Week 3 | PrepU | Chapter 24 - ML 3 | Asepsis and Infection Control

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

-81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis* -30-year-old client who has recently contracted human immunodeficiency virus (HIV) -56-year-old client with acute kidney injury who receives hemodialysis three times weekly -44-year-old client who is paralyzed and whose pressure injury on the coccyx required a skin graft

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

-Between 35°C and 36.8°C -Greater than 40.5°C* -Between 37.1°C and 38.2°C -Above 38.2°C

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 client is scheduled to receive an immune globulin. When explaining this to the client, the nurse integrates knowledge that this action results in which type of immunity?

-Cellular -Active -Passive* -Humoral

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

-Client in the ICU for one day -Client receiving chemotherapy* -Client on a short course of vancomycin -Client with a history of eczema

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* -Wash the perineal area with soap and water -Place water-soluble lubricant on catheter tip prior to insertion -Ensure opening port of the catheter is closed

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?

-Educate the client of the importance of infection prevention. -Assess client's pain level and manage pain accordingly.* -Inform the client that these exercises must be done at regular intervals. -Inform the health care provider of the client's noncompliance

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

-Medical asepsis -Universal precautions -Contact precautions -Surgical asepsis*

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.

-Nurses may use a waterproof gown more than one time. -To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.* -During some care activities for an individual client, nurses may need to change gloves more than once.* -Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse. -Nurses should remove PPE at the doorway or in an anteroom, except for the respirator.* -Nurses need only apply clean gloves when performing or assisting with invasive client procedures.

An older adult client from a long-term care facility is being admitted to the hospital with an infected wound on the left foot. What action should the nurse perform upon admission related to the client's residential occupancy?

-Perform a nasal swab to identify colonization with methicillin-resistant Staphylococcus aureus (MRSA).* -Give the client a complete bath to make sure the pathogens from the wound are decreased.* -Ask the client if any other clients in the facility have infected wounds. -Insert an indwelling urinary catheter.

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

While the nurse is conducting morning rounds, the nurse notices that the client's temperature has gradually increased for the past 3 days. Which assessment(s) should the nurse do next? Select all that apply.

-Review how compliant the client has been with ambulation.* -Check site of wound.* -Check IV site for infiltration.* -Auscultate lung sounds.* -Call the laboratory for blood culture test.

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?

-Since the bottle has been open, previously used, and unexpired, "lip" it by pouring a small amount into a waste container or waste cup. -Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening. -Discard the bottle and get a new one because the saline has expired.* -Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container.

A nurse has identified the client's lack of knowledge regarding their prescribed antibiotic therapy. Which outcome is appropriate for the nurse to include in the client's care plan based on this nursing concern?

-The client will state how to safely take the prescribed antibiotic.* -The client will identify signs and symptoms of worsening infection. -The client will verbalize measures appropriate to minimize infection transmission. -The client demonstrates the proper technique for hand hygiene.

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 applies nonmedicated hand cream after performing hand hygiene. -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 nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene?

-The nurse refrains from using hand moisturizer following hand hygiene. -The nurse keeps fingernails less than 1/4 in (0.63 cm) long.* -The nurse uses hand hygiene instead of gloves when in contact with blood. -The nurse uses gloves in place of hand hygiene.

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 sterile field is set up at waist level. -Direct visualization of the sterile field is maintained. -The new nurse touches 1.5 in (4 cm) from the outer edges.* -The top flap of the package is opened away from the new nurse's body.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding confirms the client has developed an infection?

-Urine culture is positive for vancomycin-resistant enterococci (VRE).* -The nurse notes the client's urine is dark yellow with sediment. -The client reports nausea and vomiting. -The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C).

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?

-abnormal breath sounds -clear mucus* -dyspnea -productive cough

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?

-applying a face mask with shield -wearing clean unsterile gloves when changing the dressing -changing the soiled dressing* -isolating the client's belongings

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.

A client is receiving prescribed antibiotic therapy to treat an infection. On the fourth day of therapy, the client comes to the clinic and tells the nurse that she has developed a really sore mouth. After inspection, the nurse suspects that the client has developed a fungal oral infection. The nurse identifies this as:

-endotoxin. -superinfection. -healthcare-associated infection (HAI). -bacteremia.*

The most common infection in children is:

-gastrointestinal. -respiratory.* -neurologic. -urinary.

Which nursing action is a component of medical asepsis?

-handwashing after removing gloves* -insertion of an indwelling urinary catheter -insertion of an intravenous catheter -drawing blood from a central line

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?

-inserting an arm within each sleeve while touching the outer surface of the gown* -unfolding the gown while avoiding contact with the floor -picking up the gown at the sterile neckline -holding the gown away from the body and other unsterile objects

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

-remove the garments that are most contaminated -make contact between two contaminated surfaces -make contact between two clean surfaces -handwashing before leaving the client's room*

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?

-signs and symptoms of infection -hand hygiene measures -vital sign monitoring -intravenous antibiotic administration*

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?

-washes hands for 20 seconds with soap and water -picks up the glove at the folded edge with the thumb and forefinger -stretches the glove over the hand without touching the unsterile area -reaches down to the bed to pick up a sterile drape*

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?

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

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."

The nurse is caring for the following clients. Which client requires a negative air flow room?

-81-year-old client with active tuberculosis and a productive cough.* -4-year-old client with Clostridioides difficile -3-year-old client with influenza A and a productive cough -21-year-old client with latent tuberculosis who is postoperative following repair of a femoral fracture

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

-Allow many family members to visit at once. -Deliver flowers and balloons to the room. -Remove fresh fruit from the room.* -No special precautions are required.

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?

-Client with an intravenous catheter -Client with a urinary catheter* -Client with a diabetic foot ulcer -Client with a surgical wound

During an interaction with a client who is HIV-positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period?

-Convalescent period -Acute phase of illness -Incubation period -Prodromal period*

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?

-Discard the sphygmomanometer in the trash. -Cleanse and disinfect the sphygmomanometer.* -Send the sphygmomanometer for sterilization. -Use the sphygmomanometer.

Which action is the best example of a nurse donning/removing protective equipment properly?

-Donning gown after entering client's room -Donning respirator inside of client's room -Removing gown after leaving client's room -Removing respirator after leaving client's room*

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?

-Place client in a private room that has monitored negative air pressure. -Ensure that hard surfaces in the room are disinfected at least once per day. -Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.* -Use a private room with the door closed at all times.

A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client?

-wearing a mask when working within 3 feet (1 m) of the client* -washing hands with an antimicrobial agent or waterless antiseptic agent -using a special high-filtration particulate respirator -changing gloves after contact with the client's infective material

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?

-Bacteria -Fungi -Virus* -Parasites

Which of the following are considered the building blocks of the immune system?

-Macrocytes -Red blood cells -Macrophages -T lymphocytes*

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

-Rickettsiae -Helminths -Protozoans -Fungi*

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?

-Use hand sanitizer after touching any public surface -Self-quarantine yourself for 2 weeks if you feel ill -Avoid contact with mosquitoes* -Use a face mask when in crowds

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* -PICC line -Salem sump nasogastric tube -endotracheal tube

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 term describes foreign particles that enter a host and stimulate the body's immune response?

Phagocyte Antibody Antigen* Macrophage

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 caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?

-changing the soiled dressing* -wearing clean unsterile gloves when changing the dressing -isolating the client's belongings -applying a face mask with shield

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?

-narrows the therapeutic range to avoid prolonged use -helps in reducing proliferation of multidrug-resistant organisms -permits selection of antibiotic concentration -helps to determine prescribed antibiotic therapy*

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

-opening the sterile package toward the nurse to prevent reaching over -keeping sterile field above waist level* -putting on sterile gloves before opening sterile package -maintaining a 3-in. (7.5-cm) border around the sterile field

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?

-to eliminate disease-producing organisms from the nurse's skin* -to protect the integrity of the nurse's immune system -to sterilize the nurse's hands to prevent infection -to prevent the nurse from developing disease

Nursing students are reviewing information about healthcare-associated infections (HAI). What would the students expect to find as a possible risk factor? Select all that apply.

-use of antibiotic therapy* -shortened length of stay -strong cough reflex -use of steroid therapy* -insertion of invasive devices* -multiple wounds*

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 care and interaction with this client* -wearing a face mask when entering and staying at a distance from the client -wearing protective eyewear for contact with this client -placing the client in a regular, private room

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?

-"I understand; wearing these items is not pleasant but it really isn't optional." -"If you don't come into contact with anything with your body, you may wear gloves only, as long as you wash your hands after removing the gloves." -"These barriers help prevent the transmission of infection to you or other people."* -"Wearing the gloves and gown prevents sharing additional microorganisms with the client."

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?

-"Using either side of the drape is okay, as long as you do not contaminate the sterile supplies on the field." -"I use my whole hand to touch the non-waterproof surface before placing the sterile equipment on it." -"It is okay to turn the drape on the other side." -"The way you are doing it helps to minimize contamination of the non-waterproof side."*

The nurse is preparing to provide wound care for a client who is on droplet precautions. Place the following steps in the correct order that the nurse should take. All options must be used.

Perform hand hygiene. Put on gown, with the opening in the back and tie gown securely at neck and waist. Apply mask with face shield, secure ties at the middle of the head and neck. Put on clean disposable gloves.

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

-an 80-year-old woman* -a 2-year-old toddler -a 12-year-old girl -an 18-month-old infant

The nurse is caring for a client that is suspected of having a latex allergy. What item of personal protective equipment should the nurse use with caution?

-Surgical masks* -Goggles -Pillows -Gowns

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?

-Iatrogenic -Endogenous healthcare-associated -Antibiotic-resistant -Exogenous healthcare-associated*

The nurse is preparing to enter a client's room who is on airborne precautions. Which technique should the nurse use when wearing a nonparticulate respirator (N-95) mask? Select all that apply.

-Remove the mask by grasping the front of mask. -Tie the upper strings of mask snugly against back head.* -Replace the mask after 20-30 minutes.* -The mask covers the nose and mouth.* -Discard the mask in a paper lined wastebasket.