Foundations Exam 1 Prepu

The local high school has been exposed to methicillin-resistant Staphylococcus aureus (MRSA) infection and the school nurse is preparing an education plan on prevention of MRSA. Which steps should the nurse include? Select all that apply.

20-second handwashing use of hand sanitizer when necessary keep draining wounds covered

The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team? A. "Avoid touching the outside of your gown when removing it." B. "Whenever possible, remove your PPE outside the client's room." C. "You should remove your mask before you remove your gown." D. "it's best to let me assist you with removal of your gown."

A. "Avoid touching the outside of your gown when removing it."

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? A. Perform hand hygiene B. Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps C. Don a new pair of gloves to dispose of materials D. Wrap all used materials together and discard in biohazard container

A. Perform hand hygiene

For which client would the use of standard precautions alone be appropriate? A. an incontinent client in a nursing home who has diarrhea B. a client with diphtheria who needs p.m. care C. a client with TB who needs medications administered D. a child with chickenpox who is treated in the emergency room

A. an incontinent client in a nursing home who has diarrhea

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? A. fold soiled side to the inside and roll with inner surface exposed B. fold side to the outside and roll with inner surface exposed C. fold soiled side to the inside and roll with outer surface exposed D. fold soiled side to the outside and roll with outer surface exposed

A. fold soiled side to the inside and roll with inner surface exposed

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? A. handwashing before leaving the client's room B. make contact between two contaminated surfaces C. make contact between two clean surfaces D. remove the garments that are most contaminated

A. handwashing before leaving the client's room

A physician 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? A. helps to determine prescribed antibiotic therapy B. permits selection of antibiotic concentration C. helps in reducing proliferation of multidrug-resistant organisms D. narrows the therapeutic range to avoid prolonged use

A. helps to determine prescribed antibiotic therapy

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

A. the client who is 48-hours postsurgical procedure

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? A. "I will tell my visitors to keep their distance from me." B. "I can leave my room any time I want as long as I wear a mask." C. "Any staff who enters my room will be wearing personal protective equipment (PPE)." D. "My personal belongings should remain in the room until I am discharged."

B. "I can leave my room any time I want as long as I wear a mask."

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission? A. "I understand; wearing these items is not pleasant but it really isn't optional." B. "These barriers help prevent the transmission of infection to you or other people." C. "Wearing the gloves and gown prevents sharing additional microorganisms with the client." D. "If you don't come into contact with anything with your body, you may wear gloves only, as long as you wash your hands after removing the gloves."

B. "These barriers help prevent the transmission of infection to you or other people."

Which client would the nurse consider the most infectious? A. A client who is in the full stage of illness B. A client who is in the prodromal stage C. A client who is in the incubation period D. A client who is in the convalescent period

B. A client who is in the prodromal stage

Which client presents the most significant risk factors for the development of Clostridium difficile infection? A. A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft B. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis C. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior D. A client with renal failure who receives hemodialysis three times weekly

B. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

Which term describes foreign particles that enter a host and stimulate the body's immune response? A. Antibody B. Antigen C. Phagocyte D. Macrophage

B. Antigen

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? A. Perform hand hygiene before removing the gown. B. Avoid touching the outer surfaces of the gown. C. Remove the gown immediately after exiting the room. D. Remove the gown before removing gloves.

B. Avoid touching the outer surfaces of the gown.

Which mask should the nurse don when caring for a client with tuberculosis? A. Surgical mask B. Filtered respirator C. Low-efficiency particulate air (LEPA) D. No mask is needed

B. Filtered respirator

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection? A. Helminth B. Healthcare-associated infection (HAI) C. Protozoa D. Virus

B. Healthcare-associated infection (HAI)

What is the second line of defense in microbial invasion? A. Disability B. Inflammation C. Infection D. Disease

B. Inflammation

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next? A. Inform the client that the antibiotics will resolve this problem. B. Inform the physician about this finding. C. Encourage the client to brush his teeth 3 times a day. D. Assess for the expiration dates of the antibiotics being administered.

B. Inform the physician about this finding.

The nurse is caring for a client who has an intravenous (IV) catheter in place with a saline lock. The nurse is preparing to change the dressing to the IV site. After reviewing the image, what should the nurse do next? A. Lift up the entire occlusive dressing then reapply the dressing 1 in (2.5 cm) higher B. Obtain a new intravenous dressing change kit C. Remove the gloves then reapply the occlusive dressing to avoid the dressing sticking to the gloves D. Cleanse the site under the intravenous site with an alcohol swab and proceed with using the same transparent dressing

B. Obtain a new intravenous dressing change kit

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? A. Monocytes B. T-lymphocytes C. Eosinophils D .Neutrophils

B. T-lymphocytes

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care? A. Clean the site with a disinfectant. B. Use a sterile intravenous catheter. C. Dip the IV catheter into an antiseptic before use. D. Wear a mask and gown for the procedure.

B. Use a sterile intravenous catheter.

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

B. Wear gloves whenever entering the client's room.

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? A. airborne B. contact C. droplet D. vehicle

B. contact

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

B. has manicured nails that are 1-in. (2.5-cm) long

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? A. communicable disease B. noncommunicable disease C. infectious disease D. contagious disease

B. noncommunicable disease

A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply.

Basophils Neutrophils Eosinophils

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate? A. "It's just a sign that your wound is infected." B. "It results from the swelling caused by the pain of the inflammation. C. "Your white blood cells have increased in the area." D. "Metabolism in your wound tissues is increased."

C. "Your white blood cells have increased in the area."

A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area? A. Soiled dressing B. Deep into the cavity C. Area of active drainage D. Edge of the wound

C. Area of active drainage

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? A. Client on a short course of vancomycin B. Client in the ICU for one day C. Client receiving chemotherapy D. Client with a history of eczema

C. Client receiving chemotherapy

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? A. The nurse applies nonmedicated hand cream after performing hand hygiene. B. The nurse performs hand hygiene after touching the client's surroundings. C. The nurse removes her gown and then removes her gloves. D. The nurse performs hand hygiene before putting on gloves.

C. The nurse removes her gown and then removes her gloves.

What is the most common client site for development of healthcare-associated infections (HAI)? A. Surgical wound B. Respiratory tract C. Urinary tract D. Bloodstream

C. Urinary tract

The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. Which precautions should the nurse take? A. Use a gown when within 3 ft (1 m) of the client B. Implement full isolation protocol while client is contagious C. Use a mask when within 3 ft (1 m) of the client D. Ensure all visitors wash their hands upon entering the room

C. Use a mask when within 3 ft (1 m) of the client

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from: A. chickenpox. B. hepatitis. C. bacterial infection. D. viral infection.

C. bacterial infection.

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

C. into a private room

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? A. maintaining a 3-in. (7.5-cm) border around the sterile field B. putting on sterile gloves before opening sterile package C. keeping sterile field above waist level D. opening the sterile package toward the nurse to prevent reaching over

C. keeping sterile field above waist level

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? A. invasion B. stationary C. prodromal D. resolution

C. prodromal

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

D. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? A. "I may have gotten the virus when I got a tattoo while I was in prison." B. "I received a blood transfusion in 1989, which could be a factor in contracting the disease." C. "I can't transmit the virus other people if I shake their hands." D. "I probably got the virus when I sat on the toilet seat in a dirty bathroom."

D. "I probably got the virus when I sat on the toilet seat in a dirty bathroom."

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? A. "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue." B. "I will not visit my family member in the first 3 days of my cold." C. "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." D. "I will obtain a mask from the staff and wash my hands before touching my family member."

D. "I will obtain a mask from the staff and wash my hands before touching my family member."

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

D. "This antibiotic is the best choice since the causative organism is not known."

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: A. 4 days. B. 5 days. C. 2 days. D. 3 days.

D. 3 days.

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

D. contact precautions

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify: A. increased humoral immunity response. B. decreased susceptibility to infection. C. increased effectiveness of phagocytosis. D. decreased cellular immunity.

D. decreased cellular immunity.

The most common infection in children is: A. neurologic. B. urinary. C. gastrointestinal. D. respiratory.

D. respiratory

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

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply.

Infectious disease communicable disease contagious disease

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.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply.

The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis?

The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field.

The nurse is preparing to perform handwashing. Place the following steps in the correct order.

Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.

The nurse has applied personal protective equipment (PPE) before caring for an immunocompromised client. When removing PPE, what action should the nurse perform?

When removing gloves, the nurse should do so by pulling on the cuff with two fingers, being careful not to touch the outside of the contaminated glove. The nurse should not touch the outside of the contaminated gown.

An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Standard

airborne