Chapter 25: Asepsis and Infection Control

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond?

"As we age, our immune system does not function as well." -Rationale: The nurse should explain that during the aging process, the immune system decreases in function and the older adult client is at greater risk for becoming infected. Other risk factors for the older adult client include poor nutrition and fluid intake. Although washing hands is an important part of the prevention of infection, there are other methods such as airborne and droplet transmission that may be unavoidable. When it comes to visitation, the only limitation that should be set is that those who are ill or possibly infected should refrain from visiting the client. Informing the client that nothing can be done is not accurate, as there are preventative measures that may be taken to avoid exposure.

The nurse is teaching the client how to self-administer an insulin injection. What response(s) indicates that the client understands the safety principles of self-administration? Select all that apply.

"I will rotate the site of my injection." "I will immediately dispose of the needle and syringe into a puncture-resistant container." "I will gently mix my insulin by gently rolling the vial between the palms of my hands." -Rationale: Rotating injection site is considered a safe practice as is disposing the syringe into a puncture-resistant container. Rolling the vial to mix and rotating the sites are correct practices and will prevent developing scar tissue from repeated injections or from receiving inappropriate amounts of insulin. Vials of insulin should be stored in the refrigerator and cartridges at room temperature, not specifically a dark cabinet. Needles should never be recapped for safety purposes.

The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?

"Your infant's resistance comes from the antibodies you passed on to him before birth and now with breast feeding." -Rationale: The immune system does not become fully operational until an infant reaches about 6 months of age (Shaw, Thalapial, Shaw, & Malla, 2007). Before then, the infant's resistance to infection comes from the antibodies passed by way of the placenta and breast milk. Newborns have difficulty localizing infections (preventing the spread of organisms from the site of contact). Their phagocytes have difficulty trapping microbes, and they do not produce enough antibodies. Newborns have immature thermoregulatory mechanisms and do not become febrile.

The medical nurse is caring for several clients who are receiving treatment for infection. Which client is most likely to be experiencing a healthcare associated infection (HAI)?

A client being treated for a Clostridium difficile infection -Rationale: Clostridium difficile infection is among the five most common HAI's in the United States. None of the other listed infections are among the most common HAI's.

Which client would the nurse consider the most infectious?

A client who is in the prodromal stage -Rationale: 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.

The nurse is speaking to the health care provider regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridioides difficile infection". Which part of the SBAR communication will this statement fall into?

A= Assessment -Rationale: SBAR: Situation, Background, Assessment, and Recommendations (SBAR) is a shared mental model for improving communication between and among clinicians. Note that situation, background, and assessment are all based on the collection of complete and accurate assessment data. The last piece, recommendations, encompasses the nurse's suggestions for the next interventions. Situations: What is happening at the present time? Background: What are the circumstances leading up to this situation? Assessment: What do I think the problem is? Recommendations: What should we do to correct the problem?

A client is fighting an infection because foreign particles have entered the client's body, stimulating an immune response. These foreign particles are described as what?

Antigens -Rationale: Antigens are foreign particles, such as microbes, that enter a host. Antibodies are what the immune system produces to counter their effects. Phagocytes and macrophages are components of the immune system response to the presence of antigens.

A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area?

Area of active drainage -Rationale: When obtaining a specimen for an aerobic wound culture, the nurse would obtain the specimen from deep in an area of active drainage. The specimen for an anaerobic culture is obtained from deep in the cavity to identify organisms that may grow where oxygen is not present. Cultures are not taken from the edges of the wound or from the soiled dressing.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?

Avoid contact with mosquitoes -Rationale: Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate.

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?

Cleanse and disinfect the sphygmomanometer -Rationale: 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.

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. -Rationale: If the nurse realizes that the sterile field is broken, the most appropriate response is to stop and don another pair of sterile gloves. A sentinel event has not occurred, and calling the PCP is unnecessary. Doing nothing and moving forward with foley insertion places the client at greater risk of infection and is not an appropriate action.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract -Rationale: Escherichia coli residing in the intestinal tract is typical normal flora. Escherichia coli in the urinary tract is indicative of a urinary tract infection. Shigella germs are a common cause of severe diarrhea and are contagious. Shigella in the urinary tract is indicative of a urinary tract infection.

Which mask should the nurse don when caring for a client with tuberculosis?

Filtered respirator -Rationale: When caring for a client with tuberculosis, the nurse should don a filtered respirator mask to filter the inspired air. A surgical mask, also known as a procedure mask, is intended to be worn by health care professionals during surgery and during nursing to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose. Low-efficiency particulate air (LEPA) masks are not used in health care.

A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take?

Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes. -Rationale: The nurse should educate clients and visitors to health care facilities to cover the mouth/nose with a tissue when coughing; to promptly dispose of used tissues; to use surgical masks on the coughing person when tolerated and appropriate; to use hand hygiene after contact with respiratory secretions; and to use spatial separation, ideally greater than 3 feet (1 meter), between people with respiratory infections in common waiting areas when possible. Having all clients in the waiting room don face masks would be inconvenient and unnecessary. Asking the parent to take the child home would be inappropriate.

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

Greater than 40.5°C -Rationale: A temperature greater than 40.5°C is referred to as hyperpyrexia. A low-grade fever is a temperature that is slightly elevated, 37.1°C to approximately 38.2°C. A temperature elevation above 38.2°C is considered a high-grade fever. A temperature between 35°C and 36.8°C is a subnormal temperature.

A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply.

Hepatitis B, Hepatitis C, HIV -Rationale: Tuberculosis would be a significant respiratory exposure, but it is not transmitted by blood.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

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

The nurse is caring for a client who is on neutropenic precautions following a bone marrow transplant. When applying infection control principles to this client's care, the nurse will perform what action?

House the client in a private room with a securely closing door -Rationale: Private rooms are imperative for clients on neutropenic precautions. Visitors must perform thorough hand hygiene but sterile gloves are not necessary. Injections should be avoided whenever possible and oral care is important, though it should be performed gently to avoid disrupting tissue integrity.

Unbeknownst 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 -Rationale: The correct sequence of the stages of infection are (1) incubation period, (2) prodromal stage, (3) full stage of illness, and (4) convalescent period.

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?

Inform the health care provider about this finding. -Rationale: The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare. Chemical composition aids these physical barriers further. For example, the acidic nature of the skin and vagina helps to kill potential invaders before they enter the body. Certain illness or treatments can interfere with the body's delicate balance, causing overgrowth of Candida fungus.

A client has a diagnosis of HIV. Which statement would concern the nurse?

My dog likes to roam the neighborhood and often eats from garbage cans. -Rationale: HIV is a viral infection that impairs the immune system, making individuals with the virus more likely to acquire infectious diseases. A dog who roams the neighborhood and eats from garbage cans is likely to pick up a bacterial infection, which can easily be spread to the individual with HIV. The virus is spread through exposure to blood and body fluids of an infected person. Using the same bathroom as family members, preparing their meals, or hugging them does not place them at risk for being infected with the virus.

An 86-year-old client reports an inability to concentrate, lightheadedness, weakness, muscle and joint discomfort. The client's temperature is 35.9C (96.6F), heart rate is 91 beats per minute and blood pressure is 133/78 mm Hg. What is the nurse's most appropriate action?

Perform a focused assessment for infection -Rationale: Older adults may not show a fever or may produce only a low-grade fever when an infection is present. The nurse should monitor the client closely. The incubation phase normally does not produce symptoms. Antibiotics would be premature until an infection is confirmed. The client's symptoms are not characteristic of normal physiological changes of aging.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next?

Perform hand hygiene -Rationale: Inverting the gloves into each other encloses the soiled surface and blocks a potential exit route for microorganisms. After removing gloves, the next step would be to perform hand hygiene which should be conducted before touching the loved one. Used materials are not always disposed of in biohazard containers. Donning new gloves should not be necessary as materials should have already been disposed of prior to removing the gloves. Lotions that work in conjunction with soaps and lotions should be used when applying lotion after performing hand hygiene but this is not the next step.

The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?

Perform hand hygiene. -Rationale: When preparing for a sterile procedure, the nurse will perform hand hygiene followed by any personal protection equipment, if required. Next, the nurse confirm the client's identity with the order and explains the procedure to the client. Then, the nurse the will check that the sterile package or kit is dry and unopened as well as the expiration date. Next, the nurse will set up a work area at waist level or higher followed by opening the outside package and remove the kit.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

Pour the liquid into a sterile container within the sterile field. -Rationale: The solution container should be held outside the edge of the sterile field and poured steadily from a height of 4 to 6 inches into a sterile container previously added to the sterile field and positioned at the side of the sterile field. This assures minimal splashing, as moisture contaminates the sterile field, and maintains sterility of the bottle and solution.

A client is experiencing generalized weakness and body aches resulting from exposure to an infectious microbe. The client is experiencing what stage in the progress of infection?

Prodromal period -Rationale: The prodromal period is characterized by nonspecific symptoms such as nausea, fever, general weakness, or aches and pains. The incubation period usually has an absence of symptoms while symptoms are more specific in the subsequent stages after the prodromal stage.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) -Rationale: Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together. Clostridioides difficile requires contact isolation and is contagious. Diabetic ketoacidosis is considered a medical diagnosis and requires standard precautions. A surgical incision from an appendectomy is considered clean. A draining leg ulcer can transmit an infection to a client with a clean surgical incision. In both of these cases, rooming these clients together violates infection control standards. Tuberculosis requires airborne precautions and pneumonia requires standard precautions. Based on the mode of transmission of tuberculosis, these clients cannot room together.

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply.

Redness, swelling, pain, exudate. -Rationale: Cardinal signs of infection include redness (heat), swelling, pain, and loss of function. As leukocytes and neutrophils enter the area, exudate made up of fluid, cells, and inflammatory by-products may be released by the wound. Warmth and heat at the site versus coolness are a sign of infection.

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from the room. -Rationale: 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.

A client with an intact immune system has been exposed to Mycobacterium tuberculosis, initiating a cellular immune response. This response will begin with what physiological process?

Stimulation of T lymphocytes -Rationale: T cell stimulation is the first stage in the process of cellular immunity. Phagocytosis and creation of memory cells occur later in the immune response. Antibody production by B cells is a component of humoral immunity.

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:

Survival adaptation -Rationale: An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae. Bacterial resistance is not demonstrated by aerobic activity. Spore production is another form of adaptation. Means of transmission is a component of the chain of infection, not an example of bacterial resistance.

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

T-lymphocytes -Rationale: T-lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.

The gerontological nurse will prioritize assessment of which client's infection, due to the likelihood of developing to a life-threatening infection?

The client being treated for a urinary tract infection -Rationale: Urinary tract infections and respiratory infections are most common and most lethal for older adult clients. For this reason, a client with a UTI likely faces a greater risk for serious consequences that a client with an ear, eye or skin infection.

The nurse works at an agency that requires its employees to wear a face mask as long as the employee is in the building. Which activity(ies) performed by the nurse is correct? Select all that apply.

The mask is positioned so that it covers both the nurse's nose and the mouth. The nurse does not touch the mask with their hands while wearing the mask. The nurse touches only the strings of the mask when applying or removing the mask. The nurse performs hand hygiene following removal of the their mask. -Rationale: The nurse should perform hand hygiene when removing the face mask. The purpose of hand hygiene at this time is to remove any microorganisms from their hands that could have been transferred from the mask to the hands during removal of the mask. Positioning the mask to cover the nose and mouth reduces entry and exit routes for transmission of microorganisms. Not touching the mask while wearing it also prevents the transfer of microorganisms to the hands. Touching only the strings of the mask when removing it helps to prevent transferring microorganisms to the nurse's hands. Putting on gloves prior to donning the mask would contaminate the gloves prior to the nurse caring for the client.

The charge nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction?

The new nurse slides the item from the wrapper into the side of the sterile field -Rationale: The nurse should hold the wrapped sterile item in the dominant hand and use the non-dominant hand to first open the top flap away from the body, then open both sides, and finally pull the remaining flap back toward the wrist and gather all corners of the wrapper back toward the wrist to cover the hand and wrist. The nurse should take care not to touch the inner surface of the wrapper or the sterile item. The sterile item should be held 6 inches above the surface of the sterile field and dropped onto the field. The nurse should be careful to avoid touching the surface or other items, or dropping any item onto the 1-inch border. This prevents contamination of the field and inadvertent dropping of the sterile item too close to the edge of or off the field. Any items landing on the 1-inch border are considered contaminated.

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?

The new nurse touches 1.5 in (4 cm) from the outer edges. -Rationale: Only the outer 1 in (2.5 cm) of the sterile package is safe to touch. In this case, the nurse touches 1.5 in (4 cm), which is inside the sterile field. 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 parent brings a child into the pediatric office with reports of an itchy red rash with fluid filled blisters. Two siblings at home are reported to have the same rash. Drag words from the choices below to fill in each blank in the following sentence.

The nurse knows that since the parent had the same virus during childhood they will have CELLULAR immunity in the form of ANTIBODIES. -Rationale: Humoral immunity consists of antibodies that are formed in response to exposure to an antigen. Artificial immunity would be obtained via a vaccine, whereas lymphocytes are considered part of cellular immunity. Cellular immunity is stimulated upon exposure to an antigen (foreign material) and results in the lymph system producing T-cells to attack the antigen. Passive immunity is acquired from another individual, for example a pregnant client to a fetus or through a blood transfusion. T-cells are part of cellular immunity that is activated upon response to an antigen.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles?

The nurse removes her gown and then removes her gloves. -Rationale: Gloves should be removed prior to a gown. Hand hygiene is necessary before applying gloves and after touching a client's surroundings. The use of moisturizers is acceptable.

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

Use a sterile cotton-tipped applicator to apply the prescription to the site -Rationale: Applying the ointment with the gloved finger contaminates the prescription ointment. Sterile cotton-tipped applicators are used to apply ointments or solutions to the wound bed to avoid contaminating the wound. A 4 × 4 gauze pad should not be applied until the wound is cleansed properly with sterile supplies. Soiled dressing supplies should be placed in a biohazardous trash bag or container.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

WBC of 25,000 mcL -Rationale: Leukocytes, also called white blood cells (WBCs), and the inflammatory response make up the second line of defense to microbial invasion. A normal WBC count is 5,000 to 10,000 cells/mm3. A count above this range is indicative of infection.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. -Rationale: 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. Frequent disinfecting is not indicated.

The client was exposed to an infectious microorganism but did not develo a systemic infection because phagocytosis took place. What process took place during this response to microbes?

White blood cells ingested and destroyed microorganisms -Rationale: Many leukocytes function as phagocytes, digesting and destroying microbial invaders, rather than altering their DNA. Phagocytosis does not involve changes in pH or activation of the thymus gland.

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne -Rationale: Tuberculosis is transmitted via the air. Therefore, airborne precautions are required. Standard, droplet, and contact precautions will not be selected by the nurse for a client who has tuberculosis.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman -Rationale: Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerable to infection, so the 80-year-old woman is the client most at risk for infection. A neonate is defined as a child less than 4 weeks of age. An adolescent is a child aged 9 to 12 years. A toddler is a child who is 12 to 36 months or 1 to 3 years of age.

For which client would the use of standard precautions alone be appropriate?

an incontinent client in a nursing home who has diarrhea -Rationale: Standard precautions apply to blood and all body fluids, secretions, and excretions except sweat. Transmission-based precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as is the case in answers A, B, and D.

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

bacteria. -Rationale: Bacteria may be transmitted through air, food, water, soil, vectors, or sexual activity.

The nurse is initiating isolation precautions for a client who has chronic Clostridioides difficile infection. What should the nurse be sure to include with these precautions?

be sure that there are gloves of various sizes and gowns for use -Rationale: All health care workers and visitors should don a gown and gloves prior to entering the client's room. These bacteria are not transmitted by droplet. An N95 respirator mask is not required for this client.

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?

handwashing -Rationale: A person's defenses may be compromised when exposed to the health care system, for a multitude of reasons. Healthcare-associated infections (HAIs) often result from poor hand hygiene and invasive procedures occurring within the health care system. HAIs occur frequently in skilled nursing facilities (SNF), jails, and other residential facilities where auxiliary staff have varied levels of training to care for high-risk individuals.

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

helps to determine prescribed antibiotic therapy -Rationale: Gram staining helps to order antibiotic therapy while waiting for specific culture results, whereas minimum inhibitory concentration permits selection of antibiotic concentration, helps in reducing proliferation of multidrug-resistant organisms, narrows the therapeutic range, and avoids prolonged use.

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.

increased respiratory rate, enlarged lymph nodes and fever. -Rationale: Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, and lymph node enlargement.

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?

intravenous antibiotic administration -Rationale: The discharge education plan would most likely include teaching the client and caregivers about the signs and symptoms of infection, hand hygiene measures, and vital sign monitoring. Because the client's infection has resolved, the client would probably not require intravenous antibiotic administration.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

keeping sterile field above waist level -Rationale: When setting up a sterile field, the correct technique is to keep the sterile field above the waist level. A nurse would open the sterile package away from him- or herself first. The sterile gloves are applied after the sterile container is opened. The sterile field is maintained with a 1-in. (2.5-cm) border.

A nurse is caring for four clients. Which client has the highest risk of infection?

older male with an enlarged prostate -Rationale: An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on infection.

The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as:

parasite. -Rationale: Lyme disease is spread through the bite of an infected tick, an arthropod, which is classified as a parasite. The bacteria Borrelia burgdorferi causes Lyme disease in humans. Viruses cause numerous infections but are not associated with Lyme disease. Fungi also cause disease in humans but are not associated with Lyme disease.

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal -Rationale: Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature.

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?

reaches down to the bed to pick up a sterile drape -Rationale: 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 notes that the client's temperature is 101.2°F (38.4°C) at 8 a.m. Elevated temperature may be due to several factors. What could be the reason for this?

respiratory infection -Rationale: Assess vital signs frequently to detect infection or to monitor its progress. The accuracy of such assessment is important in determining if infection is present. In client with an infection, look for elevations in temperature (above 38.4°C [101°F]), pulse rate, and respiratory rate.

Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care?

skin is dry and intact -Rationale: The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare.

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is:

standard precautions. -Rationale: Standard or universal precautions relate to blood and certain body fluids to protect health care workers from clients possibly carrying HIV, hepatitis B virus, or other bloodborne pathogens.

The nurse observes a member of the care team removing a gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?

teach the colleague to let the gown fall away rather than pulling on the sleeves -Rationale: The individual should allow the gown to fall away from the shoulders, touching only the inside of the gown. Gloves are removed first; this should be performed inside the client's room, unassisted.

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?

the client who is 48-hours postsurgical procedure -Rationale: 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 begin with the client who is postoperative, then see the other clients who have symptoms of infections.

The nurse is creating a care plan for a client. Risk for Infection is the identified problem. Which situation supports this problem?

the client with a urinary catheter inserted at the emergency department -Rationale: In the diagnosis Risk For Infection, the client is vulnerable to invasion and multiplication of pathogenic organisms which may compromise health. Risk for Infection relates to a foreseen problem that can cause infection if prevention is not initiated, followed, and maintained.

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

urinary catheter -Rationale: Urinary catheters account for the highest percentage (26%) of hospital-associated infections. The four most common types of HAIs are related to invasive devices or surgical procedures: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated events (VAEs). A peripherally inserted catheter is an invasive line. Nasogastric tubes and endotracheal tubes are not associated with HAIs.

A team of nurses is caring for a client with tuberculosis. They have not been fitted for N95 respirators. How will the team proceed with care?

utilize a powered air purifying respirator (PAPR) -Rationale: A PAPR is an alternative that can be used if a caregiver has not yet been fitted with a N95 respirator. All the other options are inappropriate.

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?

wash the area with soap and water -Rationale: The first action by the nurse should be to wash the hands gently with soap and water to reduce exposure of blood or pathogens to the wound. Filling out a risk management form is required but should be done after first aid care is performed. Finding out who left the blade on the tray is not relevant at this time, but further education for the unit may be required at a later time. Going to employee health is the step that will be taken after immediate first aid.

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all care and interaction with this client -Rationale: 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 placed in a negative pressure room to prevent the potential spread of TB.

The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

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