Chapter 24 Asepsis and infection control

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an): A. bacteria. B. virus. C. fungi. D. protozoa.

A. Bacteria Bacteria may be transmitted through air, food, water, soil, vectors, or sexual activity.

Personal Protective equipment (PPE) is used in health care facilities for primarily which reason? A. To protect both the staff and clients from becoming infected by one another B. To protect clients from becoming infected by staff members C. To protect staff members from becoming infected by clients D. To protect the hospital from legal liability

A. To protect both the staff and clients from becoming infected by one another.

Surgical Asepsis is defined as: A. absence of all virulent microorganisms. B. absence of all microorganisms. C. slowed growth of microorganisms. D. use of hand washing, gowning, and gloving.

B. Absence of all microorganisms Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

To eliminate needlesticks as potential hazards to nurses, the nurse should: A. place the uncapped needle on a tray and carry it to the medicine room for disposal. B. immediately deposit uncapped needles into a puncture-proof plastic container. C. stick the uncapped needle into a Styrofoam block and deposit it in a plastic container. D. slide the needle into the cap and deposit it in a puncture-proof plastic container.

B. immediately deposit uncapped needles into a puncture-proof plastic container. All uncapped needles should be placed in a puncture-proof plastic unit immediately after use.

A new nurse is caring for a client who has a prescription for a stool specimen analysis. As the nurse performs the procedure in the image, the charge nurse walks in to the client's bathroom and observes the new nurse obtaining the specimen. What is next priority action by the charge nurse? A. Reprimand the new nurse B. Ask the new nurse to leave the client's room immediately C. Instruct the new nurse to put more stool in the specimen container to send to the laboratory D. Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids

D. Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids Glove use remains the critical step for preventing transmission, and contact precautions. Standard precautions apply to blood, all body fluids, secretions, excretions except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? A. wear gloves when touching the client B. wear a mask and gown in the client's room C. avoid direct contact with the client D. perform hand hygiene before and after entering the client's room

D. Perform hand hygiene before and after entering the client's room. Hand hygiene is the most important way to prevent transmission of infection.

A nurse who created a sterile field field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? A. Place the bottle cap on the table with the edges down. B. Hold the bottle inside the edge of the sterile field. C. Hold the bottle with the label side opposite the palm of the hand. D. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

D. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? A. Escherichia coli in the intestinal tract B. Escherichia coli in the urinary tract C. Shigella in the intestinal tract D. Shigella in the urinary tract

A. Escherichia coli in the intestinal tract Escherichia coli resides in the intestinal tract, is normal flora, and does not cause harm or infection in the client. Shigellosis is an infectious disease caused by a group of bacteria called Shigella, closely related to E. coli. Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria.

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client? A. standard B. airborne C. droplet D. contact

B. Airborne Tuberculosis is transmitted via the air. Therefore, airborne precautions are required. Standard, droplet, and contact precautions will not be selected by the nurse for a client who has tuberculosis.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene? A. Washes hands for 15 seconds B. Has manicured nails that are 1-inch (2.5 cm) long

B. Has manicured nails that are 1-inch (2.5 cm) long

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. which steps in this procedure are performed correctly? select all that apply. A. The nurse removes all jewelry including a platinum wedding band. B. The nurse washes hands to one inch above the wrists. C. The nurse uses approximately two teaspoons of liquid soap. D. The nurse keeps hands higher than elbows when placing under faucet. E. The nurse uses friction motion when washing for at least 15 seconds. F. The nurse rinses thoroughly with water flowing toward fingertips.

B. The nurse washes hands to one inch above the wrists. E. The nurse uses friction motion when washing for at least 15 seconds. F. The nurse rinses thoroughly with water flowing toward fingertips.

Which is not appropriate regarding the use of gowns as PPE? A. use of paper or cloth gowns B. donning a gown when splashing C. use of one gown per person per shift D. use of a new gown each time the nurse enters the room

C. Use of one gown per person per shift A new gown should be used by the nurse each time the nurse enters the client's 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.

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.

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others? A. "All visitors who enter the room must wear N95/surgical masks." B. "Under no circumstances should you touch the client." C. "Everyone who enters the room must wear a gown and gloves." D. "No visitors are allowed in the room to decrease the spread of disease."

A. "All visitors who enter the room must wear N95/surgical masks." Tuberculosis is an airborne respiratory disease, which requires a HEPA-style respirator or N95 mask when visitors or staff enter the room of a client with known or suspected disease. Gowning and gloving do not prevent airborne transmission. Visitors are permitted and there is no firm prohibition against touching the client.

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. A. "If someone is exposed to my blood, I may transmit the virus to him or her." B. "I may transmit the virus to my child during pregnancy and childbirth." C. "I may transmit the virus if I share needles with another person." D. "If I sweat at the gym and someone touches me, he or she can contract the virus." E. "If someone uses the bathroom after I have been on the toilet, he or she can catch the virus."

A. "If someone is exposed to my blood, I may transmit the virus to him or her." B. "I may transmit the virus to my child during pregnancy and childbirth." C. "I may transmit the virus if I share needles with another person." The client has demonstrated that an understanding of the transmission of the virus may occur through exposure to blood, during pregnancy and childbirth, and through sharing of needles. Transmission of the virus does not occur through sweat or by exposure on a toilet seat. The virus is fragile and does not live on inanimate objects.

A client is admitted for fever, crackles in the lungs, and cough asks the nurse, "if they do not know what type of bacteria caused my pneumonia, why are they giving me the antibiotics?". What is the appropriate response by the nurse? A. "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." B. "You cannot be admitted to the hospital with pneumonia without receiving some sort of antibiotics." C. "We give antibiotics to treat the virus that are causing your the pneumonia." D. "The antibiotics we are giving you will boost your immune system and help fight off whatever pathogen is present."

A. "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." Many bacteria are susceptible to broad-spectrum antibiotics and prior to the diagnosis of a specific bacteria, a broad-spectrum antibiotic will be prescribed to help eradicate the present bacteria until a culture result is returned. A client may be admitted to the hospital with pneumonia without receiving antibiotics, although it is likely that an antibiotic will be given at some point during hospitalization. Antibiotics do not boost the immune system and may destroy normal healthy flora. Antibiotics are used to treat bacterial infections, not viral infections; antibiotics do not kill viruses.

The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "when will these airborne precautions be removed?" what is the appropriate nursing response? A. "When your sputum culture is negative." B. "Until you leave the hospital." C. "For 2 days as you get settled onto the unit." D. "only until you begin to feel better."

A. "When your sputum culture is negative." The client will be on airborne precautions until a sputum culture is negative. The other answers are incorrect.

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. A. A patient diagnosed with rubella. B. A patient diagnosed with diptheria. C. A patient diagnosed with varicella. D. A patient diagnosed with tuberculosis. E. A patient diagnosed with MRSA. F. An infant diagnosed with adenovirus infection.

A. A patient diagnosed with rubella. B. A patient diagnosed with diptheria. F. An infant diagnosed with adenovirus infection.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? A. an 80-year-old woman B. a 2-year-old toddler C. a 12-year-old girl D. an 18-month-old infant

A. An 80-year-old woman Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerable to infection, so the 80-year-old woman is the client most at risk for infection. A neonate is defined as a child less than 4 weeks of age. An adolescent is a child aged 9 to 12 years. A toddler is a child who is 12 to 36 months or 1 to 3 years of age.

Which client presents the most significant risk factors for the development of Clostridium difficile infection? A. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis B. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior C. A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft D. A client with renal failure who receives hemodialysis three times weekly

A. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Two common factors that increase a persons risk of becoming infected with C difficile are age greater than 65 and current or recent use of antibiotics. In this scenario, old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? A. Avoid contact with mosquitoes B. Use hand sanitizer after touching any public surface C. Self-quarantine yourself for 2 weeks if you feel ill D. Use a face mask when in crowds

A. Avoid contact with mosquitoes Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate.

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown? A. Before entering the client's room B. After entering the client's room C. Before taking the client's pulse D. After taking the client's pulse

A. Before entering the client's room pg: 612 The nurse should don the gown before entering the client's room to prevent soiling/contamination of the nurse's clothing with infectious bacteria/viruses and/or the client's blood and body fluids. The donning of the gown should be performed prior to assessing the client or performing a full set of vital signs (e.g., pulse, respirations).

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection? A. Create an area for sterile field and opening packages B. Place water-soluble lubricant on catheter tip prior to insertion C. Wash the perineal area with soap and water D. Ensure opening port of the catheter is closed

A. Create an area for sterile field and opening packages. Pathogens require a portal of entry to cause infection. Insertion of an indwelling urinary catheter is a sterile technique; any contamination could cause a portal of entry. Using water-soluble lubricant on catheter tip prior to insertion is correct but will not prevent an infection nor will closing the opening port. Likewise, washing the perineal area with soap and water will reduce microorganisms but will not prevent infection alone.

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? A. Discard the sterile field and the supplies and start over. B. Call for help and ask for new supplies. C. Proceed with the procedure since it was only touched by the client. D. Change the sterile field, but reuse the sterile equipment.

A. Discard the sterile field and the supplies and start over. The nurse's next appropriate action would be to discard the sterile field and the supplies and start over. The client touching the end of the sterile field contaminated the field and the items on the field. The nurse cannot reuse the sterile equipment because the items are no longer sterile. The nurse cannot proceed with the procedure since the items have been contaminated. Calling for help and asking for new supplies is not the best answer. The field has been contaminated also.

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? A. fold soiled side to the inside and roll with inner surface exposed B. fold soiled side to the outside and roll with outer surface exposed C. fold soiled side to the inside and roll with outer surface exposed D. fold soiled side to the outside and roll with inner surface exposed

A. Fold soiled side to the inside and roll with inner surface exposed. To dispose of the gown, the nurse will fold the soiled side to the inside and roll with the inner surface exposed. The other answers are incorrect.

Which piece of personal protective equipment (PPE) should be removed first? A. Gloves B. Respirator C. Gown D. Goggles

A. Gloves The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.

The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection? A. Hand hygiene B. Good nutrition and getting enough rest C. Avoid crowded areas and people who have the flu D. How to properly wear a mask during flu season

A. Hand hygiene Hand hygiene is the most effective way to control the spread of microorganisms. While it is true that the client may be less susceptible to illness when well rested, exposure to a pathogen can still result in influenza. Avoiding those with the flu is also appropriate; however, hand washing remains the best answer for prevention. Wearing a mask all season may or may not prevent the flu and is not the most reasonable choice.

Which nursing action is a component of medical asepsis? A. hand washing after removing gloves B. insertion of an indwelling urinary catheter C. insertion of an intravenous catheter D. drawing blood from a central line

A. Hand washing after removing gloves Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood).

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients? A. indwelling catheter B. bath blanket C. face shields D. specimen containers

A. Indwelling catheter. Infections are often transmitted to older adult clients through equipment reservoirs (e.g., indwelling urinary catheters, humidifiers, and oxygen equipment) or through incisional sites, such as those for intravenous tubing, parenteral nutrition, or tube feedings. Use of proper aseptic techniques is essential to prevent the introduction of microorganisms. Bath blankets, face shields, and specimen containers are not part of the equipment reservoir that transmits infection easily, because they are disposed of immediately after one-time use.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? A. into a private room B. with a client with pneumonia C. with a client with a myocardial infarction D. with another client with a draining wound

A. Into a private room The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection. A. Perform hand hygiene before and after entering the client's room. B. Wear a mask and gown in the client's room. C. Wear gloves when touching the client. D. Avoid direct contact with the client.

A. Perform hand hygiene before and after entering the client's room. Hand hygiene is the most important way to prevent transmission of infection.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? A. Surgical asepsis technique B. Medical asepsis technique C. Droplet precautions D. Strict reverse isolation

A. Surgical asepsis technique Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others.

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

A. The mask covers the nose and mouth. B. Replace the mask after 20-30 minutes. D. Tie the upper strings of mask snugly against back head. The nonparticulate respirator (N-95) mask should be worn by covering the mouth and nose with the strings tied snugly against the back of head and lower strings against the back of the neck. The mask should be replaced every 20-30 minutes or when visibly damp or soiled. The mask should be removed by the strings, never touching the front of the mask. The mask should be discarded in a waterproof container.

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 soap and water? Select all that apply. A. The nurse has entered the client room to adjust settings on the intravenous pump. B. The nurse has just completed documentation and is entering another client room. C. The nurse is going from one room to another to introduce self at the start of the shift.

A. The nurse has entered the client room to adjust settings on the intravenous pump. B. The nurse has just completed documentation and is entering another client room. C. The nurse is going from one room to another to introduce self at the start of the shift.

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 soap and water? Select all that apply. A. The nurse is going from one room to another to introduce self at the start of the shift. B. The nurse has entered the client room to adjust settings on the intravenous pump. C. The nurse has just completed documentation and is entering another client room. D. The nurse is exiting a room after completed indwelling urinary catheter care. E. The nurse has assisted a client with changing and caring for a new colostomy.

A. The nurse is going from one room to another to introduce self at the start of the shift. B. The nurse has entered the client room to adjust settings on the intravenous pump. C. The nurse has just completed documentation and is entering another client room. Alcohol-based handrub is preferred in situations when hands are not visibly soiled; before and after touching a client; before handling an invasive device for client care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; and after removing sterile or nonsterile gloves. Use of an alcohol-based handrub does not replace the need for gloves or for handwashing, however. After performing catheter care and assisting with changing a colostomy, gloves are worn and handwashing should take place.

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. A. The nurse is providing a bed bath for a patient. B. The nurse has visibly soiled hands after changing the bedding of a patient. C. The nurse removes gloves when patient care is completed. D. The nurse is inserting a urinary catheter for a female patient. E. The nurse is assisting with a surgical placement of a cardiac stent. F. The nurse removes old magazines from a patient's table.

A. The nurse is providing a bed bath for a patient. C. The nurse removes gloves when patient care is completed. D. The nurse is inserting a urinary catheter for a female patient. F. The nurse removes old magazines from a patient's table.

A new preoperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply. A. The nurse's back is facing the sterile field. B. The nurse keeps hands above waist level while donning sterile gloves. C. The nurse touches an unsterile object to the instrument tray. D. The nurse is talking with the scrub nurse over the sterile field. E. The nurse disposes of an opened container of sterile saline after 24 hours.

A. The nurse's back is facing the sterile field. C. The nurse touched an unsterile object to the instrument tray. D. The nurse is talking with the scrub nurse over the sterile field. Principles of surgical asepsis include never turning one's back on a sterile field. The nurse should avoid talking, coughing, or sneezing over the field and keep sterile objects above waist level. Sterile objects may only be touched by other sterile objects. Most solutions are considered sterile for 24 hours after they are opened.

The nurse is providing an in-service educational program for the interprofessional health care team about infection control precautions. What teaching will the nurse include? Select all that apply. A. Wear personal protective equipment (PPE). B. Practice hand hygiene. C. Use standard precautions only for clients with infection. D. Use equipment repeatedly on clients with similar conditions. E. Keep client's environment clean.

A. Wear personal protective equipment (PPE) B. Practice hand Hygiene. E. Keep client's environment clean Wearing PPE, practicing hand hygiene, and keeping the client's environment clean interfere with the chain of infection. Standard precautions should be used for all clients, and equipment should be cleaned, disinfected, or sterilized between uses.

In which situation is an alcohol-based rub not the appropriate option for hand hygiene? A. When the nurse's hands are visibly soiled B. When the nurse anticipates contact with the client's skin C. When the nurse leaves the room of an immunocompromised client D. When the nurse is caring for a client with an active infection

A. When the nurse's hands are visibly soiled Alcohol-based handrubs may be used if hands are not visibly soiled or have not come in contact with blood or body fluids. They should be used before and after each client contact, or when in contact with surfaces in the client's environment. Handwashing is required before eating or after using the restroom.

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative? A. diligent handwashing practices B. reduced length of stay for MRSA-positive clients C. constant use of gloves when on the unit D. prophylactic antibiotic therapy for MRSA-negative clients

A. diligent handwashing practices As with all forms of infection, thorough handwashing is the most important infection-control measure. It is inappropriate to reduce clients' length of stay based on their MRSA status, and prophylaxis is not normally used. It is unnecessary to wear gloves at all times on the unit.

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? A. removes gloves and walks out of the room B. asks the client to state name and date of birth C. applies a mask with face shield D. performs hand hygiene before donning gloves

A. removes gloves and walks out of the room The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used as barriers to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients. Asking the client to state his or her name and date of birth is important to make sure the specimen is collected with the correct laboratory label. To protect the UAP from direct contact with the urine, a face mask is indicated.

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? A. surgical asepsis B. increased T cells C. decreased antibiotics D. increased vitamin C

A. surgical asepsis Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response? A."Help me understand your thoughts about vaccinations." B. "Has your child received any previous vaccinations?" C. "Vaccinations prevent disease." D. "Transmission of certain disease is halted with Vaccination."

A."Help me understand your thoughts about vaccinations." Seeking to understand the caregiver's perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. The nurse could then collect assessment data regarding past vaccines and provide appropriate teaching.

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond? A. "It is possible that you are not washing your hands well enough." B. "As we age, our immune system does not function as well." C. "You will have to limit who comes to visit since they may be exposing you." D. "There are a lot of infectious processes around and there is nothing that can be done."

B. "As we age, our immune system does not function as well." The nurse should explain that during the aging process, the immune system decreases in function and the older adult client is at greater risk for becoming infected. Other risk factors for the older adult client include poor nutrition and fluid intake. Although washing hands is an important part of the prevention of infection, there are other methods such as airborne and droplet transmission that may be unavoidable. When it comes to visitation, the only limitation that should be set is that those who are ill or possibly infected should refrain from visiting the client. Informing the client that nothing can be done is not accurate, as there are preventative measures that may be taken to avoid exposure.

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

B. Discard the bottle and get a new one because the saline has expired. Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening. Lipping the opening of the bottle and pouring the saline into a sterile container by holding it 6 in (15 cm) above the container would be appropriate, but contents in the bottle are expired. The nurse should discard the bottle and get a new one.

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

B. During some care activities for an individual client, nurses may need to change gloves more than once. E. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. D. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. Several examples represent the proper use of personal protective equipment in a health care agency. First, during some care activities for an individual client, nurses may need to change gloves more than once. Nurses should remove PPE at the doorway or in an anteroom except, for the respirator. The nurse should remove a gown by unfastening ties, if at the neck and back, and allow the gown to fall away from the shoulders. The nurse would apply clean gloves for most care activities, not just when assisting or performing an invasive client procedure. A waterproof gown is to be used only once. Nurses cannot wear a mask around the neck when not being worn nor can it be brought back over the nose and mouth for reuse.

Which mask should the nurse don when caring for a client with tuberculosis? A. Low-efficiency particulate air (LEPA) B. Filtered respirator C. Surgical mask D. No mask is needed

B. Filtered respirator When caring for a client with tuberculosis, the nurse should don a filtered respirator mask to filter the inspired air. A surgical mask, also known as a procedure mask, is intended to be worn by health care professionals during surgery and during nursing to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose. Low-efficiency particulate air (LEPA) masks are not used in health care.

The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first? A. Put on personal protective equipment, if required. B. Perform hand hygiene. C. Check that the packaged kit is dry and unopened. D. Set up a work area at waist level.

B. Perform hand hygiene.

A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? A. Incubation period B. Prodromal stage C. Full stage of illness D. Convalescent period

B. Prodromal stage

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? A. Clostridium difficile and diabetic ketoacidosis. B. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD).

B. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD).

What action is the best example of a nurse donning/removing protective equipment properly? A. Donning gown after entering client's room B. Removing respirator after leaving client's room.

B. Removing respirator after leaving client's room.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement? A. All new residents are prescribed antibiotics. B. Review the current infection control protocols. C. Culture all residents and staff. D. Restrict visitors to public places.

B. Review the current infection control protocols. The nurse manager that notes an increase in infection rates should first review the current infection control protocols. Reviewing the protocols can identify if the protocols are appropriate and being implemented by the staff. Prescribing antibiotics to all new residents will not decrease infections rates, but may increase the rate of antibiotic resistant bacteria. Culturing all residents and staff would identify infection, but not decrease the rates. Restricting visitors would not decrease rates.

A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is considered: A. The nurse's preference. B. Safe for the home setting. C. Unethical behavior. D. Grossly negligent.

B. Safe for the home setting.

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? A. The nurse puts on PPE after entering the patient room. B. The nurse works from "clean" areas to "dirty" areas during bath. C. The nurse personalizes the care by substituting glasses for goggles. D. The nurse removes PPE prior to leaving the patient room.

B. The nurse works from "clean" areas to "dirty" areas during bath.

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the priority action of the nurse following exposure? A. Report the incident to the appropriate person and file an incident report. B. Wash the exposed area with warm water and soap. C. Consent to postexposure prophylaxis at appropriate time. D. Set up counseling sessions regarding safe practice to protect self.

B. Wash the exposed area with warm water and soap.

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? A. "I will not visit my family member in the first 3 days of my cold." B. "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." C. "I will obtain a mask from the staff and wash my hands before touching my family member." D. "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."

C. "I will obtain a mask from the staff and wash my hands before touching my family member." Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is elderly or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.

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

C. "The way you are doing it helps to minimize contamination of the non-waterproof side." The sterile drape is to be positioned with the drape on work surface with the moisture-proof side down. It is important that only a sterile object touch another sterile object. Unsterile touching results in contamination of the sterile field. If this occurs, the procedure should be started again with new supplies. It is not okay to turn the drape on the other, non-waterproof side. This action will increase the risk for contamination.

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? A. "I understand; wearing these items is not pleasant but it really isn't optional." B. "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." C. "These barriers help prevent the transmission of infection to you or other people." D. "Wearing the gloves and gown prevents sharing additional microorganisms with the client."

C. "These barriers help prevent the transmission of infection to you or other people." Contact precautions block transmission of pathogens by direct or indirect contact Wearing a gown and gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing or even to others the visitors may come in contact with. While wearing gloves and gown may prevent sharing additional microorganisms with the client, that is not the reason for contact precautions. Agreeing that wearing the gown and gloves is not pleasant doesn't educate the family member.

The nurse assesses patients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection? A. A 60-year-old patient who smokes two packs of cigarettes daily. B. A 40-year-old patient who has a white blood cell count of 6,000/mm^3. C. A 65-year-old patient who has an indwelling urinary catheter in place. D. A 60-year-old patient who is a vegetarian and slightly underweight.

C. A 65-year-old patient who has an indwelling urinary catheter in place.

For which client would the use of standard precautions alone be appropriate? A. a client with diphtheria who needs p.m. care B. a client with TB who needs medications administered C. an incontinent client in a nursing home who has diarrhea D. a child with chickenpox who is treated in the emergency room

C. An incontinent client in a nursing home who has diarrhea. Standard precautions apply to blood and all body fluids, secretions, and excretions except sweat. Transmission-based precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as is the case in answers A, B, and D.

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin? A. airborne B. droplet C. contact D. none

C. Contact Wearing PPE, practicing hand hygiene, and keeping the client's environment clean interfere with the chain of infection. Standard precautions should be used for all clients, and equipment should be cleaned, disinfected, or sterilized between uses.

What is the primary purpose for the demonstrated glove application? A. Help adjust for glove size B. Anchor gown sleeves C. Cover exposed wrist skin D. Minimize risk of a glove tear

C. Cover exposed wrists Gloves are intended to protect hands and wrists from exposure to microorganisms. This is best accomplished by extending the gloves up the arm to cover the cuffs of the gown. While the proper application of the gloves does anchor the cuffs, the primary purpose is directed at the risk management of microorganism expose to the wrists. This application has no value to adjusting for glove size or to prevent tearing of the glove.

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation. A. Ask another nurse to hold the hand of the patient and continue setting up the field. B. Remove the instrument that was touched by the patient and continue setting up the sterile field. C. Discard the supplies and prepare a new sterile field with another person holding the patient's hand. D. No action is necessary since the patient has touched his or her own sterile field.

C. Discard the supplies and prepare a new sterile field with another person holding the patient's hand.

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? A. Pour the liquid onto gauze on the sterile field until the gauze is moist. B. Pour the liquid into the cap of the bottle and dip the gauze as needed. C. Pour the liquid into a sterile container within the sterile field. D. Pour the liquid into the palm of a sterile gloved hand for use.

C. Pour the liquid into a sterile container within the sterile field. The solution container should be held outside the edge of the sterile field and poured steadily from a height of 4 to 6 inches into a sterile container previously added to the sterile field and positioned at the side of the sterile field. This assures minimal splashing, as moisture contaminates the sterile field, and maintains sterility of the bottle and solution.

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? A. Increased vitamin C B. Increased T cells C. Surgical asepsis D. Decreased antibiotics

C. Surgical Asepsis Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? A. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air. B. The nurse places soiled bed linens and hospital gowns on the floor when making the bed. C. The nurse moves the patient table away from the nurse's body when wiping it off after a meal. D. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items.

C. The nurse moves the patient table away from the nurse's body when wiping it off after a meal.

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? A. Remove gown, goggles, mask, gloves, and exit the room. B. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles. C. Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand hygiene. D. Remove goggles, mask, gloves, gown, and perform hand hygiene.

C. Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand hygiene.

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care? A. Dip the IV catheter into an antiseptic before use. B. Clean the site with a disinfectant. C. Use a sterile intravenous catheter. D. Wear a mask and gown for the procedure.

C. Use sterile intravenous catheter

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 friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor? A. "You should not visit your friend if you have an infection of any kind because your friend may also get sick." B. "If you wash your hands before coming in contact with your friend you will prevent infection during your visit." C. "As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend." D. "Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

D. "Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." Visitors with respiratory infections need to wear a mask until their symptoms have subsided. The other options do not control transmission of airborne or droplet infections. Hand hygiene is appropriate and should be encouraged but used alone it won't prevent the spread of an airborne or droplet infection.

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? A. "Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it." B. "If you do not wear gloves you will also get the infection." C. "Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." D. "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."

D. "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." Contact precautions, which are not optional, block transmission of pathogens by direct or indirect contact. Explaining that the loved-one understands is not teaching information. Educating the visitor about drug-resistant infections is important but does not explain how to prevent transmission of the infection. Telling the visitor that he or she will get the infection if the visitor does not wear gloves is incorrect, the visitor is at a greater risk of getting and spreading the infection. Wearing gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing.

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? A. Only patients with diagnosed infections. B. Only patients with visible blood, body fluids, or sweat. C. Only patients with non-intact skin. D. All patients receiving care in the hospitals.

D. All patients receiving care in the hospitals.

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: A. Keep splashes on the sterile field to a minimum. B. Cover the nose and mouth with gloved hands if a sneeze is imminent. C. Use forceps soaked in a disinfectant. D. Consider the outer 1 inch of the sterile field as contaminated.

D. Consider the outer 1 inch of the sterile field as contaminated.

The nurse is teaching a client the correct procedure for pouring a sterile solution. Which client action indicates the need for further education from the nurse? A. pouring out a small amount of the solution and discarding B. placing the cap upside down on the table C. pouring the solution slowly D. holding the container off to the side

D. Holding the container off to the side. The client should hold the bottle in front of them for the most control and to see what they are pouring. Pouring out a small amount of the solution is appropriate; this is called lipping. Holding the lid or placing it upside down prevents contamination when the lid is reapplied to the sterile solution. Splashing can contaminate the area around the client. Pouring slowly will avoid splashing.

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

D. Reaches down to the bed to pick up a sterile drape. The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully.

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. A. offer the student a mask B. do nothing, as the precautions observed are appropriate C. teach that a gown and shoe coverings must be worn in addition to gloves D. remind the student that a fitted N95 respirator is required

D. Remind the student that a fitted N95 respirator is required A fitted N95 respirator must be worn in addition to other precautions when caring for clients with pulmonary tuberculosis. The other answers do not recommend the appropriate precautions that must be used for this type of infection.

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient? A. Imbalanced Nutrition: More Than Body Requirements related to immobility. B. Impaired Physical Mobility related to pain and discomfort. C. Chronic Pain related related to immobility. D. Risk for infection related to altered skin integrity.

D. Risk for infection related to altered skin integrity.

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: A. Means of transmission B. Spore production C. Aerobic activity D. Survival adaptation

D. Survival adaptation An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae. Bacterial resistance is not demonstrated by aerobic activity. Spore production is another form of adaptation. Means of transmission is a component of the chain of infection, not an example of bacterial resistance.

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? A. The nurse places the client in a private room with the door open. B. The nurse uses droplet precautions when providing care for the client. C. The nurse keeps visitors 3 feet away from the infected person. D. The nurse places the client in a private room with monitored negative air pressure.

D. The nurse places the client in a private room with monitored negative air pressure. When a client is diagnosed with tuberculosis it is important for the nurse to remember that the client should be placed in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The nurse must wear the appropriate respirator when caring for the client, but visitors must wear masks. Simply being 3 feet away will not keep the visitor from being exposed to the client. The nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason? A. To protect clients from becoming infected by staff members. B. To protect the hospital from legal liability. C. To protect staff members from becoming infected by clients. D. To protect both the staff and clients from becoming infected by one another.

D. To protect both the staff and clients from becoming infected by one another.

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care? A. Clean the site with a disinfectant. B. Wear a mask and gown for the procedure. C. Dip the IV catheter into an antiseptic before use. D. Use a sterile intravenous catheter.

D. Use a sterile intravenous catheter. Any item entering sterile tissues or the vasculature must be sterile. Therefore, an IV catheter must be sterile. It should not be dipped in an antiseptic before use. A chemical used on lifeless objects is called a disinfectant, whereas one used on living objects is an antiseptic. The nurse would clean the IV site with an antiseptic, not a disinfectant, before insertion. An IV insertion does not require the nurse to wear a mask and gown.