FON Chapter 29 - Infection Prevention and the Nursing Process

A provider writes postoperative orders that include cleaning a patient's surgical wound twice daily with sterile normal saline. Which techniques are appropriate when following these orders? Select all that apply. Wipe around the edge of the wound first. Wipe the center of the wound first. Clean outward away from the wound. Clean inward toward the wound. Clean the wound using strokes in any direction.

Rationale The surgical wound is considered sterile and the edges of the wound are considered contaminated. To reduce the risk of infecting the wound, the outermost edge of the wound should be wiped first. Then the wound itself should be cleaned, beginning at the center and moving outward away from the wound. This prevents the entry of microorganisms into the wound. Wiping the center of the wound before wiping the outermost edge, cleaning inward toward the wound, and cleaning the wound in any direction all are techniques that would increase risk of wound contamination. p. 465

The nurse is assessing a group of patients in a health screening program. What should the nurse evaluate when assessing the infection risk in these patients? Select all that apply. Inquire about diet and appetite. Compare monthly earnings. Assess immunization details. Inquire about travel history. Inquire about medication history.

Rationale A patient's nutritional health directly affects the patient's susceptibility to infection. Assessing immunization details is important to understand which vaccines have been given as preventive measures. The travel history can reveal important information regarding the risk of exposure to communicable diseases. The medication history will help to identify any medications that can increase the susceptibility of infections. Comparing monthly earnings is unrelated to assessment of risk for contracting an infection. pp. 449-450

During a health fair the nurse examines a family of four people. The 66-year-old father is healthy with no history of respiratory problems. The 60-year-old mother has a family history of chronic respiratory problems. Their 26-year-old son and 20-year-old daughter have been on medication for asthma since birth. Who should be given the pneumonia vaccine in this case? Select all that apply. Father Mother Son Daughter None of the family members

Rationale A pneumonia vaccine is available and recommended for all persons with chronic respiratory problems and those over 65 years of age. Because the father is over 65 years of age and the mother and both children have chronic respiratory problems, they all need a pneumonia vaccine. p. 451

The nurse is changing the dressing of a patient at a bedside table. Which are the techniques of asepsis that the nurse should perform? Select all that apply. Wearing a mask Using protective eyewear Using an instant alcohol hand antiseptic Having well-manicured nails Washing hands with soap and water followed by rinsing under a stream of water for 15 seconds

Rationale Asepsis is the cleaning technique adopted for reducing the number of organisms present and preventing their transfer. It includes techniques such as using an instant alcohol hand antiseptic, having trimmed nails, and washing hands with soap and water. Wearing a mask and using protective eyewear are used in surgical asepsis. p. 458

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

Rationale 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. p. 456

After assessing a patient with an infection, the nurse follows contact precautions. Which disease condition does the nurse suspect the patient to have? Scabies Pertussis Chickenpox Pneumonic plague

Rationale Contact precautions are used in conditions that are easily transmitted by direct patient contact or by contact with the patient's belongings. Scabies is an infection that spreads by contact. Pertussis, also called whooping cough, is transmitted by droplets; therefore, the nurse should follow droplet precautions for patients who have pertussis. Chickenpox is an airborne infection; the nurse should follow airborne precautions in this case. Pneumonic plague is a droplet infection; the nurse should follow droplet precautions in this case. p. 459

A head nurse is teaching cough etiquette to staff members at the hospital. What should the nurse include in the instructions? Select all that apply. Cover the nose and mouth with a tissue when coughing. Dispose of any contaminated tissue promptly. Maintain a distance of at least 2 feet from persons with respiratory infections. Maintain a distance of greater than 3 feet from persons with respiratory infections. Place a surgical mask on a patient if it does not compromise respiratory function.

Rationale Cough etiquette involves covering the nose and mouth with a tissue when coughing. It helps to prevent the spread of infections. Disposing of contaminated tissue promptly helps to contain the microbes. Spatial separation of greater than 3 feet from persons with respiratory infections helps to avoid contracting the infection through droplets. Placing a surgical mask on a patient if it does not compromise respiratory function helps to prevent infection in the patient. A distance of 2 feet is too close and promotes the spread of infection through droplets. pp. 457, 459

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. Examine for paleness of skin. Palpate the area for tenderness. Inquire about pain and tightness. Inspect the area for redness and swelling. Inquire about gastrointestinal disturbances.

Rationale 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. Test-Taking Tip: Narrow the choices first by eliminating answers you know are incorrect. For this question, paleness of skin does not indicate infection and so would be eliminated. Gastrointestinal disturbances are not related to localized infection so that choice would be eliminated. Then reread the others, which are all consistent with a localized infection, and voila! You are left with the correct answers. p. 450

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? Leave the gloves on to administer the medication. Remove gloves and administer the medication. Remove gloves and perform hand hygiene before administering the medication. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room.

Rationale 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. pp. 459-460

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

Rationale 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. p. 458

A hospital employee fails to properly dispose of a syringe used on a patient and subsequently sustains a needle-stick injury. The nurse in the emergency department assesses the hospital employee knowing that the employee is at risk for contracting numerous illnesses from the needle-stick injury. Which types of infections could result from this incident? Select all that apply. Hepatitis A Hepatitis B Hepatitis C HIV Tuberculosis

Rationale Hepatitis B, hepatitis C, and HIV can be contracted from a needle-stick injury because they are blood-borne infections. Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV). Hepatitis C is a liver infection caused by the hepatitis C virus (HAV). HIV infection is caused by the HIV virus, which can result in acquired immunodeficiency syndrome (AIDS). Hepatitis A spreads through the oro-fecal route. Tuberculosis spreads through droplet infection. p. 470

The nurse is analyzing the laboratory results of a hospitalized patient. The nurse reads the differential count of white blood cells and makes a note that the eosinophils, basophils, and monocytes are within normal limits. The neutrophilic count, which should be between 55% and 70%, is increased to 90%. The lymphocytes, which should be between 20% and 40%, are increased to 60%. What does the increased count indicate? Select all that apply. Sepsis Viral infection Tuberculous infection Chronic bacterial infection Acute suppurative infection

Rationale Lymphocytes are increased when there is chronic viral and bacterial infection. Neutrophils are white blood cells that ingest and destroy microorganisms by a process called phagocytosis. They are increased in cases of acute suppurative infection. Lymphocytes are decreased when there is sepsis, while monocytes increase in tuberculous infection. p. 451

The nurse is changing the dressing of a patient with cellulitis who has been admitted to the hospital. Meanwhile, another health care provider in the same unit asks for the nurse's help with the blocked intravenous line of another patient. What should the nurse do? Leave the first patient, immediately flush the IV line and restore its patency. Inform the other health care provider to leave the IV line as it is. Complete the dressing and then go to the next patient. Leave the first patient, perform hand hygiene, and then ensure the patency of the IV line.

Rationale Nurses should be aware of the routes through which transmission of infections can occur. During the procedure of changing a dressing, if the nurse handles the IV line of the other patient without performing hand hygiene, the infection is likely to spread to the other patient. Therefore, the nurse should perform hand hygiene before handling the IV line. Restoring the patency of the IV line requires the nurse to flush the IV line, which may increase the risk for contracting an infection if performed before hand hygiene. The IV line needs to be unblocked immediately, so the nurse should attend to the patient with the blocked IV line before completing the dressing of the patient with cellulitis. p. 448

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? There is no risk with either situation. The nurse with artificial nails has a higher risk. The nurse with chipped nail polish has a higher risk. Both nurses have an equal risk of causing infection.

Rationale 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. Test-Taking Tip: Were you puzzling over whether artificial nails versus chipped nail polish were a higher risk? The best answer included both, because both are a risk. This is an example of why it is necessary to read every choice before finalizing your answer. p. 469

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

Rationale 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. pp. 458-459

While reviewing the laboratory blood reports of a male patient, the nurse finds that his iron level is 60 mcg/mL. What does the nurse suspect from this finding? The patient has a chronic infection. The patient has a parasitic infection. The patient has a suppurative infection. The patient has a tuberculosis infection.

Rationale The normal range of iron level is from 80 to 180 mcg/mL for men and 60 to 160 mcg/mL for women. Iron levels decrease due to infections. Therefore, a male patient with a 60 mcg/mL iron level indicates a chronic infection. Increased levels of eosinophils (levels higher than 4%) indicate a parasitic infection. The normal range of neutrophils is from 55% to 70%. Increased levels of neutrophils indicate a suppurative infection. The normal range of monocytes is from 2% to 8%. Increased levels of monocytes indicate a tuberculosis infection. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. p. 451

Which questions posed by a nurse during an assessment indicate that the nurse is assessing existing possible infections? Select all that apply. "Do you have a cough and if you do, is there any sputum?" "Do you have any pain or burning during urination?" "What medications are you currently taking?" "What recent diagnostic testing have you undergone?" "Do you have any recent cuts or lacerations?"

Rationale The nurse should assess the patient's defense mechanisms, susceptibility, and knowledge of how infections are transmitted to provide proper nursing care. The presence of cough and sputum indicates the presence of pulmonary infection. Pain during urination indicates urinary tract infection. Therefore, asking questions about a patient's cough or urination indicate that the nurse is assessing existing possible infections. Questions about a patient's medication show that the nurse is assessing the patient's medication history. Questions about recent diagnostic testing, cuts, or lacerations indicate that the nurse is assessing risk factors that may cause infection. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 450

Which nursing actions are examples of following precautions to eliminate reservoirs of infection? Select all that apply. Changing soiled dressings Emptying urinary drainage bags every 4 hours Covering the mouth and nose when coughing or sneezing Instructing the patient to maintain adequate fluid intake Wearing disposable gloves while making contact with patients

Rationale The nurse should follow certain precautions to prevent infection and control reservoirs of infection. Soiled dressings, body fluids, and urinary drainage bags act as reservoirs of infection. Changing the soiled dressings and emptying the urinary drainage bags help to eliminate reservoirs of infection. Instructing the patient to maintain adequate fluid intake promotes normal urine formation and outflow to flush the bladder and urethral lining of microorganisms, also preventing infection within the urinary system. The mouth and nose should be covered when coughing or sneezing to prevent the spread of airborne infections. Wearing disposable gloves while making contact with patients indicates that the nurse is following contact precautions. p. 456

A registered nurse teaches a group of nursing students about standard precautions to prevent infections. Which statement made by the nursing student needs correction? "I should stand at least 3 feet away from patients who have a cough." "I should dispose of used needles, uncapped, in a puncture-resistant container." "I should perform hand hygiene before, after, and between direct contact with patients." "I should wash my hands with antimicrobial soap and water if my hands are not visibly soiled."

Rationale The nurse should wash his or her hands with an alcohol-based, waterless antiseptic agent to perform hand hygiene if his or her hands are not visibly soiled. The nurse should follow respiratory hygiene and cough etiquette to prevent droplet infections; therefore, the nurse should remain at least 3 feet away from patients who are coughing. The nurse should dispose of used needles uncapped and in a puncture-resistant container to prevent infections and needlestick injuries. The nurse should perform hand hygiene before, after, and between direct contact with patients to prevent the risk of developing infections. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 459

The nurse in a postoperative surgical unit is instructed to perform wound care for a patient with an open fracture to his right tibia. What steps are included in wound cleaning? Select all that apply. Clean inward from a wound site. Clean outward from a wound site. When applying antiseptic, wipe around the wound edge first. When applying antiseptic, wipe outward and away from the wound first. Use clean gauze for each revolution around the wound's circumference.

Rationale The surgical wound is considered sterile. To prevent entry of microorganisms into the wound, the nurse should always clean outward from a wound site . When applying an antiseptic or cleaning with soap and water, the nurse should wipe around the wound edge first and then clean outward and away from the wound. The nurse should use clean gauze for each revolution around the circumference of the wound. Test-Taking Tip: Read every word of each question and option before responding to the item. Skimming the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. In this question, two of the choices differ by just one very important word, so reading carefully is essential! p. 465

A 56-year-old patient has a severe, productive cough. The patient is diagnosed with tuberculosis (TB) and is placed in an isolation room. What are the possible reasons for this action? Select all that apply. To perform a chest x-ray To prevent the spread of infection To provide intravenous fluids To prevent the patient's exposure to other infections To restrict the patient's movements

Rationale Tuberculosis of the lungs is an airborne infection, so patients with suspected or confirmed active TB are usually treated in an airborne infection isolation room to restrict their movements. This helps to prevent the spread of infection to others. Isolation rooms are not meant for chest x-ray procedures. Isolation of the patient is not required to administer intravenous fluids. Though all patients are prone to secondary contagious infections, the reason for isolation is to prevent the spread of infection from an isolated patient to other patients. Depending on the mode of the spread of infection, there are different isolation precautions, such as an airborne, droplet, contact, and protective environment. p. 448

A patient who is diagnosed with laryngeal tuberculosis requires isolation precautions. The nurse finds that the patient is depressed, angry, and rejected. What is the most appropriate nursing intervention that would provide relief to the patient? Provide a dark, quiet room to calm the patient Explain the isolation procedures to provide meaningful stimulation Disallow visits by the patient's family members to reduce the risk of spreading the infection Avoid explaining the patient's risk for depression to the patient's family members

Rationale When a patient who has laryngeal tuberculosis is on isolation process, the nurse should follow certain measures to improve the patient's stimulation. The nurse should explain the isolation procedures that are used to maintain infection prevention and control practices and he or she should discuss ways to provide meaningful stimulation to the patient. Darkening the room can increase the patient's sense of isolation. The nurse should allow family members to visit as long as they follow infection precautions. The nurse should explain the patient's risk for depression or anger to the patient's family so they can provide proper emotional support. pp. 460-461

The nurse is assessing a patient who complains of sore throat, fever, and productive cough. The nurse needs to assess for lymph node enlargement. In which area should the nurse palpate? Cervical Inguinal Mammary Para-aortic

Rationale When a systemic infection occurs, lymph nodes draining the region become enlarged. This patient has an upper respiratory tract infection and cervical lymph nodes will be enlarged. Inguinal lymph nodes are enlarged in cases of infection in the perineal or groin region. Mammary nodes may be enlarged in breast infections, and paraaortic nodes in cases of intraabdominal infections. p. 451

Which nursing intervention should a nurse perform while dealing with a patient with a droplet infection? Wearing a gown while entering the room Wearing a respiratory device while entering the room Wearing a mask while working within 3 feet of the patient Placing the patient in a room with 12 air exchanges per hour

Rationale While caring for a patient with a droplet infection, the nurse should wear a surgical mask when working within 3 feet of the patient to help prevent the spread of infection. Wearing a gown while entering the room is a contact precaution. Wearing a respiratory device and placing the patient in a room with 12 air exchanges per hour should be performed with a patient who has an airborne infection. p. 460

The registered nurse is evaluating a nursing student who is caring for a patient with an infection. The registered nurse suspects that the nursing student is acting as a transmitter of infection. Which action made by the nursing student would confirm this suspicion? Wearing a finger ring Having1/3-inch fingernails Wearing an expandable watch Wearing long uniform sleeves above the wrists

Rationale While providing care for patients who have infections, the nurse should avoid wearing rings because microorganisms may get lodged in the grooves of the ring. Wearing a ring will make the nurse act as a transmitter of infection. Fingernails up to 1/3 inch past the fingertips are safe. The nurse can wear a watch with an expandable band, which can be pushed above the wrist. The nurse can wear long uniform sleeves above the wrists while caring for patient with an infection. p. 471