ADN 001 PrepU Ch 24

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."

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 probably got the virus when I sat on the toilet seat in a dirty bathroom."

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 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

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.

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take?

Drop the item from 6 in (15 cm) above the sterile field.

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

Fungi

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 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 caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes 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.

An operating room (OR) nurse on the facility's infection control team notices that a coworker in the OR is wearing artificial nails. What is the appropriate action/response by the nurse?

Remind coworker that artificial nails increase infections

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

Surgical asepsis technique

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 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.

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.

within normal limits

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

Standard precautions apply to blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes.

True

Surgical asepsis is defined as:

absence of all microorganisms.

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?

airborne

Which client would require a negative flow room?

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

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 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 is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact precautions

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?

noncommunicable disease

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

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

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 student that N-95 is required

A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is:

semen

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

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 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