PrepU Chap24: Asepsis and Infection Control
A client who has been diagnosed with a cold is upset that antibiotic therapy was not prescribed. Which nursing response is most appropriate?
"The common cold is a virus and will not respond to antibiotics."
The nurse is preparing to perform hand washing. Arrange the steps in the correct order.
1. Turn on the faucet and adjust force and temperature of the water. 2. Wet the hand and wrist areas. 3. Apply soap product. 4. Wash the palms and back of the hands for at least 15 seconds. 5. Pat hands dry with a paper towel. 6. Turn the faucet off with a paper towel.
How long should a health care worker rub hands that are not visibly soiled for effective hand hygiene?
15 to 20 seconds
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room
The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection?
Hand hygiene
A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?
indwelling catheter
A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?
Hold sterile objects above waist level to prevent accidental contamination.
When do we perform Hand hygiene?
Moment 1 - Before touching a patient Moment 2 - Before a clean or aseptic procedure Moment 3 - After a body fluid exposure risk Moment 4 - After touching a patient Moment 5 - After touching patient surroundings
A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?
The client's immune system became further weakened
Examples of Surgical Asepsis (sterile technique)
inserting an undwelling urinary cath inserting an IV cath
Surgical asepsis is defined as:
absence of all microorganisms.
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 assistive personnel (UAP) to remove the sterile gloves by inverting one glove into the other. The UAP 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."
An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate?
Airborne
After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter?
Alcohol-based hand rub
HAND HYGIENE: USING AN ALCOHOL-BASED HANDRUB
Apply product to the palm of one hand, using the amount of product recommended on the package (it will vary according to the manufacturer but usually is 1 to 3 mL). Rub hands together, making sure to cover all surfaces of the hands, fingers, and in between the fingers. Also, clean the fingertips and the area beneath the fingernails. Continue rubbing until the hands are dry (at least 15 seconds).
After the nurse has set up a sterile field for a dressing change, the nurse realizes that an essential item has been forgotten. How should the nurse proceed?
Ask another staff member to bring the forgotten item.
when an alcohol-based handrub can be used to decontaminate hands (IHI, 2018):
Before direct contact with patients After direct contact with patient's skin After contact with body fluids, mucous membranes, nonintact skin, and wound dressings, if hands are not visibly soiled After removing gloves Before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement Before donning sterile gloves prior to an invasive procedure (e.g., inserting a central intravascular catheter) If moving from a contaminated body site to a clean body site during patient care After contact with objects (including equipment) located in the patient's environment
A student nurse is addressing the chain of infection when implementing the principles of infection control. How can the student best address the mode of transmission?
By performing hand hygiene consistently
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?
Discard the sterile field and the supplies and start over.
The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?
Perform hand hygiene.
Cardinal signs of infection are?
Redness Heat Swelling Spike in fever Pain Loss of function
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 nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
auscultate the lung sounds and count respirations
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria
The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?
be sure that there are gloves of various sizes and gowns for use
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?
bradypnea is a response to IICP.
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
hand washing
The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?
health care-associated infection (HCAI)
To eliminate needlesticks as potential hazards to nurses, the nurse should:
immediately deposit uncapped needles into a puncture-proof plastic container.
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
listen for heart sounds
A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the priority nursing action the nurse must perform before leaving the client's room?
thorough handwashing
A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?
wash the area with soap and water
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 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.
What is the pulse pressure of a client whose blood pressure is 132/82 mm Hg?
50
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.
The nurse is caring for a client with a cough and copious secretions. Before providing care, the nurse observes the licensed practical nurse (LPN) standing outside the client's room and donning personal protective equipment as shown above. How should the nurse best interpret the LPN's actions?
The LPN is donning personal protective equipment appropriately.
The nurse working with the hospital's infection control team is attempting to decrease the transmission of health care-associated pathogens. Which of the following will be most effective?
Incentivizing health care workers to utilize hand hygiene
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?
Incentivizing health care workers to utilize hand hygiene
Which interventions will be most effective in preventing the spread of infection in the health care setting?
Proper handwashing
A nurse is caring for a 55-year-old post-operative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
Urinary catheter
The nurse is caring for a postpartum mother who delivered her second child yesterday. The mother states her older child has just been diagnosed with chickenpox. She is concerned her newborn will develop the disease. What is the best response by the nurse?
"Have you had chickenpox?"
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 obtain a mask from the staff and wash my hands before touching my family member."
Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.
-Incubation period -Prodromal stage -Full stage of illness -Convalescent period
Which term describes foreign particles that enter a host and stimulate the body's immune response?
Antigen
Examples of medical asepsis(clean technique)?
Hand hygiene Using clean gloves Cleaning the environment routinely
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?
Hand hygiene is needed after contact with objects near the client.
What is the most common client site for development of healthcare-associated infections (HAI)?
Urinary tract Explanation: The urinary tract is the most common site for healthcare-associated infections (HAI).
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:
an older adult can have an infection without a fever.
The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin?
contact
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?
contact
The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?
contact Wound infectious agents are transmitted through contact; therefore contact precautions are appropriate. p.615
Which nursing action is a component of medical asepsis?
handwashing after removing gloves
The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?
"When your sputum culture is negative."
A nurse has finished providing morning care for a patient and is now planning to perform hand hygiene. Alcohol-based hand rub would be inappropriate in which of the following circumstances?
The nurse's hands are visibly soiled.
The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. Which precautions should the nurse take?
Use a mask when within 3 ft (1 m) of the client
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate
The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?
"Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."
When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?
Cleanse and disinfect the sphygmomanometer.
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene?
Decontaminate hands using an alcohol-based hand rub.
When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?
Discard the bottle and get a new one because the saline has expired.
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?
Keep hands lower than elbows to allow water to flow toward fingertips.
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.
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?
Surgical asepsis
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
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:
Survival adaptation
Which should be documented by the nurse?
The fact that sterile technique was used for a given procedure Explanation: The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?
handwashing before leaving the client's room
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
The nurse is caring for a postoperative client in contact isolation. Which actions should the nurse employ to reduce the spread of disease? Select all that apply.
Wash hands after removing gloves before leaving the client's room. Place used syringes and uncapped needles in a puncture-resistant container after use.
A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?
write it down
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 handrub is appropriate in which of the following situations?
When hands are visibly soiled
In which situation is an alcohol-based rub not the appropriate option for hand hygiene?
When the nurse's hands are visibly soiled
Which of the following are names of the transmission-based precautions defined by the Centers for Disease Control (CDC)? Select all that apply.
airborne precautions droplet precautions contact precautions
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?
an 80-year-old woman
Which client would require a negative flow room?
an 81-year-old man with active tuberculosis and a productive cough
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
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?
change to airborne precautions
Which piece of personal protective equipment (PPE) should be removed first?
Gloves
A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?
"All visitors who enter the room must wear special masks."
The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?
"Help me understand your perspective about vaccinating."
A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?
"Help me understand your thoughts about vaccinations."
The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required?
"I can leave my room any time I want as long as I wear a mask."
The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the the education provided was effective? Select all that apply.
"I may transmit the virus to my child during pregnancy and childbirth." "If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus if I share needles with another person."
The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?
"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."
The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?
"The way you are doing it helps to minimize contamination of the non-waterproof side."
Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?
"These barriers help prevent the transmission of infection to you or other people."
Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gown, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the appropriate nursing response?
"These barriers help to prevent the transmission of infection."
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."
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?
"This medication will cure me of this virus."
A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse?
"We are giving you broad spectrum antibiotics because they are active for many types of bacteria."
The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator?
"Wearing an N95 respirator is critical when I care for clients in droplet precautions." Explanation: N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.
A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:
"You may have infection in your birth canal that you are unaware of."
Lab data indicating infection are?
-Elevated WBC count: normal is 5000 to 10,000/mm3 -Increase in specific types of WBC -Elevated erythrocyte sedimentation rate (RBCs settle more rapidly to the bottom of a tube of whole blood when an inflammation is present) -Presence of pathogen in urine, blood, sputum, or draining cultures
The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps, in the correct order, that the nurse should take when donning sterile gloves. All options must be used.
1. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.
A nurse is working with an 82-year-old man following gallbladder surgery. He is NPO. and has IV access in his hand. He also has a Foley catheter in place. He is able to ambulate with the aid of a walker. What does not lower this client's immunity?
Ambulation
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?
5,850 mL
A nursing student is preparing to perform wound care for a hospital patient. When establishing a sterile field, the nurse should consider what areas to be nonsterile?
A 1-inch (2.5 cm) margin around the edge of the field
Which practice is a correct application of infection control practices?
A nurse performs hand washing each time the nurse removes a pair of gloves.
Which client would the nurse consider the most infectious?
A patient who is in the prodromal stage
The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?
Assess client's pain level and manage pain accordingly.
About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?
Avoid contact with mosquitoes
A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?
Avoid touching the outer surfaces of the gown.
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.
four categories that are responsible for a majority of HAIs in the acute care hospital setting
Catheter-associated urinary tract infection (CAUTI) Surgical site infection (SSI) Central line-associated bloodstream infection (CLABSI) Ventilator-associated pneumonia (VAP)
A client is admitted to the hospital with pneumonia. The nurse is preparing to enter the client's room. Which action would the nurse perform first?
Complete hand hygiene and don gloves
The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?
Create an area for sterile field and opening packages
The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply.
Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene. Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside.
The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?
Discard the supplies and field and prepare a new sterile field.
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?
Disinfect it with alcohol swabs.
A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?
Early infection treatment is needed to prevent the spread of infection.
An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?
Exogenous healthcare-associated Explanation: The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.
The nurse is caring for a client with human immunodeficiency virus (HIV) who currently has no signs or symptoms of the disease. Which important information about being an HIV carrier does the nurse teach the client?
HIV can be transmitted from an infected person to another person through blood, semen, vaginal fluids and breast milk. Explanation: HIV can be carried from an infected person to another person through blood, semen, vaginal fluids and breast milk. HIV cannot be transmitted through the secretions of an infected person who is coughing, sneezing, or talking. HIV cannot be transmitted through body surface-to-body surface contact between an infected person and another person. When a person is positive for HIV, regardless of whether symptoms of the disease are present, HIV can be transmitted from an infected person to another person.
What is the most effective way to prevent the spread of infectious disease?
Hand hygiene
A nurse is inserting a male client's indwelling urinary catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he has brought the wrong-sized catheter to the bedside. What is the nurse's best action?
Illuminate the client's call light and have a colleague bring the correct catheter to the bedside. If you realize a supply is missing after setting up the sterile field, you should call for help. Leaving the sterile field unattended renders it contaminated.
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?
Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol.
A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter?
Keep hands lower than elbows to allow water to flow toward fingertips.
The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?
Open a new sterile dressing kit
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.
Pain with redness and swelling Localized heat Purulent or malodorous drainage
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 into a sterile container within the sterile field.
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
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?
Perform hand hygiene before and after entering the client's room.
An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?
Perform surgical hand scrub using detergent.
The nurse is providing care to a client who is hospitalized for uncontrolled diabetes and performs the following activities. Which activity(ies) would it be recommended for the nurse to wear clean gloves? Select all that apply.
Performing a fingerstick to check the blood glucose level Administering subcutaneous insulin based on the glucose level
The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time
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?
Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)
The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?
Remove fresh fruit from the room. Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities. p.598
Which action is the best example of a nurse donning/removing protective equipment properly?
Removing respirator after leaving client's room
What is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled. If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas. p.624-628
The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?
Review the current infection control protocols.
The nurse is preparing a sterile field for a dressing change. How would the nurse add paper-wrapped sterile items to the sterile field?
Separate the sealed flaps and drop contents onto field.
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in. (4 cm) from the outer edges.
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 self at the start of the shift. The nurse has just completed documentation and is entering another client room. The nurse has entered the client room to adjust settings on the intravenous pump.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?
The nurse keeps fingernails less than 1/4 in (0.63 cm) long.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the appropriate use of hand hygiene?
The nurse keeps fingernails less than ¼ inch long.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
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 removes her gown and then removes her gloves. Explanation: 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 performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?
The nurse washes at least 1 inch above the area of contamination if present.
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 touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field.
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?
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. p.604; 618
The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?
Use a sterile intravenous catheter.
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
Vehicle
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?
contact precautions
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?
contact precautions Explanation: 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 school nurse is educating a group of teenagers about ways in which human immunodeficiency virus (HIV) can be transmitted. Which methods of infection transmission will the nurse educate the group about? Select all that apply.
contact with blood via sexual contact contact with wound openings via mucous membranes via syringes shared between the client and others
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?
decontaminate hands using an alcohol-based hand rub
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:
decreased cellular immunity
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 statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure?
if the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair
The nurse is admitting a client who has been receiving prescribed antibiotics for pneumonia. The client reports experiencing loose, watery stools for the past 4 days. What would be the initial action for the nurse to take?
implementing contact isolation
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
Medical asepsis (clean technique)
involves procedures used to reduce and prevent the spread of microorganisms.
A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is:
it is a vaccine given to booster antibodies towards the tetanus pathogen.
The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?
keeping sterile field above waist level
A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?
no stethoscope is required
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe food poisoning. p.595
The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?
remind the student that a fitted N95 respirator is required
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?
older adult
Any microorganism capable of disrupting normal physiologic body processes is a:
pathogen.
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?
perform hand hygiene before and after entering the client's room
Surgical technique (sterile technique)
practices used to render and keep objects and areas free of microorganisms
A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?
reaches down to the bed to pick up a sterile drape
An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:
recapping a needle.
A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client?
rectum
The nurse observes an unlicensed assistive personnel (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 most common infection in children is:
respiratory
Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care?
skin is dry and intact
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
The nurse manager is developing a plan to decrease the transmission of healthcare associated infections. What would be the best to implement?
staff education on utilizing hand hygiene
The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart?
stethoscope that remains in the client's room
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?
surgical asepsis
The nurse observes a member of the care team removing a gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?
teach the colleague to let the gown fall away rather than pulling on the sleeves
The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?
the client who is 48-hours postsurgical procedure Explanation: Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between clients, the nurse should see clients from the "clean" to "dirty." The nurse should see the client who has no signs of infection first. Among these clients, the nurse should begin with the client who is postoperative, then see the other clients who have symptoms of infections.
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
there is an auscultatory gap
Personal protective equipment (PPE) is used in health care facilities to protect the staff from potentially infected clients.
true
Standard precautions apply to blood; all body fluids, secretions, and excretions; intact and nonintact skin and mucous membranes.
true
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
urinary catheter
The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection?
urine culture is positive for vancomycin-resistant enterococci (VRE)
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift A new gown should be used by the nurse each time the nurse enters the room.