of transmission, portal to entry, and host. First, infectious agents choose a reservoir to multiply. After multiplying, they exit through sites such as the skin, urinary tract, and reproductive tract. These agents find different modes of transmission to enter the host.

A patient with influenza is admitted to a hospital. Which infection-control precautions should the nurse take to prevent spread of the virus? Select all that apply. 1 Wearing gloves while reviewing the medical report Correct2 Wearing a surgical mask within 3 feet of the patient 3 Wearing a sterile gown while entering the patient's room Correct4 Maintaining proper hand hygiene during the assessment 5 Placing the patient in an airborne infection isolation room

Influenza is an example of an infection that is transmitted by large droplets. Therefore droplet precautions are required, which include wearing a surgical mask within 3 feet of the patient and maintaining hand hygiene during the assessment. While reviewing the patient's medical report, the nurse does not need to wear gloves. The patient is placed in an airborne infection isolation room when an airborne infection, such as tuberculosis, is present or suspected. Contact precautions require a gown and gloves, as in the case when caring for a patient with Clostridium dificile (C. dif) or drug resistant microorganism strains (MRSA, ORSA, VRE).

When the nurse is performing surgical hand asepsis, where should the nurse keep his or her hands? 1 Below the elbows Correct2 Above the elbows Incorrect3 At a 45-degree angle 4 In a comfortable position

Keeping the hands above the elbows when performing a surgical scrub prevents contaminated water from coming into contact with the hands.

The nurse provides care to four patients with different medical conditions in four units. In which medical unit should the nurse use an N95 respirator? Correct1 Medical unit I 2 Medical unit II 3 Medical unit III 4 Medical unit IV

Laryngeal tuberculosis is an airborne infection that spreads through small droplets. Therefore, the nurse should use an N95 respirator to prevent infection in medical unit I. Shigella infection spreads through contact; contact precautions should be followed in medical unit II. Scabies spreads through contact; contact precautions should be followed in medical unit III. Disseminated varicella zoster spreads through contact; contact precautions should be followed in medical unit IV.

A registered nurse (RN) teaches a nursing student about applying a sterile gown. The registered nurse instructs the student to lift the folded gown directly upward and step back from the table. What is the reason behind this instruction? 1 To provide proper positioning 2 To ensure dexterity Correct3 To provide a wide margin of safety 4 To ensure that the hair is protected from contamination

Lifting the folded gown and stepping back from the table provides a wide margin of safety and avoids contamination of the gown. This action does not provide proper positioning. The nurse's dexterity Is ensured while wearing gloves. Wearing a clean cap protects the hair from contamination.

Which microorganism exits through a man's urethral meatus during sexual contact? 1 Ebolavirus 2 Clostridium difficile Correct3 Neisseria gonorrhea 4 Legionella pneumophila

Neisseria gonorrhea exits through a man's urethral meatus or a woman's vaginal canal during sexual contact. Ebolavirus is transmitted through blood or body fluids. Clostridium difficile causes antibiotic-induced diarrhea. Legionella pneumophila grows only at certain temperatures.

A patient who had undergone a hysterectomy 10 days ago came for a follow-up visit. The patient notices purulent drainage at the incision site. The nurse suspects wound infection and performs assessment for confirmation. Which clinical findings would the nurse evaluate? Select all that apply. Correct1 Pain Correct2 Redness 3 Paleness Correct4 Tenderness 5 Cold sensation

Pain is an important finding in wound infection because it is due to inflammation. Redness is commonly seen in wounds that are infected. Tenderness is observed in a wound infection due to localized swelling and inflammation. The infected wound appears red; it does not appear pale. The skin around the infected wound is warm to the touch.

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1 Provide a dark, quiet room to calm the patient. 2 Reduce the level of precautions to keep the patient from becoming angry. Correct3 Explain the reasons for isolation procedures and provide meaningful stimulation. 4 Limit family and other caregiver visits to reduce the risk of spreading the infection.

Patients on isolation precautions [1] [2] [3] may interpret the needed restrictions as a sign of rejection by the healthcare worker. Explaining the reasons for isolation and providing meaningful stimulation can help the patient accept and adapt to the isolation precautions. Keeping a patient in a dark, quiet room can increase the patient's perception of social isolation and decrease sensory stimulation. Reducing the level of precautions can lead to cross contamination and hospital-acquired infections. Family and caregiver visits do not need to be limited unless the family members or caregivers are immunocompromised.

A family member is providing care to a loved one who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? 1 Wear gloves before eating or handling food. 2 Place any soiled materials into a bag and double bag them. 3 Have the family member check with the doctor about the need for immunization. Correct4 Perform hand hygiene before and after care and/or handling contaminated equipment or material.

Performing hand hygiene before and after care interrupts the transmission of microorganisms from family members. Hands should be washed before eating or handling food, but gloves are not necessary. In the home care setting, soiled materials should be placed in an impervious plastic or brown paper bag. Immunizations are important, but in this situation, they would not protect against a leg wound infection.

What is the most effective technique in preventing and controlling the transmission of an infection? Correct1 Performing hand hygiene 2 Using isolation precautions 3 Performing sterilization procedures 4 Wearing personal protective equipment (PPE)

Performing hand hygiene is the most effective and basic technique in preventing and controlling the transmission of infection. Isolation precautions cannot control the transmission of microorganisms that cause infections unless the nurses and other health care workers follow proper control measures to prevent infections. Performing sterilization procedures help to control the transmission of infections through surgical instruments or other medical materials. Wearing personal protective equipment (PPE) is used to perform procedures that carry the risk of direct contact with contaminated material. This intervention is a more complicated step, however.

The nurse cares for a patient who is scheduled for surgery. Which objects would require high-level disinfection with phenolics? 1 Stethoscopes 2 Urinary catheters 3 Surgical instruments Correct4 Anesthesia equipment

Phenolics are used for high-level disinfection. Semi-critical items such as anesthesia equipment, endoscopes, and endotracheal tubes require high-level disinfection or sterilization. Noncritical items such as stethoscopes require a disinfection of surfaces. Critical items such as urinary catheters and surgical instruments require sterilization.

Which risk factor causes secondary infections? Correct1 Trauma 2 Heredity 3 Nutrition 4 Chronic disease

Physical trauma may cause fractures and internal bleeding, which may lead to secondary infections. Heredity causes diseases, such as sickle cell disease, diabetes resulting in anemia, and delayed healing. Poor nutrition causes obesity and anorexia, resulting in an impaired immune response. Chronic disease causes chronic obstructive pulmonary disease, heart failure, diabetes resulting in pneumonia, skin breakdown, and venous stasis ulcers.

Your ungloved hands come into contact with the drainage from your patient's wound. What is the correct method to clean your hands? Correct1 Wash them with soap and water. 2 Use an alcohol-based hand cleaner. 3 Rinse them and use the alcohol-based hand cleaner. 4 Wipe them with a paper towel.

Physically removing wound drainage is most effectively accomplished by washing with soap and water. According to the Centers for Disease Control and Prevention (CDC), when hands are visibly soiled due to contact with bodily fluids, only cleaning with soap and water and using friction to clean the hands helps prevent contamination.

A patient who had a hysterectomy 10 days ago has come for a follow-up visit. The patient is experiencing pain and itching at the incision site. The nurse suspects a wound infection and performs an assessment for confirmation. When assessing this patient, what actions should the nurse perform to reduce the spread of infection? Select all that apply. 1 Call for a senior nurse. 2 Wait for the laboratory results. Correct3 Perform hand-hygiene practices. Correct4 Use gloves when assessing the wound. Correct5 Use appropriate, personal protective equipment.

Proper hand-hygiene practices are important to control the spread of infection to other sites or other patients. The nurse should use gloves when assessing the wound to prevent cross contamination of the wound and her hand. The nurse should use appropriate, personal protective equipment (PPE) when assessing the wound to prevent the microorganisms from spreading. Calling a senior nurse may be considered only if there is additional assistance required. Waiting for the laboratory results is not required to perform an assessment.

The nurse who is working in a postoperative unit realizes that there is chipped nail polish on her fingers. Another colleague who has artificial nails tells the nurse that it is not a concern. Which of them poses a greater risk for contracting an infection to the patients? 1 There is no risk with either situation. 2 The nurse with artificial nails has a higher risk. 3 The nurse with chipped nail polish has a higher risk. Correct4 Both nurses have an equal risk of causing infection.

Research has shown that health care providers with chipped nail polish or with artificial nails have greater numbers of microorganisms, and therefore pose a greater risk to the patients. The Centers for Disease Control and Prevention's (CDC) hand hygiene guidelines recommend that artificial nails should not be worn by health care providers when working with high-risk patients.

To which patients do standard precautions apply? Correct1 All patients receiving care 2 Patients with blood-borne infections 3 Patients with infected, draining wounds 4 Patients believed to have an infectious disease

Standard precautions were implemented to provide safety for caregivers and patients regardless of infectious status. The answer choices concerning the use of standard precautions only for patients with blood-borne infections; those patients with infected, draining wounds; or patients believed to have infectious diseases are incorrect because they limit the scope of standard precautions that are used with certain populations.

Which type of specimen is collected by using a sterile tongue blade? Correct1 Stool specimen 2 Urine specimen 3 Blood specimen 4 Wound specimen

Stool specimens are collected with sterile tongue blades. Urine specimens are collected with needleless safety syringes. Blood specimens are collected with 20-mL needle-safe syringes. Wound specimens are collected with sterile cotton-tipped swabs or syringes and collection tubes.

A nurse reviews the laboratory reports of a patient with infection. Which laboratory parameter would be normal during infection? Correct1 Basophil count 2 Monocyte count 3 Neutrophil count 4 Lymphocyte count

The basophil count would be normal during infection. The monocyte count may increase if the patient has a protozoan infection. The neutrophil count may increase if the patient has an acute suppurative infection. The lymphocyte count may increase if the patient has a chronic bacterial or viral infection.

Which statement regarding health care-associated infections requires correction? Correct1 The costs of health care-associated infections are reimbursed. 2 Health care-associated infections can significantly increase the cost of health care. 3 The length of hospitalization influences the risk of health care-associated infections. 4 Health care-associated infections result from the delivery of health services in a healthcare facility.

The costs of health care-associated infections (HAIs) are not reimbursed; therefore, the prevention of HAIs plays an important role in the managed care of health care systems. HAIs can increase the cost of health care because they increase infections in patients. The invasive procedure involved, the therapies received, and the length of hospitalization can influence the risk of HAIs in patients. HAIs can be caused by invasive procedures performed during the delivery of health services in a health care facility.

When does the nurse wear a gown? 1 The patient's hygiene is poor. 2 The nurse is assisting with medication administration. 3 The patient has acquired immunodeficiency syndrome (AIDS) or hepatitis. Correct4 Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform.

The gown serves as a barrier between the patient's blood and/or body fluids and potential contact with the caregiver's skin. In some cases, if the patient's hygiene is unacceptable, it may require the nurse to wear a gown, but it is not the best answer. It is not necessary to wear a gown during medication administration or if the patient has AIDS or hepatitis.

What is the portal of exit of the influenza virus? 1 Blood Correct2 Respiratory tract 3 Reproductive tract 4 Skin and mucous membrane

The influenza virus is released from the body via the respiratory tract when an infected person sneezes or coughs. Organisms that cause communicable disease such as Hepatitis B and HIV exit from wounds and bloody stool. Organisms such as Neisseria gonorrheae and HIV exit through the reproductive tract during sexual contact. Any break in the skin and mucous membranes allows pathogens to exit the body; the influenza virus does not exit through the skin.

A 47-year-old patient has arrived at the clinic after accidentally cutting his forearm with a pair of scissors. Which clinical manifestations would the nurse expect to indicate a local inflammation? Select all that apply. Correct1 Swelling Correct2 Redness Correct3 Pain 4 Anorexia 5 Vomiting

The local manifestations of inflammation include swelling, redness, and pain. These manifestations are caused by protective vascular reactions that help to combat inflammation. Anorexia and vomiting are systemic manifestations of inflammation.

Which action is performed by the nurse in the given image? 1 Opening of the last and innermost flap 2 Opening of the first side flap and pulling aside 3 Opening of the second side flap and pulling it aside Correct4 Opening of the outermost flap of the sterile kit away from body

The nurse is opening the outermost flap of the sterile kit away from the body to avoid microbial contamination. This is the first step of opening a sterile kit. The first side flap is opened and pulled aside in the second step. The second side flap is opened and pulled aside in the third step. The last and the innermost flap are opened in the last step.

A registered nurse teaches a group of nursing students about home care considerations for patients with infections. Which statement made by the nursing student indicates the need for further learning? 1 "I should determine potential sources of contamination." 2 "I should evaluate hand washing facilities in the patient's home." 3 "I should anticipate the need for alternative hand washing products." Correct4 "I should see if cold running water faucets are available."

The nurse should check if warm running water faucets at the patient's home. The nurse should determine potential sources of contamination and possible preventive measures. The nurse should evaluate all hand washing facilities in the patient's home. The nurse should anticipate the need for alternative hand washing products for use in emergency and immediate situations.

Which action should the nurse avoid while opening a sterile item on a flat surface? 1 Keeping the inner contents sterile before use Correct2 Grasping 3.5 cm of the border to maneuver the field on the table surface 3 Holding the item with one hand while pulling the wrapper away with the other hand Incorrect4 Using 1 inch of the inner surface of the package border as a sterile field to add sterile items

The nurse should grasp only 2.5 cm (1 inch) of the border to maneuver the field on a table surface while opening a sterile item on a flat surface. The inner contents should be kept sterile before use to prevent infection. The nurse should hold the item in one hand while pulling the wrapper away with the other hand. The nurse should use nearly 1 inch of the inner surface of the package border around the edges as a sterile field to add sterile items.

A patient is admitted to a hospital for surgery to correct urinary incontinence. About what should the nurse instruct the patient in order to avoid infections while cleaning the perineal region? Correct1 Wipe from the urinary meatus toward the rectum. 2 Wipe from the rectum toward the urinary meatus. 3 Clean the perineal region once a day. 4 Cleaning the perineal area is more important for young women then for older women past menopause.

The nurse should instruct the patient about cleaning the perineal region correctly to reduce the incidence of genitourinary infections. The rectum is a highly contaminated area compared to the urinary meatus. It is necessary to wipe the perineal area from the urinary meatus toward the rectum, as cleaning should be done from least to most contaminated regions to reduce infections. Wiping from the rectum to the urinary meatus would increase the risk for contracting infection. Cleaning the perineal area only once a day increases the risk for contracting infection; the perineal region should be cleaned after every voiding and bowel movement. Keeping the perineal region meticulously clean is particularly important for older women who may wear incontinence pads.

Which statement is true regarding donning a sterile gown? 1 The circulatory nurse should also wear sterile gown. 2 Nurses should wear sterile gowns before applying masks. 3 The anterior surface of the sleeves of a gown is also considered sterile. Correct4 The nurse should wear sterile gowns while assisting a health care provider during surgery.

The nurse should wear a sterile gown while caring for a patient with large open wounds and while assisting the healthcare provider during invasive procedures, such as inserting an arterial catheter. A circulatory nurse generally does not wear a sterile gown. Nurses should not apply a sterile gown until after applying a mask and surgical cap. Only certain areas of the gown are considered sterile; the collar and the anterior surface of the sleeves may not be considered sterile.

What would a nurse use for a high-level disinfection? 1 Moist heat 2 Boiling water 3 Ethylene oxide gas Correct4 Hydrogen peroxide

The nurse uses chemical sterilants such as hydrogen peroxide, iodophors, phenolics, and quaternary ammonium compounds for high-level disinfection. Moist heat, boiling water, and ethylene oxide gas are used for sterilization.

A registered nurse teaches a patient about measures to control the exit and entry of microorganisms. Which statement made by the patient needs correction? 1 "I will brush my teeth regularly." 2 "I will apply lotion to my skin appropriately." Correct3 "I will apply water-insoluble ointment to my lips." 4 "I will clean my perineal area by wiping from the urinary meatus toward the rectum."

The patient should maintain the integrity of his or her skin and mucous membranes to reduce the risk of microorganism infections. The patient should apply water-soluble ointment to the lips to keep them lubricated and maintain skin integrity. The patient should brush his or her teeth regularly to prevent the drying of mucous membranes. The patient should apply lotion to the skin appropriately to keep the skin lubricated. The patient should clean the perineal area from the urinary meatus toward the rectum to prevent the entry of infectious microorganisms into the urinary tract.

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? 1 It keeps an incontinent patient's skin dry. 2 It can get caught in the linens or equipment. Correct3 It obstructs the normal flushing action of urine flow. 4 It allows the patient to remain hydrated without having to urinate.

The presence of a catheter in the urethra breaches the natural defenses of the body . The reflux of microorganisms up the catheter lumen from the drainage bag or backflow of urine in the tubing increases the risk of infection. A catheter can help in keeping an incontinent patient's skin dry, but that normally does not lead to a urinary tract infection. The catheter can become caught up in the linens or with other equipment, but that does not cause a urinary tract infection. A patient with a catheter is producing urine and urinating; thus the patient is staying hydrated and still urinating.

The nurse is planning discharge instructions for a patient diagnosed with human immunodeficiency virus (HIV). Which statement made by the patient would indicate effective teaching? 1 "The virus cannot spread through sexual contact." 2 "The virus can spread through feces only when I have symptoms of the disease." Correct3 "The virus can be spread to another person by contact with body fluids." 4 "The virus can cause Rocky Mountain spotted fever."

The primary routes of HIV infection are associated with contact of HIV-infected body fluids such as blood or semen, blood transfusions, sharing of infected needles, and needle-stick injuries. The virus spreads through sexual contact and does not spread through feces. The virus does not cause Rocky Mountain spotted fever, which is caused by Rickettsia rickettsii.

A patient who is infected with herpes simplex complains of itching and tingling. There are no visible lesions found on examination. To which stage of herpes simplex infection does this patient belong? 1 Illness stage 2 Incubation stage Correct3 Prodromal stage 4 Convalescence stage

The prodromal stage is defined as the interval from onset of nonspecific signs and symptoms to more specific symptoms related to the type of infection or disease. In this stage the microorganisms grow and multiply. Itching and tingling sensations are nonspecific symptoms of herpes simplex that occur before the lesions appear. In the illness stage, the patient actually develops the signs and symptoms specific to the type of infection. The incubation period is an interval between entrance of the pathogen into body and appearance of the first symptoms. In the convalescence stage, acute symptoms of infection will disappear.

Which instrument used by the nurse requires surface disinfection? 1 Endoscope 2 Cardiac catheter 3 Urinary catheter Correct4 Blood pressure cuff

There are two types of disinfection: disinfection of surfaces and high-level disinfection. Noncritical items such as blood pressure cuffs require a surface disinfection. Semi-critical items such as endoscopes require high-level disinfection. Critical items such as cardiac and urinary catheters require sterilization.

A patient is suspected of having malaria. Which mode of transmission spreads malaria? Correct1 Vector 2 Vehicle 3 Airborne 4 Direct contact

Vector transmission, such as infection by a mosquito, is responsible for malaria. Vehicles such as water, solution, and blood do not transmit malaria. Respiratory infections are possible through the airborne transmission of microorganisms. Malaria is not transmitted by direct contact with infected persons.

What is an infective disease that can be transmitted directly from one person to another considered? 1 A susceptible host Correct2 A communicable disease 3 A port of entry to a host 4 A port of exit from the reservoir

When an infectious disease can be transmitted directly from one person to another, it is termed a communicable disease. No vector is necessary for transmission. A susceptible host is someone who is more prone to develop an infectious disease process. The port of entry is where microorganisms enter the body and the portal of exit is where microorganisms exit a host such as blood or the skin.

Which action made by the nurse may contaminate the surface of the sterile item? 1 Disposing of the outer wrapper Correct2 Holding the arm over the sterile field 3 Peeling the wrapper onto the nondominant hand 4 Allowing the drape to unfold on a surface above waist level

While adding sterile items, the nurse should not hold the arm over the sterile field because it may contaminate the surface of the sterile item. Disposing of the outer wrapper prevents accidental contamination of the sterile field. The nurse should carefully peel the wrapper onto the nondominant hand. The nurse should allow the drape to unfold on a surface above the waist and work surface to prevent contamination.

Which action increases the risk of contamination while applying a sterile gown? Correct1 Lifting the gown upward and stepping forward near the table 2 Grasping the inside front of the gown with both hands just below neckband 3 Asking the circulating nurse to tie the back of the gown at the neck and waist 4 Slipping both arms into the armholes with the hands at shoulder level

While applying a sterile gown, the nurse should lift the gown directly upwards and step backwards (not forward) away from the table to provide a wide margin of safety. The nurse can ask the circulating nurse to tie the back of the gown at the neck and waist; this action can reduce the risk of contamination. Clean hands can touch the inside of the gown without contaminating the outer surface. With the hands at shoulder level, the nurse should slip both arms into the armholes simultaneously to prevent contamination.

While using an antiseptic hand rub to perform hand hygiene, the nurse feels dryness in his or her hands after rubbing them together for 10 to 15 seconds. What is the reason for this dryness? 1 Occurrence of an allergic reaction 2 Insufficient time taken to rub hands Correct3 Insufficient antiseptic solution applied 4 Complete antimicrobial action maintained

While maintaining hand hygiene, if the nurse's hands are dry after rubbing them together for 10 to 15 seconds, an insufficient volume of product was likely applied. Dryness of the hands does not indicate allergic reaction. Ten to 15 seconds is a sufficient amount to time to rub the hands the together. Complete antimicrobial action is not achieved if an insufficient antiseptic solution is applied.

A nurse performs hand hygiene before providing direct patient care. Which action made by the nurse may cause an infection? Correct1 Wearing rings on both hands 2 Maintaining nail tips less than a quarter-inch long 3 Rubbing both hands together after applying the antiseptic Incorrect4 Pushing the wristwatch and long uniform sleeves above the wrists

While performing hand hygiene, finger rings should be removed. Wearing rings increases the risk for infection because the skin underneath the rings carries a high bacterial load. The nail tips should be less than a quarter-inch long. Antiseptic should be applied on the palm and both hands should be rubbed together. Any wristwatches and long uniform sleeves should be pushed above the wrist to provide complete access to the fingers, hands, and wrists.

A licensed practical nurse is preparing to assist in a sterile procedure. Which nursing action is appropriate in surgical hand asepsis? Correct1 Scrubbing the hands for 5 minutes 2 Washing over the rings and watch 3 Keeping the hands and arms below the elbows 4 Allowing the water to flow from the elbows to the hands

While performing surgical hand asepsis, the nurse should scrub the hands for 5 minutes to eliminate transient microorganisms and reduce resident hand flora. During a sterilizing procedure, the nurse should remove all jewelry and accessories, such watches and rings. The hands should be above the elbows while performing a surgical scrub.

The nurse pours a sterile liquid into a container. Which action made by the nurse is appropriate? Incorrect1 Holding the bottle with its label pointed outside the palm of the hand 2 Placing the cap with the inner surface facing down on the table 3 Keeping the edge of the bottle close to the edge of the container Correct4 Pouring a small amount in a disposable cap before pouring in the container

While pouring a sterile liquid into a container, a small amount of liquid should be poured in a disposable cap before it is poured into the container because the discarded solution cleans the lip of the bottle. The cap should be placed with its inner surface facing upwards on the table because the inner surface should not be contaminated. The nurse should hold the bottle with its label in the palm of the hand to prevent the possibility of the solution wetting and fading the label. The edge of the bottle should be kept away from the container.

The nurse assists a surgical technician in preparing a sterile field. Which action made by the nurse indicates a need for correction? 1 Allowing the flap to lie flat on the table's surface 2 Grasping the outer edge of the tip of the outermost flap Correct3 Standing close to the sterile field while opening the last flap 4 Opening the outermost flap of the sterile kit away from the body

While preparing a sterile field, the nurse should open the last flap while standing away to field as to avoid contamination. The flap should be allowed to lie flat on the table surface. The outer edge of the tip of the outermost flap should be grasped because the outer surface of the package is considered unsterile. The outermost flap of the sterile kit should be kept away from the body to prevent contamination.

A registered nurse evaluates the nursing assistive personnel who is wearing a mask. Which action made by the nursing assistive personnel indicates a need for correction? Correct1 Having a casual conversation while wearing a mask 2 Changing an unused mask due to a moist feeling 3 Tying the two top ties at the back of the head and above the ears Incorrect4 Wearing the mask such that the top of the mask fits below the glasses

While wearing a mask, talking should be kept to a minimum to reduce respiratory airflow. A mask that has become moist does not provide a barrier to microorganisms and should be discarded. While wearing a mask, the two top ties should be tied at the back of the head and above the ears. The top of the mask should fit below the glasses.