N2 Ch. 25 asepsis and infection

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

"Avoid touching the outside of your gown when removing it." To prevent contamination, the outside of a gown should not be handled during removal. Gown removal should take place in the client's room, and the mask is not normally removed first. Assistance is not usually required with removal of a gown.

The nurse is caring for a client admitted with tuberculosis. The client asks why the nurse wears a respirator, gown, and gloves whenever they are in the room. How should the nurse respond? "Because of the tuberculosis, I need to follow airborne precautions for protection." "The droplet precautions are to protect me from the tuberculosis." "I wear the equipment to protect you from anything I could give you." "This equipment is just standard precautions for all clients."

"Because of the tuberculosis, I need to follow airborne precautions for protection." The client has tuberculosis, which requires airborne precautions as described by the respirator, gloves, and gown. Droplet precautions are insufficient for clients with tuberculosis. Equipment to protect the client describes neutropenic precautions, which would only be a mask and proper hand hygiene when entering the room. Standard precautions do not include respiratory, gown, and gloves.

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation? "Do not touch this, or I will have to start over. " "Everything is ready, I will leave the tray here for the provider." "I have set up this sterile field for your procedure, so please do not touch anything around the tray." "It is alright if you want to look at the supplies. Just be careful not to touch them."

"I have set up this sterile field for your procedure, so please do not touch anything around the tray." If the client touches the sterile field, the nurse will need to discard the supplies and prepare a new sterile field. When any portion of the sterile field becomes contaminated, all portions of the sterile field must be discarded. The nurse should call for help if a supply is needed. The nurse should not leave the sterile field unobserved.

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

"I will obtain a mask from the staff and wash my hands before touching my family member." Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is an older adult or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism? "Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it." "If you do not wear gloves you will also get the infection." "Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." "The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with." Contact precautions, which are not optional, block transmission of pathogens by direct or indirect contact. Explaining that the loved-one understands is not teaching information. Educating the visitor about drug-resistant infections is important but does not explain how to prevent transmission of the infection. Telling the visitor that he or she will get the infection if the visitor does not wear gloves is incorrect, the visitor is at a greater risk of getting and spreading the infection. Wearing gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing.

The nurse is providing education to a senior circle group during an active flu season about the differences between viruses and bacteria. What statements made by the attendees indicates that the education has been effective? Select all that apply. "I can take an antibiotic to eradicate a viral infection ". "There are some Immunizations that are available for select viruses. "There are some viruses that may be associated with cancers." "The virus enters the host cell's metabolism and replicates itself" "Viruses are not as harmful as bacteria."

"There are some Immunizations that are available for select viruses. "There are some viruses that may be associated with cancers." "The virus enters the host cell's metabolism and replicates itself" A virus invades a living cell many times its size, uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup. Viruses cause AIDS, chickenpox, colds, cold sores, encephalitis, hepatitis, herpes, HPV, influenza, measles, mononucleosis, mumps, polio, rabies, shingles, pneumonia, and many other diseases. They have been associated with some cancers and leukemias and with many autoimmune diseases. Viruses may be just as harmful as bacteria since there is not an effective treatment for a virus.

On a preoperative surgical unit, as a standard of care, all clients are swabbed for methicillin-resistant Staphylococcus aureus (MRSA). Prior to his surgery, a nurse notes that a specific client's results have come back positive. the client ask the nurse what this means. What is the nurse's best response? "These results indicate that you re infected with MRSA," "These results indicate that you are contaminated with MRSA." "Two positive tests are required before results can be confirmed." "These results indicate that you are colonized with MRSA."

"These results indicate that you are colonized with MRSA." Colonization occurs when microorganisms are introduced into a body surface, grow and multiply, but do not invade or cause illness. in a vulnerable host, colonization can lead to infection. The client is not considered "contaminated", nor are two positive tests required to confirm results.

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? "This antibiotic is the best choice since the causative organism is not known." "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." "Drug resistance can develop when the wrong antibiotic is used for pneumonia." "Pneumonia is usually caused by multiple organisms."

"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.

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.

5, 7, 2, 1, 3, 4, 6

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

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 has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate? Discard it in the waste can. Do nothing; it can be used again immediately. Disinfect it with alcohol swabs. Sterilize it by placing it in the autoclave.

Disinfect it with alcohol swabs. Equipment such as stethoscopes, sphygmomanometers, and other assessment tools that are used for clients on contact precautions should be cleaned and disinfected before use on other clients. The other answers are incorrect.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation. Antibody production is characteristic of the immune response to infection.

During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area.

The nurse is assessing a three year-old toddler and is aware that the child's eustachian tubes are shorter and straighter than those of an older adult. The nurse will consequently prioritize assessment for what health problem? COVID-19 Pneumonia Ear infections Protozoal infections

Ear infections The most common infections in early childhood are respiratory infections. In children, the eustachian tubes are shorter and straighter; middle ear infections (otitis media) are common because bacteria can easily pass from the nasopharynx to the ear canal. This does not increase the risk for pneumonia, protozoal infections or COVID-19.

A nurse has put on personal protective equipment (PPE) to perform the dressing change of a client's surgical wound. While the nurse is cleansing the incision, the client begins bleeding and blood hits the nurse's wrist, running down under the cuff of her glove. What is the nurse's best action? Perform thorough hand hygiene immediately after completing the dressing change. Rinse the infected hand with hydrogen peroxide after applying a sterile bandage to the client's wound. Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol. Remove the contaminated gloves and apply a clean pair of gloves.

Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol. If the nurse is accidentally exposed to blood, it is necessary to stop the task and immediately follow facility protocol for exposure, including reporting the exposure. It would be unsafe to proceed with the dressing change before addressing the exposure. Applying new gloves does not eliminate the exposure.

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

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 is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply. Inside edges of the ulcer appear to be drawing together Scabs forming over the ulcer Pain with redness and swelling Localized heat Purulent or malodorous drainage

Pain with redness and swelling Localized heat Purulent or malodorous drainage Signs of infection of the client's foot ulcer that the nurse includes in discharge teaching include redness, swelling, and pain; localized heat; and purulent or malodorous drainage. If the inside edges of the ulcer appear to be drawing together and/or if scabs are forming over the ulcer, the ulcer is likely to be healing.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? Perform hand hygiene Don a new pair of gloves to dispose of materials Wrap all used materials together and discard in biohazard container Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

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

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? Pour the liquid onto gauze on the sterile field until the gauze is moist. Pour the liquid into the cap of the bottle and dip the gauze as needed. Pour the liquid into a sterile container within the sterile field. Pour the liquid into the palm of a sterile gloved hand for use.

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

Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process? Select all that apply. ( right answer) Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.

RIght answers these are the wrong answers "Nurses use personal protective equipment (PPE), which is the most effective way to help prevent the spread of organisms." its washing hands not PPE Limiting the spread of microorganisms is accomplished by breaking the chain of infection, not by directing the chain. The practice of asepsis includes all activities to prevent infection or break the chain of infection. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Surgical asepsis, or sterile technique, includes practices used to render and keep objects and areas free from microorganisms. Hand hygiene is the most effective way to help prevent the spread of organisms. The use of Standard and Transmission-Based Precautions is an important part of preventing infection.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? Clostridioides difficile and diabetic ketoacidosis Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Tuberculosis and pneumonia Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

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

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection? airborne droplet contact reverse isolation

contact Any multidrug resistant organism requires contact precautions to help prevent the spread of the organism to others. This will include MRSA. Airborne precautions can be utilized with diseases in which the causative organism is passed through the air after the infected person has coughed, sneezed, or talked. Tuberculosis is an example. Droplet precautions are warranted when the disease is spread through large particle droplets such as rubella and mumps. Reverse isolation is used to protect the client from any new infectious organisms. This can be utilized for client's who may be immunocompromised or already have a serious infection and the nursing team is trying to prevent further infections from complicating the client's health.

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

contact precautions VRE is transmitted via contact. The nurse caring for a client with VRE should implement contact precautions which is wearing a gown and gloves while in the client's room. Droplet precautions include wearing a surgical mask while in the room. Special masks for airborne precautions are used for, but are not limited to: measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis. Standard precautions are used with all clients.

The nurse is admitting a client who has a draining wound that is contaminated with methacillin-resistant Staphylococcus aureus. What type of precautions should the nurse initiate for this client? droplet precautions airborne precautions neutropenic precautions contact precautions

contact 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.

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

decreased cellular immunity. As a person ages, there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to infection.

The nurse is preparing to help mobilize a client with an abdominal wound that is colonized by methicillin-resistant Staphylococcus aureus (MRSA). Which of the shown actions should the nurse perform before assisting the client? gown and gloves mask gown, mask, face protection gown and face mask

gown and gloves Drug-resistant wounds normally require contact precautions. This necessitates the use of gloves and a gown but not a mask, goggles, or face shield.

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

has manicured nails that are 1-in. (2.5-cm) long Fingernails should be less than ¼-in. (0.625-cm) long, as this reduces the reservoir for flora to accumulate and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. Both the hands and wrists should be wetted. Allowing the hands to drain lower than the wrist promotes gravity drainage.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply. The nurse's back is facing the sterile field. The nurse keeps hands above waist level while donning sterile gloves. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. The nurse disposes of an opened container of sterile saline after 24 hours.

he nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. Principles of surgical asepsis include never turning one's back on a sterile field. The nurse should avoid talking, coughing, or sneezing over the field and keep sterile objects above waist level. Sterile objects may only be touched by other sterile objects. Most solutions are considered sterile for 24 hours after they are opened.

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason? permits selection of antibiotic concentration helps in reducing proliferation of multidrug-resistant organisms narrows the therapeutic range to avoid prolonged use helps to determine prescribed antibiotic therapy

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

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply. decreased pulse rate increased respiratory rate absence of pain lymph node enlargement fever

increased respiratory rate lymph node enlargement fever Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, and lymph node enlargement.

A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection? adult child older adult pregnant woman

older adult Long-term care residents and older adult hospitalized clients are at increased risk for antibiotic-resistant infections. Pneumonia, influenza, urinary tract and skin infections, and TB are common in older people, especially residents of long-term care facilities. These infectious diseases are not commonly seen in young adults, children, or pregnant women admitted to health care facilities.

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

Neutrophils Eosinophils Basophils Granulocytes include neutrophils, eosinophils, and basophils. T-lymphocytes and monocytes are agranulocytes.

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens? wear gloves and a gown when transporting the specimen place each of the three sealed specimens in a separate paper bag place the specimens into plastic biohazard bags swab the outside of each specimen container with alcohol prior to transport

place the specimens into plastic biohazard bags Specimens should be placed in sealed plastic bags to prevent them from becoming contaminated or causing the transmission of infective microorganisms. Paper bags are not used for this purpose, and it is not customary to swab the outsides of specimen containers. Standard precautions should be implemented, but this does not necessitate the use of a gown in all cases.

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? After completing a wound dressing Before direct contact with clients After direct contact with clients When hands are visibly soiled

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.

The nurse is educating a client with human immunodeficiency virus (HIV) on a new antiviral medication. Which client statement indicates a need for further teaching? "The medication will stop the virus from multiplying." "I will need to take the medication every day." "This medication will cure me of this virus." "This medication will limit the viral load in my body."

"This medication will cure me of this virus." The discovery and use of antiviral medications has turned once-deadly viral infections, such as HIV, into chronic diseases. The antiviral medication will not cure the client from the virus; however, it will decrease the viral load and limit multiplication of the virus. The antiviral medication will need to be taken daily for life.

The nurse is caring for the following clients. Which client requires a negative air flow room? 21-year-old client with latent tuberculosis who is postoperative following repair of a femoral fracture 4-year-old client with Clostridioides difficile 81-year-old client with active tuberculosis and a productive cough 3-year-old client with influenza A and a productive cough

81-year-old client with active tuberculosis and a productive cough The client who requires a negative airflow room (airborne precautions) is the client with active tuberculosis. Active tuberculosis always requires a negative airflow room; latent tuberculosis does not. Clostridioides difficile requires contact precautions, not airborne precautions; therefore, negative airflow is not necessary. Influenza requires droplet precautions, not negative airflow.

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? When a sterile item touches something that is not sterile, it may not be contaminated. Any partially uncovered sterile package need not be considered contaminated. A commercially packaged surgical item is not considered sterile if past expiration date. Sterility may not be preserved even when one sterile item touches another sterile item.

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.

The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant? Hairless, shiny legs 2+ edema to lower extremities Thick overgrown toenails An absent popliteal pulse

An absent popliteal pulse Priority assessments address the ABCs. Absence of a pulse (circulation) is a significant finding, which without intervention could lead to loss of limb. The other listed integumentary changes do not pose a short-term threat, even though they are clinically significant.

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

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.

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

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

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? Avoid contact with mosquitoes Use hand sanitizer after touching any public surface Self-quarantine yourself for 2 weeks if you feel ill Use a face mask when in crowds

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

The laboratory calls the nurse to report the client's white cell differential reveals a shift to the left. The nurse will assess the client for signs and symptoms of what medical diagnosis? Viral infection Bacterial infection Protozoal infection Autoimmune disorder

Bacterial infection If the infection is severe or prolonged, the body cannot manufacture neutrophils quickly enough, resulting in the release of immature granulocytes into the blood. This increase in the number of immature cells is called a shift to the left or leftward shift in the granulocyte differential count. A leftward shift is considered a strong indication of bacterial infection; the greater the leftward shift, the more worrisome the infection appears. It is not associated with viral or protozoal infections or autoimmune processes.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? 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. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing sending a VRE-positive client to the radiology department for a chest X-ray without a face mask delivering a meal tray to a VRE-positive client without first donning gloves and a gown

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.

The nurse is assisting a colleague with wound care. The colleague has established the sterile field and is pouring out normal saline into a sterile container, as seen in the picture above. What is the nurse's best action while observing the colleague perform the task? observe the colleague and take no further action remind the colleague that the container should be centered on the sterile field obtain a new dressing tray for the colleague encourage the colleague to hold the bottle closer to the sterile container

observe the colleague and take no further action

A client with an intact immune system has been exposed to Mycobacterium tuberculosis, initiating a cellular immune response. This response will begin with what physiological process? Production of antibodies by B cells Phagocytosis by macrophages Creation of new memory T lymphocytes Stimulation of T lymphocytes

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

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

Fungi

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely: Between 37.1°C and 38.2°C Above 38.2°C Greater than 40.5°C Between 35°C and 36.8°C

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

The nurse is palpating a client's precordium. Which result is an expected clinical finding? Palpable pulsation over the mitral area Palpable thrill over the aortic area Palpable heave over the pulmonic area Palpable vibration over the right sternal border

Palpable pulsation over the mitral area A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.

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: Means of transmission Spore production Aerobic activity Survival adaptation

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 whose immunizations are several years out of date. What aspect of the client's health history would contraindicate the safe and effective administration of many vaccines? The client is immunocompromised The client is hoping to become pregnant The client has anemia The client uses recreational drugs and has a substance misuse disorder

The client is immunocompromised Vaccines are often contraindicated in clients who have compromised immune systems. Some vaccines should not be administered to clients trying to become pregnant, but most can be administered. Anemia and recreational drug use do not normally rule out immunization.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply. The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room. The nurse is exiting a room after completed indwelling urinary catheter care. The nurse has assisted a client with changing and caring for a new colostomy.

The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room. Alcohol-based handrub is preferred in situations when hands are not visibly soiled; before and after touching a client; before handling an invasive device for client care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; and after removing sterile or nonsterile gloves. Use of an alcohol-based handrub does not replace the need for gloves or for handwashing, however. After performing catheter care and assisting with changing a colostomy, gloves are worn and handwashing should take place.

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

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 is initiating isolation precautions for a client who has chronic Clostridioides difficile infection. What should the nurse be sure to include with these precautions? remind others to use a mask when caring for this client recognize that this type of infection requires droplet precautions be sure that there are gloves of various sizes and gowns for use include a N95 respirator mask for health care staff entering the room

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

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? "I can't transmit the virus other people if I shake their hands." "I probably got the virus when I sat on the toilet seat in a dirty bathroom." "I received a blood transfusion in 1989, which could be a factor in contracting the disease." "I may have gotten the virus when I got a tattoo while I was in prison."

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.

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take? Apply a 1-in (2.5-cm) layer of the ointment to the site using the index finger Use a sterile cotton-tipped applicator to apply the prescription to the site Place sterile 4 × 4 gauze on the wound and secure the dressing with dressing with paper tape Put soiled dressing change supplies in the client's bathroom garbage and double bag

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

Surgical asepsis is defined as: absence of all virulent microorganisms. absence of all microorganisms. slowed growth of microorganisms. use of hand washing, gowning, and gloving.

absence of all microorganisms. Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. airborne precautions droplet precautions contact precautions respiratory precautions microbial precautions body fluid precautions

airborne precautions droplet precautions 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 client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an): bacteria. virus. fungi. protozoa.

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

The nurse is creating a care plan for a client. Risk for Infection is the identified problem. Which situation supports this problem? the client with a urinary catheter inserted at the emergency department the client who is on contact precaution for Clostridioides difficile a cancer client who is in remission for the past year a client whose wound has exudate drainage

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