Asepsis and Infection Control

The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team?

"Avoid touching the outside of your gown when removing it."

The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state:

"Everything in nature is alive with invisible forces."

The nurse is teaching a community group about transmission of HIV. Which client statement by a community member demonstrates that further teaching is needed?

"I can catch HIV by swimming in pools."

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."

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."

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."

A nurse is an oncology care unit is reviewing the laboratory test result of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection?

18,000 cells/mm

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days.

A nurse is demonstrating collegiality in professional practice. Which behaviors practiced by the nurse correlate with this standard of practice? Select all that apply.

A nurse helps a colleague write a journal article. A nurse encourages a colleague to join the hospital journal club. A nurse encourages a colleague to join the American Nurses Association (ANA)

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

The nurse is performing care for a client in the end stage of cancer. How can the nurse best facilitate the client and family's ability to cope? Select all that apply.

Assist the client with activities of daily living (ADLs). Assist the client and family with the preparation for end-of-life. Refer the client and family to hospice services.

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

Client receiving chemotherapy

What is the primary purpose for the demonstrated glove application?

Cover exposed wrist skin

Which scenario is the best example of the nurse implementing the ANA standard relating to diagnosis?

Determining a client is at risk for falls

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

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.

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

What is the second line of defense in microbial invasion?

Inflammation

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?

Inform the physician about this finding.

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.

Attracting minorities to the profession of nursing is an important consideration for the future of nursing. Which key historical figure set a precedent in this area?

Mary Elizabeth Mahoney

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

Surgical asepsis technique

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

T lymphocytes

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

T-lymphocytes

The client's plan of care is created by the nurse using which guideline for nursing practice?

Nursing process

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).

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.

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?

Place the specimens into plastic biohazard bags

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.

The nurse administered an antipyretic drug to a client with high-grade fever of 101.4°F (38.6°C). Which intervention should the nurse perform next?

Reassess temperature after 1 hour and document results in the chart.

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.

Which nursing action demonstrate the aim of nursing to facilitate coping? Select all that apply.

Teaching a client and her family how to live with diabetes Assisting a client and his family to prepare for death Providing counseling for the family of a teenager with an eating disorder

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

Which should be documented by the nurse?

The fact that sterile technique was used for a given procedure

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?

Virus

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.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

WBC of 25,000 mcL

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 a client's room. Place used syringes and uncapped needles in a puncture-resistant container after use.

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 hand rub is appropriate in which situation?

When hands are visibly soiled

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.

The older adult client received chemotherapy for cancer 2 days ago and is now admitted for intractable vomiting. The client is receiving an antiemetic and intravenous fluids at 100 ml/hr. The client has a Purewick female external catheter for urinary incontinence. What data increase the client's susceptibility for systemic infections? Select all that apply.

age of the client history of a drug that caused suppression of the immune system the intravenous catheter

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

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.

A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state?

applying for a reciprocal license in the new state

The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse dipicts concern and attachment?

asking the client, "How are you today? I am really worried about you."

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

clear mucus

The nurse is helping the unlicensed assistive personnel (UAP) bathe the client, who is experiencing a lot of pain when repositioned in bed. Which nursing responsibility is the nurse demonstrating?

client advocate

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

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 process of phagocytosis involves:

digestion of microbes by white blood cells.

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

droplet

A physician 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?

helps to determine prescribed antibiotic therapy

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.

increased respiratory rate lymph node enlargement fever

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?

noncommunicable disease

A nurse is caring for four clients. Which client has the highest risk of infection?

older male with an enlarged prostate

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 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.

Which is the best example of a nurse demonstrating the role of a caregiver?

starting an intravenous line in the client's arm

A nurse is palpating the cervical lymph nodes of a client with a suspected upper respiratory infection. Which finding would help to support the suspicion of an infection?

tenderness