(Fund Ch 24) PrepU

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. 1 Turn the faucet off with a paper towel. 2 Wet the hand and wrists. 3 Turn on the faucet and adjust force and temperature of the water. 4 Wash the palms and backs of the hands for at least 20 seconds. 5 Pat the hands dry with a paper towel. 6 Apply soap.

3 Turn on the faucet and adjust force and temperature of the water. 2 Wet the hand and wrists. 6 Apply soap. 4 Wash the palms and backs of the hands for at least 20 seconds. 5 Pat the hands dry with a paper towel. 1 Turn the faucet off with a paper towel. The correct steps to hand washing are as follows. Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrist areas. Apply soap product. Wash the palms and back of the hands for at least 15 seconds. Pat hands dry with a paper towel. Finally, turn the faucet off with a paper towel.

Which should be documented by the nurse? a. The fact that sterile technique was used for a given procedure b. The fact that the nurse donned gloves two different times during a procedure c. The specific items that the nurse transferred into a sterile field d. The fact that the nurse washed her hands before a procedure

a. The fact that sterile technique was used for a given procedure The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

Which piece of personal protective equipment (PPE) should be removed first? a. Respirator b. Gloves c. Gown d. Goggles

b. Gloves The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds: a. "You may have infection in your birth canal that you are unaware of." b. "You will likely have an outbreak due to the stress of labor and delivery." c. "A cesarean section will prevent a herpes outbreak." d. "Have you discussed this with your physician?"

a. "You may have infection in your birth canal that you are unaware of." Viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? a. Healthcare-associated infection b. Droplet infection c. Sexually transmitted infection d. Respiratory infection

a. Healthcare-associated infection This infection is best described as a healthcare-associated infection. A healthcare-associated infection is an infection not present on admission to healthcare agency and that has been acquired during the course of treatment for other conditions. The other terms listed do not apply to this infection.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? a. Surgical asepsis technique b. Medical asepsis technique c. Strict reverse isolation d. Droplet precautions

a. Surgical asepsis technique Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others.

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin? a. contact b. airborne c. none d. droplet

a. contact Wound infectious agents are transmitted through contact; therefore contact precautions are appropriate.

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? a. hand washing b. signs of healing c. putting on gloves d. sterile technique

a. hand washing Hand washing technique is the single most important procedure in reducing the spread of microorganisms from either the client to the surroundings or the surroundings to the client. A client does not need to learn a sterile technique for the abdominal incision. Most client procedures are related to clean handing and do not need gloves to be added to a dressing change. The nurse should review signs of infection and healing of the abdominal incision.

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

a. into a private room The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

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 placed in contact isolation who was admitted with a draining abdominal wound c. the client admitted with diarrhea who tested positive for Escherichia coli (E. coli) d. the client admitted with a rash who reports recent exposure to measles

a. the client who is 48-hours postsurgical procedure 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 caring for a client who has been placed in strict isolation. Which nursing action is appropriate? a. Deliver flowers and balloons to the room. b. Remove fresh fruit from the room. c. Allow many family members to visit at once. d. No special precautions are required.

b. Remove fresh fruit from the room. 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.

What is an accurate guideline for the use of PPE? a. When wearing gloves, work from "dirty" areas to "clean" ones. b. Replace gloves if they are visibly soiled. c. Put on PPE after entering the client's room. d. Substitute personal glasses for protective eyewear, if desired.

b. Replace gloves if they are visibly soiled. If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas.

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse? a. Ask a colleague to perform the task. b. Stop and obtain appropriate PPE. c. Leave PPE in the room. d. Complete the task, then obtain PPE.

b. Stop and obtain appropriate PPE. The nurse should stop the task and obtain the appropriate protective wear. Protective equipment should be left outside of the room so that it can be donned prior to entering. Completing the task without the appropriate equipment can contaminate the nurse, which can lead to cross-contamination on the unit. Asking a colleague to finish the task is inappropriate.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene? a. The nurse refrains from using hand moisturizer following hand hygiene. b. The nurse keeps fingernails less than 1/4 in (0.63 cm) long. c. The nurse uses gloves in place of hand hygiene. d. The nurse uses hand hygiene instead of gloves when in contact with blood.

b. The nurse keeps fingernails less than 1/4 in (0.63 cm) long. The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood. The nurse could use a hospital sanctioned hand moisturizer after hand hygiene, but this is not the best answer.

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct? a. Remove the goggles before removing other equipment. b. Touch the inside of the gown and pull it away from the torso. c. Remove respirator at the doorway of the client's room. d. Slide one gloved hand under the other glove for removal.

b. Touch the inside of the gown and pull it away from the torso. The outside of the equipment is considered contaminated. Removal follows a prescriptive sequence. Most personal equipment is removed at the door of the client's room. The contaminated glove grasps the other contaminated glove for removal. The nurse's clean hand reaches under the other glove for removal. Goggles are removed by holding the earpieces. Clean hands touch the inside of the gown for removal, pulling away from the torso. Roll these items up, inside out, for disposal. Grasp ties on mask on respirator for removal after leaving the room.

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

b. an incontinent client in a nursing home who has diarrhea 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 lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? a. make contact between two contaminated surfaces b. handwashing before leaving the client's room c. remove the garments that are most contaminated d. make contact between two clean surfaces

b. handwashing before leaving the client's room The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath.

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? a. washes hands for 20 seconds with soap and water b. reaches down to the bed to pick up a sterile drape c. stretches the glove over the hand without touching the unsterile area d. picks up the glove at the folded edge with the thumb and forefinger

b. reaches down to the bed to pick up a sterile drape 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 is caring for a postpartum mother who delivered her second child yesterday. The mother states that her older child has just been diagnosed with chickenpox. She is concerned that her newborn will develop the disease. What is the best response by the nurse? a. "Is there someone who could care for your older child until she is no long contagious?" b. "It would be best if your newborn weren't around your older child until the disease is no longer contagious." c. "Have you had chickenpox?" d. "Have you discussed this with your pediatrician?"

c. "Have you had chickenpox?" Passive immunity does not involve the host's immune response; rather, immunity is transferred to the recipient.

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply. a. "I may transmit the virus to my child during pregnancy and childbirth." b. "I may transmit the virus if I share needles with another person." c. "If someone is exposed to my blood, I may transmit the virus to him or her." d. "If someone uses the bathroom after I have been on the toilet, he or she can catch the virus." e. "If I sweat at the gym and someone touches me, he or she can contract the virus."

c. "If someone is exposed to my blood, I may transmit the virus to him or her." a. "I may transmit the virus to my child during pregnancy and childbirth." b. "I may transmit the virus if I share needles with another person." The client has demonstrated that an understanding of the transmission of the virus may occur through exposure to blood, during pregnancy and childbirth, and through sharing of needles. Transmission of the virus does not occur through sweat or by exposure on a toilet seat. The virus is fragile and does not live on inanimate objects.

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. A client with renal failure who receives hemodialysis three times weekly c. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis d. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior

c. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Two common factors that increase a persons risk of becoming infected with C difficle are age greater than 65 and current or recent use of antibiotics. In this scenario, old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.

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: a. Means of transmission b. Spore production c. Survival adaptation d. Aerobic activity

c. Survival adaptation 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.

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? a. Wear a protective gown and gloves with any direct contact. b. Have the client wear a mask during care. c. Wear a mask with face shield during invasive procedures. d. Apply a nonparticulate (N-95) respirator when entering the room.

d. Apply a nonparticulate (N-95) respirator when entering the room. TB is an airborne infection, and the nurse should wear a nonparticulate mask (N-95) respirator. Gown and gloves would be indicated for infections that are transmitted via direct contact. A mask with a face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? a. Limiting visitors to family members over the age of 18 b. Revising the facility's infection control protocols c. Encouraging visitors to adhere to isolation precautions d. Incentivizing health care workers to utilize hand hygiene

d. Incentivizing health care workers to utilize hand hygiene Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. Revising the agency's infection control protocols is not nursing centered. Encouraging visitors to adhere to isolation precautions is important but does not affect the immediate surroundings and personal space that can cause a contaminated work environment. Limiting visitors to family members over the age of 18 is not client-centered care and will not decrease transmission of pathogens.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter? a. Remove all jewelry, including wedding bands, before hand washing. b. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. c. Use an alcohol-based hand rub to decontaminate the hands. d. Keep hands lower than elbows to allow water to flow toward fingertips.

d. Keep hands lower than elbows to allow water to flow toward fingertips. Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms.

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator? a. "Masks, gloves, and gowns should be used to protect from infectious agents." b. "It is important to refrain from recapping needles." c. "Wearing an N95 respirator is critical when I care for clients in droplet precautions." d. "I will always wash my hands thoroughly and often."

c. "Wearing an N95 respirator is critical when I care for clients in droplet precautions." N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.

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. contact b. droplet c. airborne d. vehicle

a. contact Contact may be either direct or indirect.

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? a. Client with a surgical wound b. Client with an intravenous catheter c. Client with a diabetic foot ulcer d. Client with a urinary catheter

d. Client with a urinary catheter While all of the clients are at risk for infection, the client at the greatest risk is the one with a urinary catheter. This is because catheter-associated urinary tract infections are the most common type of hospital-acquired infections, accounting for more than 30% of HAIs in acute care hospitals. Most hospitalized clients receive an intravenous catheter. Clients go to the hospital for surgery so a surgical incision is expected. Clients with a diabetic foot ulcer may be admitted to the hospital for intravenous antibiotics.

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? a. Direct visualization of the sterile field is maintained. b. The sterile field is set up at waist level. c. The top flap of the package is opened away from the new nurse's body. d. The new nurse touches 1.5 in. (4 cm) from the outer edges.

d. The new nurse touches 1.5 in. (4 cm) from the outer edges. The outer 1 in. (2.5 cm) of the sterile package is safe to touch. 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 client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an): a. fungi. b. virus. c. protozoa. d. bacteria.

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

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: a. stable b. decreased c. elevated d. within normal limits

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

The nurse is caring for a client who developed a urinary tract infection while hospitalized. How will the nurse document this condition? a. community-acquired infection b. infectious disease c. contagious disease d. healthcare-associated infection (HCAI)

d. healthcare-associated infection (HCAI) HCAI are acquired within healthcare facilities in any setting. Community-acquired infections occur in the community. Infectious and contagious conditions can be acquired in any setting.

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition? a. communicable disease b. infectious disease c. contagious disease d. noncommunicable disease

d. noncommunicable disease A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe food poisoning.

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention? a. do nothing, as the precautions observed are appropriate b. teach that a gown and shoe coverings must be worn in addition to gloves c. offer the student a mask d. remind the student that a fitted N95 respirator is required

d. remind the student that a fitted N95 respirator is required A fitted N95 respirator must be worn in addition to other precautions when caring for clients with pulmonary tuberculosis. The other answers do not recommend the appropriate precautions that must be used for this type of infection.

A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is: a. blood. b. sputum. c. semen. d. wound drainage.

c. semen. Vehicle transmission involves the transfer of microorganisms by way of vehicles, or contaminated items that transmit pathogens. For example, food can carry Salmonella. In this case, semen can carry human immunodeficiency virus.

A client with HIV is the: a. specificity. b. pathogen. c. virulence. d. carrier.

d. carrier. Clients may become infected from people who have active disease, people in the incubation portion of their disease, or people who harbor pathogens but have no symptoms of disease.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? a. surgical asepsis b. decreased antibiotics c. increased T cells d. increased vitamin C

a. surgical asepsis Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

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? a. Pour the liquid into the palm of a sterile gloved hand for use. b. Pour the liquid into a sterile container within the sterile field. c. Pour the liquid onto gauze on the sterile field until the gauze is moist. d. Pour the liquid into the cap of the bottle and dip the gauze as needed.

b. Pour the liquid into a sterile container within the sterile field.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety? a. The nurse places the client in a private room with the door open. b. The nurse places the client in a private room with monitored negative air pressure. c. The nurse uses droplet precautions when providing care for the client. d. The nurse keeps visitors 3 feet away from the infected person.

b. The nurse places the client in a private room with monitored negative air pressure. When a client is diagnosed with tuberculosis it is important for the nurse to remember that the client should be placed in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The nurse must wear the appropriate respirator when caring for the client, but visitors must wear masks. Simply being 3 feet away will not keep the visitor from being exposed to the client. The nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis.

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 is the best choice since the causative organism is not known." d. "This antibiotic causes fewer side effects than a narrow spectrum antibiotic."

c. "This antibiotic is the best choice since the causative organism is not known." Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness. The side effects of all antibiotics are similar. The antibiotic can cause resistance when used excessively in the absence of infection. Pneumonia may or may not be caused by multiple organisms; however, this isn't the best answer regarding the medication.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? a. Rickettsiae b. Helminths c. Fungi d. Protozoans

c. Fungi Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes.

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 performs hand hygiene after touching the client's surroundings. b. The nurse performs hand hygiene before putting on gloves. c. The nurse removes her gown and then removes her gloves. d. The nurse applies nonmedicated hand cream after performing hand hygiene.

c. The nurse removes her gown and then removes her gloves. 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 conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation? a. Before direct contact with clients b. After direct contact with clients c. When hands are visibly soiled d. After completing a wound dressing

c. When hands are visibly soiled Alcohol-based hand rubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, except when the health care worker's hands are visibly soiled.

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients? a. specimen containers b. face shields c. indwelling catheter d. bath blanket

c. indwelling catheter Infections are often transmitted to older adult clients through equipment reservoirs (e.g., indwelling urinary catheters, humidifiers, and oxygen equipment) or through incisional sites, such as those for intravenous tubing, parenteral nutrition, or tube feedings. Use of proper aseptic techniques is essential to prevent the introduction of microorganisms. Bath blankets, face shields, and specimen containers are not part of the equipment reservoir that transmits infection easily, because they are disposed of immediately after one-time use.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? a. avoid direct contact with the client b. wear a mask and gown in the client's room c. perform hand hygiene before and after entering the client's room d. wear gloves when touching the client

c. perform hand hygiene before and after entering the client's room Hand hygiene is the most important way to prevent transmission of infection.

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 can't transmit the virus other people if I shake their hands." c. "I received a blood transfusion in 1989, which could be a factor in contracting the disease." 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." There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992. The virus cannot be contracted or spread through a toilet seat.

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? a. Any partially uncovered sterile package need not be considered contaminated. b. Sterility may not be preserved even when one sterile item touches another sterile item. c. When a sterile item touches something that is not sterile, it may not be contaminated. d. A commercially packaged surgical item is not considered sterile if past expiration date.

d. A commercially packaged surgical item is not considered sterile if past expiration date. When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

Standard precautions apply to which items? Select all that apply. a. Nonintact skin b. Intact skin c. Body fluid secretions d. Blood e. Sweat f. Mucous membranes

d. Blood c. Body fluid secretions f. Mucous membranes a. Nonintact skin Standard precautions do not apply to sweat or intact skin, but do apply to all of the other items listed.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? a. delivering a meal tray to a VRE-positive client without first donning gloves and a gown b. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing c. sending a VRE-positive client to the radiology department for a chest X-ray without a face mask d. Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

d. Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. Direct client contact between a VRE-positive client and another client without handwashing carries a significant risk of infection, especially when contact includes body fluids. Handwashing is necessary before a procedure such as staple removal, but foregoing this infection control measure is less likely to spread VRE unless the nurse failed to handwash after the procedure. VRE does not normally require droplet or airborne precautions. Delivering an item to a client without gloves or a gown is less of a risk than failing to wash the hands after such contact.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? a. Shigella in the intestinal tract b. Escherichia coli in the urinary tract c. Shigella in the urinary tract d. Escherichia coli in the intestinal tract

d. Escherichia coli in the intestinal tract 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.

In which situation is an alcohol-based rub an inappropriate option for hand hygiene? a. When the nurse anticipates contact with the client's skin b. When the nurse is caring for a client with an active infection c. When the nurse leaves the room of an immunocompromised client d. When the nurse's hands are visibly soiled

d. When the nurse's hands are visibly soiled Alcohol-based handrubs may be used if hands are not visibly soiled or have not come in contact with blood or body fluids. They should be used before and after each client contact, or when in contact with surfaces in the client's environment. Handwashing is required before eating or after using the restroom.

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client? a. universal precautions b. droplet precautions c. neutropenic precautions d. airborne precautions

d. airborne precautions Contact precautions should always be used when coming into contact with contaminated body fluids. Gown and gloves should be worn and protective eyewear if splashing may occur. Droplet precautions are used there is a risk of transmitting pathogens within a 3-foot (1-meter) radius of the client when sneezing, coughing, etc. Neutropenic precautions are for the protection of the client due to immunosuppression. Airborne precautions should be instituted when exposure to microorganisms are transmitted by airborne route may occur.

A student nurse is attending a clinical rotation in the perioperative department and will be allowed to scrub in to observe. What observation made by the clinical instructor requires intervention before the student is allowed to attend the rotation? Select all that apply. a. nails that are down to the nail bed b. red nail polish c. artificial nails with intact clear nail polish d. rings on finger e. nails that are cut to ½ inch (1.25 cm) beyond the nail bed

d. rings on finger c. artificial nails with intact clear nail polish b. red nail polish Artificial nails and nail polish are never appropriate and may introduce infection into a surgical wound. Nail polish may chip and enter into surgical wounds. Rings should be removed because they are a source of contamination from bacteria and other pathogens. Nail length of 1/2 inch (1.25 cm) beyond the nail bed or down to the nail bed is an appropriate length and is acceptable.

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? a. fill out a risk management form b. go to employee health for testing c. find out who left the scalpel blade on the procedure tray d. wash the area with soap and water

d. wash the area with soap and water 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 immediate first aid care. 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 are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. a. contact precautions b. respiratory precautions c. body fluid precautions d. droplet precautions e. airborne precautions f. microbial precautions

e. airborne precautions d. droplet precautions a. contact precautions The CDC has three general precautions: contact, droplet, and airborne. Use contact precautions for clients with known or suspected infections that represent an increased risk for contact transmission. Use droplet precautions for clients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a client who is coughing, sneezing, or talking. Use airborne precautions for clients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster). Respiratory, microbial, and body fluid precautions are embedded in the three precautions.

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? a. refrain from providing care until a nurse who has been fitted arrives b. use a regular mask and continue to provide care as usual c. utilize a powered air purifying respirator (PAPR) d. enter the room as normal but maintain a 3-foot (1-meter) distance from the client

c. utilize a powered air purifying respirator (PAPR) 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.

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. 1 Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas. 2 Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 3 With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 4 Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand.

2 Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 3 With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 4 Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. a Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas. The correct order of putting on sterile gloves is as follows. First, the nurse should open the package, taking care not to touch the inner surface of the package or gloves. Then, the nurse should pick up the glove at the folded cuff with the thumb and forefinger and insert fingers while pulling the glove over the hand. Next, the nurse should place the finger of the gloved hand inside the cuff of the remaining glove, taking care not to touch outside of the folded cuff. Once both gloves are on, the nurse adjusts the gloves touching only sterile areas. If gloves are donned not following this order, there is an increased risk for contamination of the sterile gloves.

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms? a. The client's immune system became further weakened b. The client's normal flora proliferated because of a nutritional deficit c. The resident microorganisms mutated and became virulent d. The client's normal flora began producing spores

a. The client's immune system became further weakened Unless the supporting host becomes weakened, normal flora remains controlled. If the host's defenses are weakened, as in cases of HIV/AIDS, even benign microorganisms can cause opportunistic infections. This phenomenon is not due to mutations, spore production or the direct effects of a nutritional deficit.

A nurse is caring for four clients. Which client has the highest risk of infection? a. older male with an enlarged prostate b. woman in second trimester of pregnancy c. young woman with a history of scoliosis d. toddler with a benign heart murmur

a. older male with an enlarged prostate 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.

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

c. Filtered respirator 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.

The nurse is providing an in-service educational program for the interprofessional health care team about infection control precautions. What teaching will the nurse include? Select all that apply. a. Use equipment repeatedly on clients with similar conditions. b. Practice hand hygiene. c. Keep client's environment clean. d. Wear personal protective equipment (PPE). e. Use standard precautions only for clients with infection.

d. Wear personal protective equipment (PPE). b. Practice hand hygiene. c. Keep client's environment clean. Wearing PPE, practicing hand hygiene, and keeping the client's environment clean interfere with the chain of infection. Standard precautions should be used for all clients, and equipment should be cleaned, disinfected, or sterilized between uses.