Quiz #5

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?"

The nurse is discussing antiviral medication with a client diagnosed with human immunodeficiency virus (HIV). Which client statement indicates a need for further teaching?

"The antiviral medication will cure the virus from my body."

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.

- Turn on the faucet and adjust force and temperature of the water. -Wet the hand and wrist areas. -Apply soap product. - Wash the palms and back of the hands for at least 15 seconds. -Pat hands dry with a paper towel. -Turn the faucet off with a paper towel.

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.

-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.

Nurses use medical asepsis, or clean technique, in practice to reduce the number and transfer of pathogens. Which of the following are principles of this practice? Select all that apply.

-Clean the least soiled areas first and then move to the more soiled ones. -Use personal grooming habits, such as shampooing hair often, to prevent spreading

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?

1500

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 observed a colleague enter a patient's room to respond to a call bell. The nurse believes that the colleague did not perform hand hygiene prior to giving care. What is the nurse's most appropriate action?

Ask the colleague if he performed hand hygiene before giving care.

A nurse is conscientious about implementing the principles of asepsis while providing care for clients. The principles of asepsis include which of the following?

Blood and body fluids are major reservoirs for microorganisms.

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.

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.

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.

To eliminate needlesticks as potential hazards to nurses, the nurse should:

Immediately deposit uncapped needles into puncture-proof plastic container.

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

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 caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from the room.

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

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

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.

A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated?

The nurse is caring for a client with a C. difficile infection.

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.

The nurse is providing an inservice educational program for the interprofessional healthcare team about infection control precautions. What teaching will the nurse include? (Select all that apply.)

Wear PPE. Practice hand hygiene. Keep client's environment clean.

A nurse is in charge of care for a client who has MRSA. Which of the following is an accurate guideline for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne

For which client would the use of standard precautions alone be appropriate?

an incontinent client in a nursing home who has diarrhea

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

Hepatitis is classified as a virus that:

causes tissue damage.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

has manicured nails that are 1-in (2.5-cm) long

The nurse is caring for a client who developed a urinary tract infection while hospitalized. How will the nurse document this condition?

healthcare associated infection (HCAI)

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse?

pouring the sterile solution from a height of 5 in (13 cm)

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

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 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 post-surgical procedure

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift

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 four clients. Which client presents the most susceptibility for infection?

46-year old with a foley catheter following anesthesia

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

A group of nursing students are learning about the World Health Organization (WHO) practice standards and their effect on the application of aseptic technique. The students should apply these standards in which of the following settings? Select all that apply.

An inpatient acute medicine unit An ambulatory clinic A community health outreach centre A long-term care facility A drop-in centre at a public health unit

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 client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?

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 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 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.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract

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.

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.

The student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains:

Stress causes the body to release cortisol, which can increase the risk of infection.

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 planning to insert an indwelling urinary catheter into a client should utilize which of the following techniques?

Surgical asepsis

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

An older adult patient has been diagnosed with a nosocomial respiratory infection and has been transferred to the intensive care unit. The nurse should understand what fact about the patient's illness?

The patient acquired the illness after he or she was admitted to the hospital

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 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

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

Which client would require a negative flow room?

an 81-year-old man with active tuberculosis and a productive cough

The nurse is caring for a client with a acute viral conjunctivitis. Which precautions will the nurse begin?

contact

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

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

An infection or the products of infection carried throughout the body by the blood is called:

septicemia.

The nurse is providing care for an older adult patient who has decreased immune function. The nurse's health education for the members of the patient's family should prioritize which of the following?

The significance of hand hygiene and techniques for performing it