Chapter 24: Asepsis and Infection control

The client's immune system became further weakened

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?

semen.

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

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

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?

Avoid touching the outer surfaces of the gown.

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?

The nurse places the client in a private room with monitored negative air pressure.

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?

Ask another staff member to bring the forgotten item.

After the nurse has set up a sterile field for a dressing change, the nurse realizes that an essential item has been forgotten. How should the nurse proceed?

airborne

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

Prevent contamination of ungloved hand

What is the primary goal of the observable action associated with the removal of contaminated gloves?

Cover exposed wrist skin

What is the primary purpose for the demonstrated glove application? (pulling gloves over the wrist of yellow gown)

A client who is in the prodromal stage

Which client would the nurse consider the most infectious?

indwelling catheter

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?

"Help me understand your thoughts about vaccinations."

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?

remove gloves, remove gown, wash hands

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

Apply a nonparticulate (N-95) respirator when entering the room.

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

health care-associated infection (HCAI)

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?

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

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?

noncommunicable disease

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

Hold sterile objects above waist level to prevent accidental contamination.

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?

Hand hygiene is needed after contact with objects near the client.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

Standard

An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate?

an incontinent client in a nursing home who has diarrhea

For which client would the use of standard precautions alone be appropriate?

5, 7, 2, 1, 3, 4, 6

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.

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

Personal protective equipment (PPE) is used in health care facilities for primarily which reason?

"Yes, as long as your spouse wears a mask and stays at least 3 feet (1 meter) away from you."

The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. The client asks, "Can my spouse visit me?" Which response is correct?

Grab, with gloved hand, near the wrist (NOT touching exposed skin) with gloved hand; ball glove into palm of opposite gloved hand; slide bare fingers inside of cuff on opposite hand; slide off and inside out.

The nurse has completed a client's personal care and is now removing personal protective equipment. What is the nurse's best action when removing gloves?

"The way you are doing it helps to minimize contamination of the non-waterproof side."

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) "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 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.

Discard the supplies and field and prepare a new sterile field.

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?

Gloves and gown

The nurse is preparing to help mobilize a client with an abdominal wound that is colonized by methicillin-resistant Staphylococcus aureus (MRSA). Which of the shown actions should the nurse perform before assisting the client?

1) Turn on the faucet and adjust force and temperature of the water. 2) Wet the hand and wrists. 3) Apply soap. 4) Wash the palms and backs of the hands for at least 20 seconds. 5) Pat the hands dry with a paper towel. 6) Turn the faucet off with a paper towel.

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

perform meticulous hand hygiene and don a new mask with each client encounter

The nurse is recovering from a very mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action?

Discard the sterile field and the supplies and start over.

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?

The new nurse touches 1.5 in. (4 cm) from the outer edges.

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?

staff education on utilizing hand hygiene

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?

removes gloves and walks out of the room

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?

Surgical asepsis

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

"The glove is an important barrier in preventing the transmission of infection."

The nurse reminds the partner of a client with an antibiotic-resistant infection that gloves are necessary. When the partner states, "I need to directly hold my loved one's hand without a barrier," what is the appropriate nursing response?

1) Pain 2) Redness 3) Swelling 4) Exudate

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply.

stethoscope that remains in the client's room

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart?

Gown and mask

The nurse will be entering the room of a client with pneumonia to provide personal care. What action should the nurse perform while applying personal protective equipment (PPE) for this situation?

Mask and gown

The nurse will be entering the room of a client with pneumonia to provide personal care. What action should the nurse perform while applying personal protective equipment (PPE) for this situation?

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:

immediately deposit uncapped needles into a puncture-proof plastic container.

To eliminate needlesticks as potential hazards to nurses, the nurse should:

Escherichia coli in the intestinal tract

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Replace gloves if they are visibly soiled.

What is an accurate guideline for the use of PPE?

Cleanse and disinfect the sphygmomanometer.

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?

Filtered respirator

Which mask should the nurse don when caring for a client with tuberculosis?

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.

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

handwashing after removing gloves

Which nursing action is a component of medical asepsis?

gown and gloves

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

Gloves

Which piece of personal protective equipment (PPE) should be removed first?

A nurse performs hand washing each time the nurse removes a pair of gloves.

Which practice is a correct application of infection control practices?