Chapter 24: Asepsis and Infection Control

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 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 obtain a mask from the staff and wash my hands before touching my family member."

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.

"If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus to my child during pregnancy and childbirth." "I may transmit the virus if I share needles with another person."

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be mostappropriate?

"Stress leads to increased secretion of cortisol, which suppresses your immune response."

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?

"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

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."

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

> Airborne Precautions > Droplet Precautions > Contact Precautions

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

> Turn on the faucet and adjust force and temperature of the water. > Wet the hand and wrists. > Apply soap. > Wash the palms and backs of the hands for at least 20 seconds. > Pat the hands dry with a paper towel. > Turn the faucet off with a paper towel.

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

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A commercially packaged surgical item is not considered sterile if past expiration date.

The nurse determines that which client is at greatest risk for a wound infection?

A two-day postoperative client

A nurse instructs a new mother on immunizations. An immunization produces:

Active Immunity

An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate?

Airborne

After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter?

Alcohol-based hand rub

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:

Bacterial Infection

The client is to receive his third dose of vancomycin IV and an order for peak and trough levels is to be done. What is the correct way of doing trough level?

Blood is drawn before the third dose is administered.

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

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.

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

Clear mucus

What is the primary purpose for the demonstrated glove application?

Cover exposed wrist skin

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.

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.

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?

Early infection treatment is needed to prevent the spread of infection.

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

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact

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

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.

A client with an infection is experiencing prolonged, severe, shaking chills with a high fever. What may the nurse expect to administer to alleviate the shaking chills?

Meperidine

Contact Precautions

Methods of infection control that must be used for patients known or suspected to be infected with epidemiological microorganisms that can be transmitted by either direct or indirect contact.

Airborne Precautions

Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei.

Droplet Precautions

Must be followed for a patient known or suspected to be infected with pathogens transmitted by large-particle droplets expelled during coughing, sneezing, talking, or laughing.

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

A nurse is providing care for a client who has had gall bladder surgery. It is the first postoperative day and the client is exhibiting a fever. The nurse suspects what as the most likely cause?

Physiologic stress

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

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

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate?

The client will state how to safely take the prescribed antibiotic.

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

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:

The elderly can have an infection without a fever

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.

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.

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

Use a sterile cotton-tipped applicator to apply the prescription to the site

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

Surgical asepsis is defined as:

absence of all microorganisms.

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

The process of phagocytosis involves:

digestion of microbes by white blood cells.

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

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

The nurse is assisting a colleague with wound care. The colleague has established the sterile field and is pouring out normal saline into a sterile container, as seen in the picture above. What is the nurse's best action while observing the colleague perform the task?

observe the colleague and take no further action

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

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