Chapter 24 Asepsis and infection control

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

Client with urinary catheter This is because catheter-associated urinary tract infections are the most common type of hospital-acquired infections, accounting for more than 30% of HAIs in acute care hospitals

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concepts should be the priority in the teaching plan?

Hand washing

The nurse is caring for assigned client 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 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 infections first.

Gram-negative organisms are the most common cause of:

Urinary infections The most common cause of UTIs are gram-negative organisms.

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

A 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 client on droplet precautions should only leave the room when necessary and wear a mask.

The nurse is suspecting that a client has an infected surgical wound should assess for which sign? Pain Redness Swelling Exudate

All of the above Cardinal signs of infection include redness (heat), swelling, pain, and loss of function. As leukocytrd snd neutrophils enter the area, exudate make uo of fluid, cells, and inflammatory by products may be released by the wound.

Which nursing action carried the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE-positive client without first donning gloves and a gown.

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply. Absence of pain Increased respiratory rate Fever Lymph node enlargement

Increased respiratory rate, fever, and lymph node enlargement. Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, and lymph node enlargement.

What are the stages of infection in the sequence in which they will occur?

Incubation period Proximal stage Full stage of illness Convalescent period

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

Inserting an arm working each sleeve while touching the outer surface of the gown. To maintain sterile technique while donning the sterile gown, the gown should be picked up at the sterile neckline to preserve the sterility of the outer gown surface.

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. Localized heat Pain with redness and swelling Purulent or malodorous drainage Scabs forming over the ulcer

Localized heat Pain with redness and swelling Purulent or malodorous drainage If the inside edges of the ulcer appear to be drawing together and/or if scabs are forming over the ulcer, the ulcer is likely to be healing

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 in the chart. Which results support the concern?

WBC of 25,000 mcl Leukocytes, also called white blood cells, and the inflammatory response make up the second line of defense to microbial invasion. A normal WBC count is 5,000 to 10009 cells/mm3

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 As a person ages there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to infection

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

semen Vehicle transmission involves the transfer of microorganisms by way of vehicles, or contaminated items that transmit pathogens.