INFECTION

Which question by the nurse specifically assesses the patient for infection or risk for infection? "When was the last time you took an antibiotic?" "Have you had a change in activity lately?" "Do you experience urinary pain or frequency?" "Are you able to finish all of your daily meals?"

"Do you experience urinary pain or frequency?" This question specifically assesses for infection or risk for infection because urinary pain and frequency are symptoms of urinary tract infection. WRONG: "When was the last time you took an antibiotic?" This question does not specifically assess the patient for infection or risk for infection. It is too vague. Asking if the patient is taking antibiotics now or within the past 2 or 3 weeks better assesses for the presence of an actual infection. "Have you had a change in activity lately?" This question does not specifically assess the patient for infection or risk for infection. Asking about a change in activity better assesses for the presence of an actual infection. "Are you able to finish all of your daily meals?" This question does not specifically assess the patient for infection or risk for infection. Asking about a change in appetite is a question that better assesses for the presence of an actual infection.

A nurse caring for a patient with an infection would anticipate a temperature less than _______°F when the infection has resolved. Use numbers only. NOT SURE

100.4 Average body temperature for the adult patient is 98.6°F (37°C). Above 100.4°F (38°C) is considered a fever and indicates an infection. A temperature below 100.4°F (38°C) indicates that an infection has resolved.

An effective alcohol-based hand scrub must contain at least______ percent alcohol.

60 Alcohol must contain at least 60% alcohol to achieve effective microbial inhibition.

Which patient has the most risk factors for developing an infection? 46-year-old recovering from elective noninvasive surgery 30-year-old with newly diagnosed early eating disorder 70-year-old with diabetes and an indwelling urinary catheter 50-year-old smoker who is receiving an intravenous antibiotic

70-year-old with diabetes and an indwelling urinary catheter This patient has three risk factors for infection, which are older age, diabetes, and an invasive indwelling urinary catheter. Having more than one risk factor makes the patient a very susceptible host and at greatest risk for developing an infection. WRONG: 46-year-old recovering from elective noninvasive surgery This patient has one risk factor for infection, which is surgery. Since it was not invasive, and there was no incision, the patient is not the most susceptible host or at greatest risk for developing an infection. 30-year-old with newly diagnosed early eating disorder This patient has one risk factor for infection, which is an eating disorder. Since the eating disorder was diagnosed early, corrective measures can be taken to prevent nutritional deficits. The patient is not the most susceptible host or at greatest risk for developing an infection. 50-year-old smoker who is receiving an intravenous antibiotic This patient has two risk factors for infection, which are smoking and an invasive intravenous line. This does make the patient a susceptible host; however, another patient is at greater risk for developing an infection.

Which patient finding is indicative of a localized infection? Tachycardia Fatigue Abscess Chills

Abscess An abscess is a patient finding indicative of a localized infection because it is limited to a specific area, such as a boil or dental pocket. WRONG: Tachycardia Tachycardia is a sign of systemic and acute infections, not a localized infection. Fatigue Fatigue is a symptom of chronic and systemic infections, not a localized or an acute infection. Chills Chills are a finding associated with systemic infections, not localized infections. However, patients with all infections, including localized infections, should be assessed for potential systemic spread of infection.

Which white blood cells are responsible for the signs and symptoms of inflammation? Neutrophils Monocytes Eosinophils Basophils

Basophils Basophils release vasoactive mediators, such as histamine, which are responsible for the signs and symptoms of inflammation: redness, heat, swelling, and pain. WRONG: Neutrophils Neutrophils defend through phagocytosis and enzymes, but they do not contribute to the signs and symptoms of inflammation. Monocytes Monocytes stimulate inflammatory responses, but they do not participate in the inflammatory response itself or contribute to the signs and symptoms of inflammation. Eosinophils Eosinophils are highly active in allergic reactions, but they do not contribute to the signs and symptoms of inflammation.

Which medical asepsis interventions by the nurse directly protect the patient from infection? Select all that apply. Cleaning patient bedside equipment routinely Disposing of used needles in sharps containers Placing items wet from body fluids in biohazard bags Providing leak-proof receptacles at bedside for tissues Preventing contamination of intravenous sites and ports Removing excess linens from the patient's room

Cleaning patient bedside equipment routinelyThis is a medical aseptic intervention that safeguards the patient by blocking infectious agents from portals of entry by removing them from equipment. Disposing of used needles in sharps containers This is a medical aseptic intervention that safeguards the patient by blocking infectious agents from portals of entry by preventing patients, staff, or visitors from accidental needlesticks. Preventing contamination of intravenous sites and ports This is a medical aseptic intervention that safeguards the patient by blocking infectious agents from entering these portals. Providing leak-proof receptacles at bedside for tissues This is a medical aseptic intervention that safeguards the patient, other patients, or visitors by blocking infectious agents from portals of entry by preventing tissues from being tracked into hallways or touched by others. WRONG: Placing items wet from body fluids in biohazard bags Placing items contaminated with blood or body fluids in biohazard bags is an environmental safeguard. Although it is part of medical asepsis, it addresses the environment, not patient safety directly. Removing excess linens from the patient's room Removing excess linens is an environmental safeguard. Although it is part of medical asepsis, it addresses the environment, not patient safety directly.

By which means are pathogens transmitted through droplets, requiring infected patients to be placed on protective precautions? Select all that apply. Coughing Sneezing Suctioning Eating TALKING

Coughing is a means by which pathogens are transmitted by droplets, which is why droplet precautions are implemented. Sneezing Sneezing is a means by which pathogens are transmitted by droplets, which is why droplet precautions are implemented. Suctioning Suctioning is a means by which pathogens are transmitted by droplets, which is why droplet precautions are implemented. Talking Talking is a means by which pathogens are transmitted by droplets, which is why droplet precautions are implemented. WRONG: Eating Eating is not a means by which pathogens are transmitted. However, eating utensils are contaminated and must be thoroughly cleaned or disposable utensils used.

Which actions by the nurse would be considered independent nursing interventions? Select all that apply. Counseling a patient Administration of antibiotics Repositioning a patient to enhance comfort Participating in a patient care conference Teaching a postoperative patient how to prevent surgical site infection

Counseling a patient Counseling a patient is an example of an independent nursing intervention. Repositioning a patient to enhance comfort Repositioning a patient to enhance comfort is an example of an independent nursing intervention. Teaching a postoperative patient how to prevent surgical site infection Teaching a postoperative patient how to prevent surgical site infection is an example of an independent nursing intervention. WRONG: Administration of antibiotics Administering a medication requires not only the nurse's knowledge, skill, and clinical judgment but also a prescription from the health care provider and is considered a dependent nursing intervention. Participating in a patient care conference Participating in a patient care conference is considered an interdependent nursing intervention.

Which factors increase the older adult's susceptibility to infections? Select all that apply. Decreased immune responses Increased cortisol production Decreased cough reflex Incomplete bladder emptying Reduced vascular supply Excessive epidermal thickening NOT SURE

Decreased immune responses Older adults have intact immune systems, but their reduced production of B and T cells and reduced function of lymphocytes decrease the immune response and leave them more susceptible to infections. Decreased cough reflex Older adults experience a decreased cough reflex with aging. As mucus collects and is not expelled, it places them at increased risk for respiratory infections. Incomplete bladder emptying Older adults are at increased risk for urinary tract infections because of decreased sphincter control and incomplete bladder emptying. Reduced vascular supply Older adults experience loss of elasticity and decreased vascular supply, which places them at risk for skin tears and resulting skin infections. WRONG: Increased cortisol production Older adults produce no more cortisol naturally than do other adults. Only when treated with external corticosteroids is this an issue. Excessive epidermal thickening Older adults experience dermal thinning and loss of elasticity, which places them at risk for skin tears and resulting skin infections.

Which term describes the administration of a medication by a nurse? Dependent intervention Independent intervention Interdependent intervention Nurse-initiated intervention

Dependent intervention Dependent interventions require a written or an oral prescription from a health care provider and include the administration of a medication. WRONG: Independent intervention Independent interventions do not require a prescription from a health care provider, supervision, or direction from others. Interdependent intervention Interdependent interventions require nursing expertise and knowledge and also require collaboration with other health care professionals. Nurse-initiated intervention Nurse-initiated interventions are the same as independent interventions and do not require a prescription from a health care provider, supervision, or direction from others.

Match the category of infection with its characteristics and example. Develops rapidly (e.g., common cold) Lasts months (e.g., mononucleosis) Pain (e.g., pressure injury) High fever (e.g., sepsis) Localized infection Chronic infection Systemic infection Acute infection

Develops rapidly (e.g., common cold) Acute infection Lasts months (e.g., mononucleosis) Chronic infection Pain (e.g., pressure injury) Localized infection High fever (e.g., sepsis) Systemic infection

Place in order the steps of establishing a sterile field. Do not turn away from the sterile field. Open sterile packages away from the body. Establish the sterile field above waist level. Don a facemask if required. Perform thorough hand hygiene.

Don a facemask if required. Perform thorough hand hygiene. Establish the sterile field above waist level. Open sterile packages away from the body. Do not turn away from the sterile field. Setting up and maintaining a sterile field proceeds from gathering supplies to actually setting up and staying within the sterile field. The nurse would establish a sterile field by performing these nursing actions in the following order: donning a face mask if required; performing thorough hand hygiene; establishing the sterile field above waist level; opening sterile packages away from the body; not turning away from the sterile field.

Which statements best describe the purpose for greeting the patient and explaining the need for personal protective equipment (PPE)? Select all that apply. Eases fear and misunderstanding Creates a professional relationship Builds a trusting relationship Fulfills legal requirements Eliminates later confusion

Eases fear and misunderstanding Greeting the patient and explaining the use of PPE eases fear and misunderstanding. Creates a professional relationship Explaining the need for PPE creates a professional relationship and reassures the patient. Builds a trusting relationship Explaining the need for PPE while greeting the patient helps build a trusting relationship through complete communication. WRONG: Fulfills legal requirements There is no legal requirement to explain the purpose or need for PPE to patients; however, there is a professional obligation to patients via the Patient's Bill of Rights to know what is happening to them when within the health care setting. Eliminates later confusion Although greeting the patient and explaining the need for PPE can eliminate later confusion, this does not describe the overall purpose for these actions.

Which action can communities engage in to help reduce infections among their citizens? Encouraging and facilitating immunization programs Providing containers for used needle disposal to patients Assisting with health care environment modifications Educating patients about home infection control measures

Encouraging and facilitating immunization programs Communities can be active in helping reduce infections by encouraging its citizens to get immunizations and facilitating immunization programs and clinics. WRONG: Providing containers for used needle disposal to patients Communities are not responsible for providing individual patients with containers for needle disposal. This is a home care action. Assisting with health care environment modifications Communities are not responsible for health care environment modifications. This is an action for each facility or agency. Educating patients about home infection control measures Communities do not educate patients about home infection control measures. This is a home care action.

Which blood test specifically assesses for the presence of an active inflammatory response? White blood cell (WBC) count Complete blood count (CBC) Culture and sensitivity (C&S) test Erythrocyte sedimentation rate (ESR)

Erythrocyte sedimentation rate (ESR) The ESR is elevated during active inflammation. Because infection causes inflammation, it is also elevated during infection. WRONG: White blood cell (WBC) count A WBC count provides the overall cell count for WBCs present in the blood and indicates the body's immune response to both inflammation and infection. It is not specific for inflammation. Complete blood count (CBC) A CBC provides cell counts for red blood cells (RBCs), WBCs, platelets, and reticulocytes. It helps determine effectiveness of treatment for infection but is not specific for inflammation. Culture and sensitivity (C&S) test Cultures indicate the specific type of microorganism causing infection. Sensitivity testing determines which antibiotics, if any, can be used to effectively treat the infection.

Which data collected during the nurse-patient interview is a subjective finding? Bowel sounds active Fatigue Swollen left elbow Blood pressure of 150/72 mm Hg NOT SURE

Fatigue This is a subjective finding because the patient had to provide this information. The nurse cannot verify that this information is correct through inspection, auscultation, or palpation. WRONG: Bowel sounds active This is objective data because the nurse can hear the patient's bowel sounds. Swollen left elbow This is objective data because the nurse can observe the patient's swollen left elbow. Blood pressure of 150/72 mm Hg This is objective data because the nurse can verify the patient's blood pressure with a sphygmomanometer.

Which type of infection would a nurse suspect when caring for a patient who has a prescription for a Clostridium difficile test? Respiratory tract infection Urinary tract infection Gastrointestinal infection Cellulitis

Gastrointestinal infection Clostridium difficile is associated with gastrointestinal infections that typically present with diarrhea and abdominal pain. WRONG: Respiratory tract infection Clostridium difficile is associated with gastrointestinal infections, not respiratory infections. Urinary tract infection Clostridium difficile is associated with gastrointestinal infections, not urinary tract infections. Cellulitis Clostridium difficile is associated with gastrointestinal infections, not cellulitis.

Match the cleaning method with its use. Germicide Chemical sterilization Physical sterilization Disinfection Process that uses gases Process that uses steam or radiation Cleans medical equipment and skin Uses chlorhexidine

Germicide Uses chlorhexidine Chemical sterilization Process that uses gases Physical sterilization Process that uses steam or radiation Disinfection Cleans medical equipment and skin

Place the personal protective equipment (PPE) in the order in which the nurse would remove them. Shoe covers Mask Gown Eyewear Gloves

Gloves Eyewear Gown Mask Shoe covers The order in which a nurse removes PPE is just as important as donning PPE so that the face, hair, and clothing do not become contaminated. The nurse removes PPE in the following order: gloves, eyewear, gown, mask, shoe covers.

Which piece of personal protective equipment (PPE) would the nurse consistently don when anticipating that contact with a patient's body secretions will be possible? Gloves Masks Eyewear Gown

Gloves Gloves are always worn during patient encounters in which the nurse anticipates that direct contact with body secretions are possible or will occur. WRONG: Masks Masks are not necessary unless there is a risk of microorganisms being spread through droplets or airborne transmission. Eyewear Eyewear is not necessary equipment unless there is a risk of body fluids splashing into the nurse's eyes. Gown A gown is not needed unless there is a high risk of the nurse's clothes being splashed or contaminated by body fluids.

Which finding would lead the nurse to conclude that a patient's surgical incision that was inflamed is now infected? Greenish drainage Warm to the touch Swelling at the edges Slightly red color

Greenish drainage Greenish drainage indicates infection caused by pathogen colonization. Drainage caused by inflammation is clear or cloudy but not green or foul smelling. WRONG: Warm to the touchWarmth is a sign of inflammation, which is a normal part of healing. Swelling at the edges Swelling at the edges of the incision is a normal finding and a sign of inflammation. It is a normal and beneficial part of healing. Slightly red color The red color is caused by infiltration of red blood cells into the area. It is a sign of inflammation and a beneficial aspect of healing.

Which step is first in the sequence for donning personal protective equipment (PPE)? Hand hygiene Head cover Mask Gown

Hand hygiene Hand hygiene is the first in the sequence of steps for donning PPE. It is also the last step after removing PPE. WRONG: Head cover The head cover is donned fourth in the sequence of donning PPE. Mask The mask is donned third in the sequence of donning PPE. Gown The gown, if needed, is donned second in the sequence of donning PPE.

Which practices would be included by the nurse when teaching about standard precautions? Select all that apply. Hand hygiene Cough etiquette Patient cleanliness Safe injection practices Use of personal protective equipment (PPE)

Hand hygiene Standard precautions are the minimum practices needed to prevent transmission of infection. Hand hygiene is the most important means for reducing transmission of microorganisms. Cough etiquette Cough etiquette is an important part of standard precautions to prevent the spread of respiratory infections. Safe injection practices Safe injection practices are an important part of standard precautions, including safe injection practices and disposal of contaminated injection equipment. Use of personal protective equipment (PPE) Regular and proper use of PPE is part of standard precautions to prevent the spread of infections. WRONG: Patient cleanliness Patient cleanliness (hygiene) is very important in breaking the chain of infection, but it is not a part of standard precautions.

Which findings are measurable data that can be used to determine whether a patient is meeting infection-related goals? Select all that apply. Handwashing Diaphoresis Pain Nausea Fatigue Fever

Handwashing Handwashing is an objective finding that can be observed. It is measurable and can be used when determining whether patients meet infection-related goals. Diaphoresis Diaphoresis can be observed; therefore, it is measurable and can be used when determining whether patients meet infection-related goals. Pain Pain can be measured objectively using a pain scale, such as a scale of 1 to 10. Only then can it be used to determine whether patients meet infection-related goals. Fever Fever is an objective finding. It is measurable and can be used when determining whether patients meet infection-related goals. WRONG: Nausea Nausea is a subjective finding that is not objectively measured. It is not a measurable way to determine whether patients meet infection-related goals. Fatigue Fatigue is a subjective finding that is not objectively measured. It is not a measurable way to determine whether patients meet infection-related goals.

Match the situation to the type of personal protective equipment required. Head cover Goggles Gloves Gown Patient on transmission precautions Surgery or labor and delivery Sprays from respiratory droplets Protection from airborne microbes Direct contact with body fluids

Head cover Surgery or labor and delivery Goggles Sprays from respiratory droplets Gloves Direct contact with body fluids Gown Patient on transmission precautions

Which action would the nurse recognize as a breach in surgical asepsis that contaminated the sterile field? Health care provider touched sterile field one-half inch from edge Health care provider reached over sterile field to pick up a towel Masked assistant talked over the sterile field Sterile packages opened facing away from body

Health care provider reached over sterile field to pick up a towel Reaching over the sterile field does contaminate the sterile field. The nurse would recognize this as a breach in surgical asepsis and call it to the attention of the health care provider. WRONG: Health care provider touched sterile field one-half inch from edge A one-inch outer margin of a sterile field is not considered sterile; therefore, touching one-half inch from the edge of the sterile field does not break surgical asepsis and contaminate the sterile field. Masked assistant talked over the sterile field As long as the assistant was masked and the mask was fitted correctly, the sterile field was not contaminated and surgical asepsis was not breached. Sterile packages opened facing away from body This is the correct technique for opening sterile packages onto a sterile field; no contamination occurred.

Which cue would support the nurse with a hypothesis of a Urinary Tract Infection? Cough Hematuria Neck stiffness Abdominal pain

Hematuria Hematuria is a cue associated with a urinary tract infection. Additional cues that a nurse would anticipate include fever, polyuria, dysuria, and foul-smelling, cloudy urine. WRONG: Cough A cough is not associated with a urinary tract infection but may be associated with a respiratory tract infection. Neck stiffness Neck stiffness is not associated with a urinary tract infection but may be associated with meningitis. Abdominal pain Abdominal pain is not associated with a urinary tract infection but may be associated with a gastrointestinal tract infection.

Which infection would prompt the nurse to implement contact precautions? Hepatitis A Streptococcal pneumonia Influenza Chickenpox

Hepatitis A Hepatitis A is transmitted by direct contact from person to person. The nurse would implement contact precautions. WRONG: Streptococcal pneumonia The nurse would implement droplet precautions for the patient with streptococcal pneumonia. Influenza The nurse would implement droplet precautions for the patient with influenza. Chickenpox The nurse would implement airborne precautions for the patient with chickenpox.

Match the type of transmission-based precaution with the infection for which it is implemented. Herpes simplex virus (HSV) Rubella Rubeola Contact Airborne Droplet

Herpes simplex virus (HSV) Contact Rubella Droplet Rubeola Airborne

Order white blood cells from most prevalent to least prevalent in the absence of infection. Basophils Lymphocytes Eosinophils Neutrophils Monocytes NOT SURE

Neutrophils Lymphocytes Monocytes Eosinophils Basophils Some white blood cells are more prevalent than others based on their functions.

Which nursing hypothesis would the nurse add to the care plan after noting an open pressure injury on the patient's coccyx during assessment? Lack of Knowledge Impaired Skin Integrity Impaired Nutritional Status Acute Pain

Impaired Skin Integrity Impaired Skin Integrity is the nursing hypothesis the nurse should place on the patient's care plan. It addresses the patient's open pressure injury. WRONG: Lack of Knowledge Lack of Knowledge is not the nursing hypothesis the nurse should place on the care plan related to the assessment finding. Knowledge can be addressed after this finding is addressed. Impaired Nutritional Status Impaired Nutritional Status is not the nursing hypothesis the nurse should place on the care plan related to the assessment finding. Nutrition is important, but the finding requires another nursing hypothesis. Acute Pain Acute Pain is not the nursing hypothesis the nurse should place on the care plan related to the assessment finding. Acute pain may or may not be present. The patient may be experiencing pain, but the finding requires another nursing hypothesis.

Which actions would a nurse take when caring for a patient with cellulitis? Select all that apply. Implement wound care Obtain a wound culture Implement isolation precautions Review the complete blood count Administer antibiotics

Implement wound care Wound care is an essential aspect of the management of cellulitis. Obtain a wound culture A wound culture may be prescribed when treating a patient with cellulitis who is not improving or suspected of a multidrug-resistant organism. Review the complete blood count A complete blood count is an important part of management for any infection. Administer antibiotics Antibiotics are essential to the management of cellulitis. WRONG: Implement isolation precautions Isolation precautions are not necessary when managing cellulitis.

Which patient behavior supports the nurse's hypothesis of a knowledge deficit? Refusal to eat yogurt served on lunch tray Inability to perform incisional care Explanation from patient about correct diet Untouched informational booklets at bedside

Inability to perform incisional care This behavior supports the nurse's hypothesis of a knowledge deficit. The patient either lacks the knowledge about how to perform the procedure or needs instruction and practice performing the procedure. WRONG: Refusal to eat yogurt served on lunch tray This behavior may or may not support the nurse's hypothesis of a knowledge deficit. The nurse needs to collect more information. The patient may simply dislike yogurt. Explanation from patient about correct diet This behavior does not support the nurse's hypothesis of a knowledge deficit because the patient is able to explain the correct diet. Untouched informational booklets at bedsideThis behavior may or may not support the nurse's hypothesis of a knowledge deficit. The nurse needs to collect more information. The patient might not have had time to read the information.

Place the steps in the order the nurse would follow when assessing a patient for infection or risk for infection. Introduction of himself or herself Head-to-toe examination Collection of subjective data Documentation of findings

Introduction of himself or herself Collection of subjective data Head-to-toe examination Documentation of findings The nurse introduces himself or herself to establish a trusting relationship, then collects subjective data from the patient. After subjective data are collected, the physical examination proceeds from head to toe. All findings are documented when the assessment is complete.

Which actions are required by the nurse when preparing for a sterile procedure? Select all that apply. Keeping sterile surfaces dry Setting up the sterile field Leaving the room for supplies Checking packaging integrity Monitoring activities of others Delegating preparations to unlicensed assistive personnel (UAP)

Keeping sterile surfaces dry Keeping sterile surfaces dry is essential to maintain sterility. Wet sheets must be replaced or covered with a dry, sterile towel or sheet. Setting up the sterile field The nurse sets up the sterile field on a flat, clean, dry work surface above waist height, near the location of the procedure. Checking packaging integrity This is an action taken by the nurse, who checks packaging for integrity (e.g., tears and sterility expiration date). This ensures package contents are sterile. Monitoring activities of others The nurse must ensure everyone participating in the procedure maintains surgical asepsis and does not contaminate the sterile field. WRONG: Leaving the room for supplies Once initiation of the sterile field begins, the nurse may not leave the room for supplies. Staying in the room is part of maintaining the sterile field to ensure that contamination does not occur. Delegating preparations to unlicensed assistive personnel (UAP) The nurse would not delegate sterile field activities to a UAP. Only those with specialized training can set up and work within a sterile field.

Match the type of inflammation with its description. Limited to the area of site of injury Involves multiple organs or tissues Quickly severe, lasting only a few days Prolonged response lasting months to years Chronic inflammation Systemic inflammation Localized inflammation Acute inflammation

Limited to the area of site of injuryLocalized inflammation Involves multiple organs or tissuesSystemic inflammation Quickly severe, lasting only a few daysAcute inflammation Prolonged response lasting months to yearsChronic inflammation

Which intervention would a nurse anticipate specifically for a patient suspected of meningitis? Antibiotics Lumbar puncture Inputs and outputs Complete blood count

Lumbar puncture A lumbar puncture is a test specifically used to help with the diagnosis of meningitis. WRONG: Antibiotics Antibiotics are used in many different types of infections and are not specific to meningitis. Inputs and outputs Inputs and outputs are monitored for patients with fluid imbalances and those who may develop fluid imbalances such as an infection causing vomiting and diarrhea. Complete blood count Complete blood counts would be obtained in all patients suspected of having an infection and are not specific to meningitis.

Which personal protective equipment (PPE) would the nurse don before observing a sterile procedure in the operating room? Mask Gown Hair cover Sterile gloves

Mask The nurse would don a mask because of closely observing the procedure. Respiratory droplets can travel 3 feet or more, contaminating the sterile field. WRONG: Gown A gown is not necessary because the nurse should be observing the procedure and not participating at the sterile field. Hair cover A hair cover is not necessary because the nurse should not be standing at the sterile field. Sterile gloves Sterile gloves are not required because the nurse is not participating in the procedure or standing at the sterile field.

Which cue would support the nurse with a hypothesis of meningitis? Cough Hematuria Neck stiffness Abdominal pain

Neck stiffness Neck stiffness is a cue associated with meningitis. Additional cues that a nurse would anticipate include fever, headache, and confusion. WRONG: Cough A cough is not associated with meningitis but may be associated with a respiratory tract infection. Hematuria Hematuria is not associated with meningitis but may be associated with a urinary tract infection. Abdominal pain Abdominal pain is not associated with meningitis but may be associated with a gastrointestinal tract infection.

Which symptoms are consistent with a chronic inflammatory disorder? Redness, swelling, and pain to the ankle while playing basketball Pain and fever from a streptococcal sore throat Pain and swelling of the knees from arthritis Discomfort from a strained back muscle

Pain and swelling of the knees from arthritis This is an example of a chronic inflammatory disorder that can last from months to years, based on duration of inflammation. WRONG: Redness, swelling, and pain to the ankle while playing basketball This is an example of localized and acute inflammation, which involves only the site of injury and is short term. Pain and fever from a streptococcal sore throat This is an example of an acute infection because it is the result of a pathogenic invasion and runs its course within 10 14 days. Discomfort from a strained back muscle This is an example of acute and localized inflammation, which involves the site of injury and starts immediately after the injury.

Which activities can a nurse easily participate in if interested in slowing infection transmission within the community? Select all that apply. Closing schools during influenza pandemics Changing employer policies regarding sick leave Participating in local handwashing campaigns Working locally to encourage immunizations Avoiding mass gatherings during flu season

Participating in local handwashing campaigns Participating in handwashing campaigns is an activity in which nurses can easily participate in their local communities if they are interested and motivated. This is an important activity for slowing infection transmission. Working locally to encourage immunizations Encouraging immunizations is an activity in which nurses can easily participate in their local communities if they are interested and motivated. This is an important activity for slowing infection transmission. WRONG: Closing schools during influenza pandemics This is an important community action; however, it is not an activity in which a nurse can easily participate. Changing employer policies regarding sick leave This is an important community action; however, it is not one in which nurses can easily participate unless they can join a committee and work toward changing policies where they work. Avoiding mass gatherings during flu season This is a very important activity; however, this action only protects the nurse, not the community as a whole.

With whom would the nurse collaborate first when setting goals for a patient with a surgical wound at risk for infection? Health care team Caregiver Patient Therapist

Patient Goals for nursing diagnoses must be based on each patient's individual capabilities. The patient, when able, is the best source for information and clues as to what those capabilities are. WRONG: Health care team Although the health care team plays an important role in setting realistic goals, the patient is still the most important person with whom to confer. Caregiver The patient's family can be collaborated with alongside the patient. But the patient should always be the priority. Therapist A therapist is only needed to confer with on a case-by-case basis.

Which measurable goal would a nurse develop for a patient who is experiencing chest discomfort from a cough related to a respiratory infection? Coughing will improve within 12-24 hours of initiation of treatment. Patient complaints of chest discomfort from cough will decrease within 4 days. Productive cough will decrease within 48 hours of starting treatment. Patient will verbalize decreased chest discomfort related to cough within 2 days.

Patient will verbalize decreased chest discomfort related to cough within 2 days. This goal is measurable because it addresses the patient's problem of chest discomfort related to cough, and patient verbalizations are measurable data. WRONG: Coughing will improve within 12-24 hours of initiation of treatment. This goal does not address the patient's complaint of chest discomfort nor is it measurable. The term improve is not a measurable term. Patient complaints of chest discomfort from cough will decrease within 4 days. This goal is not measurable. Just because the patient does not complain of pain does not mean the patient is not experiencing chest discomfort. Productive cough will decrease within 48 hours of starting treatment. This goal does not address the patient's problem, which is chest discomfort from cough.

Which goal is realistic for a nurse caring for a patient postoperatively? Patient's wound will have no drainage after surgery. Patient will be fever free on the second postoperative day. Patient's incision will heal without signs of infection by day 10. Patient will be pain free by the first postoperative day.

Patient's incision will heal without signs of infection by day 10. A realistic goal is for an infected incision to heal within a week or even 10 days. WRONG: Patient's wound will have no drainage after surgery. Surgical wounds will have some amount of drainage. The presence of a nonpurulent drainage in the first few days after surgery is expected. Patient will be fever free on the second postoperative day. Postoperative fever is common in the first week after surgery and without any other signs and symptoms may be part of the normal physiologic response to surgical trauma and stress. Patient will be pain free by the first postoperative day. A patient would be expected to experience pain the day after surgery, so this goal would be unrealistic.

Which group(s) does the Centers for Disease Control and Prevention (CDC) apply the term quarantine to? Select all that apply. People Animals Cargo Buildings Institutions

People The CDC quarantine can apply to any person who is suspected of being exposed to an infectious disease. Animals The CDC applies the term quarantine to more than just people. It also applies to animals that may carry an infection or have been exposed to an infectious agent. Cargo Cargo that is suspected of containing infectious material can be quarantined. Buildings Buildings where infectious material may be stored or found can be quarantined. WRONG: Institutions Institutions are agencies or organizations, such as the CDC itself. Institutions cannot be quarantined.

Which techniques can the nurse use for collecting patient assessment data? Select all that apply. Performing a general assessment Speaking with the patient's family Consulting the patient's medical file Performing the physical assessment Obtaining a thorough history Speaking with the patient's roommate

Performing a general assessment Performing a general assessment, including the patient's susceptibility and appearance, is one strategy of collecting key patient assessment data. Speaking with the patient's family Speaking with the patient's family may not be required when collecting key patient assessment data. However, this is a strategy that can be used to collect patient data if the patient is unable to provide data because they are confused or unable to communicate. Consulting the patient's medical file Consulting the patient's medical file is not required but can help when collecting key patient assessment data. The medical file may provide information for a patient unable to communicate because of a stroke or an acute illness. The medical file may also provide specific dates that a patient may not remember or accurate information about medications and surgical procedures. Patients with advanced dementia are also poor historians, and the medical record may be helpful in providing information. Performing the physical assessment The physical assessment is an essential strategy when collecting patient assessment data. The patient's subjective data direct the nurse when performing the physical assessment. Obtaining a thorough history Obtaining a thorough history of the patient is one strategy of collecting key patient assessment data. WRONG: Speaking with the patient's roommate Speaking with a patient's roommate may be unreliable and may violate the Health Insurance Portability and Accountability Act (HIPAA) without express permission from the patient.

Match the transmission-based precaution with the mode of transmission it prevents. Person to person Coughing, sneezing Suspended particles Airborne Contact Droplet

Person to person Contact Coughing, sneezing Droplet Suspended particles Airborne

Which type of action is the nurse taking to reduce the spread of infections by not going to work when sick? Personal Community Home Employee

Personal The nurse staying home is a personal action taken to help reduce the transmission of infection to other staff members and patients. WRONG: Community Community actions are broad actions taken by groups within the community. Nurses can participate in some of these activities. Home Home actions include teaching patients how to prevent infections at home. Employee Employee actions include those that pertain to abiding by policies and procedures pertaining to health and illness.

As a member of the infection control committee, which action would the nurse suggest to help control transmission of respiratory infections among staff during influenza season? Role model wearing gloves during patient care. Speak to peers about obtaining their immunizations. Teach hand hygiene to unlicensed assistive personnel. Post signs in bathrooms demonstrating cough etiquette.

Post signs in bathrooms demonstrating cough etiquette. This is a good suggestion and could be very effective. All nurses and many visitors go into bathrooms and can easily see signs that catch their attention. WRONG: Role model wearing gloves during patient care. Role modeling is a positive action; however, wearing gloves is a part of standard precautions. This is not likely to help control the transmission of respiratory infections among staff. Speak to peers about obtaining their immunizations. This action might be perceived as judgmental or intrusive. Some facilities have policies regarding immunizations. Also, immunizations for influenza must be administered several weeks before exposure to the virus to be effective. Teach hand hygiene to unlicensed assistive personnel. Unlicensed assistive personnel are required to know how to perform hand hygiene. This is a redundant action.

Which objective patient findings alert the nurse to the presence of infection or the risk for infection? Select all that apply. Pressure injuries Enlarged lymph nodes Hyperactive bowel sounds Reports of pain Decreased breath sounds

Pressure injuries The presence of pressure injuries places the patient at risk for infection because of loss of skin integrity. This is an objective finding. Enlarged lymph nodes The presence of enlarged lymph nodes is an indication of an immune response to infection. It is an objective finding. Hyperactive bowel sounds Hyperactive bowel sounds can indicate a gastrointestinal infection. It is an objective finding. Decreased breath sounds Decreased breath sounds indicate risk for infection because the lungs are not fully expanding, leaving room for microorganisms to multiply. This is an objective finding. WRONG: Reports of pain Reports of pain can indicate infection. This is, however, a subjective finding.

Which phrases describe the purpose of hand hygiene? Select all that apply. Prevents the spread of infection Breaks the chain of infection Interrupts organism transmission Enhances the patient relationship Kills microorganisms

Prevents the spread of infection Hand hygiene prevents the spread of infection by preventing the spread of microorganisms. It is the most important medical aseptic technique performed by nurses and other health care providers. Breaks the chain of infection Hand hygiene breaks the chain of infection by preventing the spread of microorganisms. It is the most important medical aseptic technique performed by nurses and other health care providers. Interrupts organism transmission Hand hygiene interrupts the mode of transmission of organisms, including microorganisms, thus preventing potential infections. It is the most important medical aseptic technique performed by nurses and other health care providers. WRONG: Enhances the patient relationship Seeing nurses wash their hands does enhance the patient relationship because it gives patients confidence in the care they are receiving. However, it is not the purpose of hand hygiene. Kills microorganisms Hand hygiene reduces the growth of microorganisms but does not kill them.

Which phrase describes medical asepsis? Absence of all infectious agents Procedure known as clean technique Requires use of sterile gloves Prevents microbial entry into body

Procedure known as clean technique Medical asepsis is also known as clean technique and includes hand hygiene and gloves to prevent the spread of microorganisms. WRONG: Absence of all infectious agents This statement describes asepsis, which means the complete absence of all disease-producing microorganisms. Requires use of sterile gloves Surgical asepsis, not medical asepsis, requires the use of sterile gloves. Clean gloves are used when employing medical asepsis. Prevents microbial entry into body Surgical asepsis, not medical asepsis, is used to prevent entry of microorganisms into the body from the environment.

Which cue would indicate an infection to a nurse caring for a patient 2 days after a cesarean section? Productive cough Clean surgical wound Pain on ambulation Vaginal bleeding

Productive cough A productive cough would support the presence or raise the suspicion of a respiratory tract infection and require further evaluation. Postsurgical patients are at an increased risk for atelectasis and respiratory infections. WRONG: Clean surgical wound A clean surgical incision without drainage does not support the presence of infection. A surgical wound may be at risk for infection because it is a portal of entry for infectious agents, but the clean incision indicates an infection is not currently present. Pain on ambulation Pain is common postsurgically and with no other indicators would not indicate infection. Vaginal bleeding Vaginal bleeding is not a sign of infection and is expected in this case.

Which transmission-based precaution would the nurse take for a seriously ill patient being admitted for influenza? Avoid admitting through the reception area. Admit to an airborne infection isolation room. Obtain an N95 disposable respirator mask. Provide a mask for the patient if leaving the room.

Provide a mask for the patient if leaving the room. Providing a mask for the patient if leaving the room is a precaution that applies to patients with influenza on droplet precautions. A single room with the door closed is desired; patients must wear a mask if they leave the room to protect other patients and staff. WRONG: Avoid admitting through the reception area. Avoiding admittance through the reception area is not necessary for a patient with influenza. This precaution applies to patients on airborne precautions such as tuberculosis. Admit to an airborne infection isolation room. Admittance to an airborne infection isolation room is not necessary for a patient with influenza. This precaution applies to patients on airborne precautions such as tuberculosis. Obtain an N95 disposable respirator mask. Obtaining an N95 disposable respirator mask is not necessary for a patient with influenza. This precaution applies to patients on airborne precautions such as tuberculosis.

Match the diagnostic test with the information that it provides. Provides counts for RBCs, WBCs, platelets, and reticulocytes Detects causative organism and determines effective antibiotic treatment Provides the number of each type of WBC Provides the overall number of all WBCs White blood cell (WBC) differential White blood cell (WBC) count Culture and sensitivity (C&S) Complete blood count (CBC)

Provides counts for RBCs, WBCs, platelets, and reticulocytes Complete blood count (CBC) Detects causative organism and determines effective antibiotic treatment Culture and sensitivity (C&S) Provides the number of each type of WBC White blood cell (WBC) differential Provides the overall number of all WBCs White blood cell (WBC) count

Which aspect of the general history would the nurse focus on when caring for a patient with a hypothesis related to an infection? Recent travel Tobacco abuse Previous pregnancies History of hypertension

Recent travel Recent travel may put a patient at risk for diseases that are endemic to other areas and is critical to the history of a patient with an infection. WRONG: Tobacco abuse Tobacco abuse does not directly affect infection and would not be focused on by a nurse caring for a patient with an infection but is an important part of the general history. Previous pregnancies Previous pregnancies would not be focused on by a nurse caring for a patient with an infection but is an important part of the general history. History of hypertension Hypertension is unrelated to infection but is an important part of the general history.

Which home care intervention helps reduce the transmission of infections? Reporting infections as early as recognized Using disposable dishes and utensils Soaking clothing in bleach solution Isolating the infected individual from others

Reporting infections as early as recognized Reporting signs of infection early is an intervention that helps reduce the transmission of infections in the home. Treatment or precautions can be implemented to reduce transmission. WRONG: Using disposable dishes and utensils This is expensive and unnecessary. Cleaning reusable equipment and supplies at home with soap and water and disinfecting with 10% chlorine saves money and prevents transmission of microorganisms. Soaking clothing in bleach solution Soaking clothing in bleach can ruin clothing and is unnecessary. Personal items should not be shared, but otherwise, clothing should be washed in hot soap and water as usual. Isolating the infected individual from others The infected person does not need to be isolated unless prescribed by the health care provider, state, or federal agencies. Implementing infection control practices at home is adequate for controlling infections under ordinary circumstances.

Which behavior indicates the need for additional teaching after educating a patient about respiratory etiquette? Using sanitizer hand wipes after sneezing Dropping used tissues into a waste receptacle Reusing tissues for a productive cough Wearing a mask when leaving the room

Reusing tissues for a productive cough Reusing tissues, not disposing of them, harbors microorganisms. This indicates the need for further teaching about the need to dispose of tissues immediately after use. WRONG: Using sanitizer hand wipes after sneezing Using sanitizer hand wipes demonstrates the patient's understanding of the need for hand hygiene after sneezing. This does not indicate the need for additional teaching. Dropping used tissues into a waste receptacle Dropping used tissues into a waste receptacle demonstrates the patient's understanding of the need for correct disposal of used tissues. This does not indicate the need for additional teaching. Wearing a mask when leaving the room Wearing a mask when leaving the room demonstrates understanding of infectious transmission. This does not indicate the need for further teaching.

Match the precaution with its corresponding description. Separates sick and contagious people from others Separates people exposed to a contagious disease Separates people with weak immune systems Protective isolation Isolation Quarantine NOT SURE

Separates sick and contagious people from others Isolation Separates people exposed to a contagious disease Quarantine Separates people with weak immune systems Protective isolation

Which factors would cause a nurse to increase the priority of a patient with an infection? Select all that apply. Sepsis Diabetes High fever Hearing deficit Altered mental status Multidrug resistant organisms

Sepsis Systemic inflammatory response syndrome (SIRS), sepsis, diabetes, high fever, altered mental status, and multidrug resistant organisms are factors that indicate an increased severity of infection and require prioritization by the nurse. Diabetes Systemic inflammatory response syndrome (SIRS), sepsis, diabetes, high fever, altered mental status, and multidrug resistant organisms are factors that indicate an increased severity of infection and require prioritization by the nurse. High fever Systemic inflammatory response syndrome (SIRS), sepsis, diabetes, high fever, altered mental status, and multidrug resistant organisms are factors that indicate an increased severity of infection and require prioritization by the nurse. Altered mental status Systemic inflammatory response syndrome (SIRS), sepsis, diabetes, high fever, altered mental status, and multidrug resistant organisms are factors that indicate an increased severity of infection and require prioritization by the nurse. Multidrug resistant organisms Systemic inflammatory response syndrome (SIRS), sepsis, diabetes, high fever, altered mental status, and multidrug resistant organisms are factors that indicate an increased severity of infection and require prioritization by the nurse. WRONG: Hearing deficit A hearing deficit would not be a reason to increase the priority of a patient with an infection.

Which laboratory finding is abnormal and must be reported to the health care provider? White blood cell (WBC) count of 10,100 cells/mm3 Erythrocyte sedimentation rate (ESR) 20 mm/hr Serum complement 140 hemolytic units C-reactive protein of 0.9 mg/L

Serum complement 140 hemolytic units This is significantly elevated, indicating active inflammation and/or infection and definitely needs to be reported to the patient's health care provider. WRONG: White blood cell (WBC) count of 10,100 cells/mm3 This is within the normal WBC range and does not need to be reported. Erythrocyte sedimentation rate (ESR) 20 mm/hr This is within the normal ESR range for both men and women and does not need to be reported. C-reactive protein of 0.9 mg/L This is within the normal C-reactive protein range and does not need to be reported.

Which potential infections would a nurse focus on when teaching preventive precautions to an immobile patient being discharged to home? Select all that apply. Skin infections Cardiovascular infections Urinary tract infections (UTIs) Respiratory infections Musculoskeletal infections

Skin infections Immobility is a risk factor for skin breakdown and skin infections. If the patient cannot ambulate independently and does not change positions at least every 2 hours, the patient will suffer from pressure injuries and will be at risk for infection. Urinary tract infections (UTIs) UTIs occur in patients who are unable to ambulate to the toilet independently. This could result in bladder overfilling or urinary stasis, which increases the risk for urinary tract infection. Respiratory infections Respiratory infections are more common in patients who cannot ambulate independently. Lungs build up respiratory secretions that, without activity, they cannot expectorate. Stasis of secretions leaves patients at risk for respiratory infections. WRONG: Cardiovascular infections Immobility is not a risk factor for the development of cardiovascular infections. It is, however, a risk factor for other complications. Musculoskeletal infections Immobility is not a risk factor for musculoskeletal infections unless pressure injuries in the skin become so deep and infected that underlying muscle and bone are invaded.

Which diseases can the federal government order patients to be isolated and/or quarantined for? Select all that apply. Smallpox Human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS) Measles Cholera Yellow fever Diphtheria

Smallpox Smallpox is an infection for which isolation and quarantine are federally authorized. Cholera Cholera is an infection for which isolation and quarantine are federally authorized. Yellow fever Yellow fever is an infection for which isolation and quarantine are federally authorized. Diphtheria Diphtheria is an infection for which isolation and quarantine are federally authorized. WRONG: Human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS) Federal isolation and quarantine are not authorized for HIV/AIDS. Measles Although extremely contagious, federal isolation and quarantine are not authorized for measles.

Which statement is correct regarding hand hygiene in the health care setting? Soap and water effectively reduce microorganisms on visibly dirty hands. Infectious agents are killed by soap and water when washing hands. Washing hands with very hot water helps eliminate a greater number of bacteria. Non-alcohol-based hand sanitizers inhibit microorganism growth on hands.

Soap and water effectively reduce microorganisms on visibly dirty hands. Handwashing breaks the chain of infection by interrupting microorganism transmission. Washing with soap and water effectively removes, and thus reduces, microorganisms on the skin when hands are visibly dirty. WRONG: Infectious agents are killed by soap and water when washing hands. Handwashing with soap and water does not kill infectious agents. It does eliminate their presence and reduces the risk for infection. Washing hands with very hot water helps eliminate a greater number of bacteria. Handwashing does not need to be performed with very hot water to be effective. In fact, hot water can damage the skin and affect future hygiene. Non-alcohol-based hand sanitizers inhibit microorganism growth on hands. Non-alcohol-based hand sanitizers do not inhibit the growth of or kill microorganisms. They do reduce the growth of some microorganisms but not bacteria, such as cryptosporidium or norovirus, when used for cleaning hands.

Which nursing student's note would the nurse correct? Standard precautions used during bed, bath, and mouth care. Education provided to patient about cough etiquette. Location of site where injection was administered. Patient performed a return demonstration on wound care using gloves.

Standard precautions used during bed, bath, and mouth care. It is not necessary to document the use of routine standard precautions in the patient's chart. The nurse will correct this student note. WRONG: Education provided to patient about cough etiquette. The student should document patient education. Standard precautions include cough etiquette. This is correct. Location of site where injection was administered. The student should document the injection site when administering injections. Safe injection practices are part of standard precautions. This is correct. Patient performed a return demonstration on wound care using gloves. The student should document any patient or family education provided, including use of standard precautions.

Which procedure is necessary for equipment being used to enter a sterile body cavity? Sanitization Disinfection Sterilization Decontamination

Sterilization Any item that will be used to enter a sterile body cavity must be thoroughly cleaned and sterilized before use. WRONG: Sanitization Sanitization means to clean and disinfect. Sanitizing includes cleaning and using disinfecting agents such as chlorhexidine, which is not sufficient to clean instruments entering sterile body cavities. Disinfection Disinfection with agents such as chlorhexidine is not sufficient to clean instruments entering sterile body cavities. Decontamination Decontamination is required before use, but it is not sufficient. Another procedure is required before instruments can be used to enter a sterile body cavity.

Which manifestations indicate systemic infection and warrant further patient assessment? Select all that apply. Blood pressure of 164/104 mm Hg Temperature 101.3°F (38.5°C) orally Heart rate 122 beats/min Respiratory rate 16 breaths/min Skin warm to touch and moist NOT SURE

Temperature 101.3°F (38.5°C) orally This is an abnormal finding and indicates a systemic infection. Further assessment of this patient is warranted. The normal oral temperature range for adults is 97°F (36.1°C)-99°F (37.2°C). Heart rate 122 beats/min This is an abnormal finding and indicates a systemic infection. Further assessment of this patient is warranted. The normal heart rate for adults is 60-100 beats/min. WRONG: Blood pressure of 164/104 mm Hg This blood pressure finding indicates hypertension, which is unrelated to infection. Systemic infection is sometimes associated with hypotension. Respiratory rate 16 breaths/min This is a normal finding and does not indicate infection. Skin warm to touch and moist This is a normal finding and does not indicate infection.

Which source is best for the nurse to recommend for patients interested in information about the updated immunization schedule for adults? Their health care provider's clinic or office The Centers for Disease Control and Prevention (CDC) immunization website Any health care provider at a local pharmacy The US government website

The Centers for Disease Control and Prevention (CDC) immunization website The CDC website is the best source for information about immunization schedules for children and adults. It is constantly updated. WRONG: Their health care provider's clinic or office It is possible that not all health care providers have a copy of the latest adult immunization schedule. This is a good source but not the best source for this information. Any health care provider at a local pharmacy Pharmacy health care providers may or may not have current schedules. This might be a good source, but it is not the best source for this information. The US government website This is not a specific website. There are many US government websites. This is not helpful information.

Which infection would require a nurse to don a fitted N95 respiratory mask? Tuberculosis Influenza Pneumonia Methicillin-resistant Staphylococcus aureus (MRSA)

Tuberculosis Tuberculosis is a disease transmitted through small droplet nuclei and must be countered with airborne precautions, which involves the use of an N95 respirator mask. WRONG: Influenza Influenza is transmitted through large droplets. The patient should be placed on droplet precautions, but the use of an N95 mask is not necessary. Pneumonia Pneumonia is also transmitted through large droplets. The patient should be placed on droplet precautions, but an N95 mask is not necessary. Methicillin-resistant Staphylococcus aureus (MRSA) MRSA is transmitted through direct contact. The patient should be placed on contact precautions, but a respirator mask is not necessary.

Which precaution would the nurse take when handling needles (sharps) to prevent an accidental needlestick? Recapping the needle after use Using a needleless system whenever possible Placing covered intravenous (IV) cannulas securely in the trash Flushing needles with water before disposing of them

Using a needleless system whenever possible The use of needleless systems should always be used whenever possible to avoid accidental needlesticks from either clean or contaminated needles. WRONG: Recapping the needle after use Needles must never be recapped. Recapping can result in an injury to the nurse from a contaminated needle and future infection. Placing covered intravenous (IV) cannulas securely in the trash Contaminated needles, including IV cannulas, must never be placed in the trash. They are disposed of in a sharps container, or in a biohazard container because they have blood on them. Flushing needles with water before disposing of them Needles do not need to be flushed prior to disposal. Doing so places the nurse at risk for a needlestick.

Which infection would require a patient to be admitted to the airborne infection isolation room? Pharyngeal diphtheria Meningococcal sepsis Staphylococcus aureus Varicella zoster NOT SURE

Varicella zoster This pathogen causes chickenpox. It is highly contagious and requires admitting the patient to an airborne infection isolation room. WRONG: Pharyngeal diphtheria This pathogen causes diphtheria. Droplet precautions are required but not an airborne infection isolation room. Meningococcal sepsis This pathogen causes meningitis. Droplet precautions are required but not an airborne infection isolation room. Staphylococcus aureus This pathogen causes many types of infections. Contact precautions are required but not an airborne infection isolation room.

In which situation is it permissible for the nurse to use an alcohol-based hand sanitizer? Before eating lunch or ingesting food When hands are not visibly soiled After use of the bathroom by the nurse After known exposure to norovirus

When hands are not visibly soiled Alcohol-based hand sanitizers can be used when not providing patient care and hands are not visibly soiled. WRONG: Before eating lunch or ingesting food Alcohol-based hand sanitizers should not be used before eating or ingesting food. Hands must be washed with soap and water. After use of the bathroom by the nurse Alcohol-based hand sanitizers should not be used after use of the bathroom by nurses as part of standard precautions. Hands must be washed with soap and water. After known exposure to norovirus Alcohol-based hand sanitizers should not be used after known or suspected exposure to patients with infectious diarrhea from norovirus. Hands must be washed with soap and water.

Which solutions would a nurse generate for a patient with a stage III coccygeal pressure injury at risk for infection? Select all that apply. Wound care Cold compress Vital sign monitoring Turning patient every 2 hours Reducing pressure on coccyx

Wound care Wound care would be an important solution for a patient with a stage III coccygeal pressure injury at risk for infection. Vital sign monitoring Vital sign monitoring would be important in a patient with any hypothesis related to infection and would be an important solution for a patient with a stage III coccygeal pressure injury at risk for infection. Turning patient every 2 hours Turning a patient every 2 hours would be an important solution for a patient with a stage III coccygeal pressure injury at risk for infection. Reducing pressure on coccyx Reducing pressure on the coccyx would be an important solution for a patient with a stage III coccygeal pressure injury at risk for infection and can be achieved by the use of special mattresses and dressings. WRONG: Cold compress A cold compress would be an important solution for a patient with cellulitis of a limb but not for a patient with a stage III coccygeal pressure injury at risk for infection.