Nursing Fundamentals Ch 10 TTE

A home health nurse is completing a health history for a client. What is one question that is important to ask to identify a latex allergy for this client?

"Have you had any unusual symptoms after blowing up balloons?"

Following insertion of a foley catheter, the nurse instructs the unlicensed assistant to remove the sterile gloves by inverting one glove into the other. The assistant states, "Why is that important?" Which response by the nurse is most appropriate?

"Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms."

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

-Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. -With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. -Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. -Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

A nurse has just attended to a client with diarrhea and is assigned to change the dressing of a client with a burn injury. What should the nurse do before attending to the second client? Select all that apply.

-Perform hand hygiene as soon as possible after leaving the first client. -Use disposable towels to turn off the faucet. -Wash hands thoroughly with soap and water.

How long should a health care worker scrub hands that are not visibly soiled for effective hand hygiene?

15 seconds

A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate?

A reservoir

What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high?

Antimicrobial products

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

Apply a non-particulate (N-95) respirator when entering the room

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips

A nurse is believed to have become infected by inhaling the spores of a bacterium. What precaution should have been applied when the nurse was working with the client who had this illness?

Mask

Of all possible nursing interventions to break the chain of infection, which is the most effective?

Practicing hand hygiene

After changing the bed linens for a client, the nurse uses an alcohol-based handrub to perform hand antisepsis. What is the proper way to use an alcohol-based handrub?

Rub the product between the hands until they are dry

Personal protective equipment (PPE) is used in health care facilities to protect the staff from potentially infected clients. True/False

True

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

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

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80 yo woman

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?

applying a new dressing with the gloves that were used to remove the old dressing

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

bacteria

A nurse working at a health care facility understands the need for providing aseptic care when caring for clients. Which client is at greatest risk for infections?

client with burn injuries

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field?

with sterile forceps or hands wearing sterile gloves

A nurse is preparing a sterile field and has removed the sterile drape from the outer wrapper. The nurse places the inner drape in the center of the work surface with the outer flap facing in which direction?

Facing away from the body

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

Hold sterile objects above waist level to prevent inadvertent contamination.

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

an older adult client with a history of heart failure

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?

diligent handwashing practices

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gown and gloves

A nurse is providing care to a client who has developed an infection due to Candida. The infection is resistant to several medications. The client asks the nurse how he may have developed this infection. When responding to the client, the nurse would incorporate an understanding of which factor as contributing to the organism's resistance?

over-prescription of antibiotics

The nurse observes an unlicensed assistive personal (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room

the nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?

staff education on utilizing hand hygiene

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all client care and interaction