EXAM 2 - CH 24 - ASEPSIS

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? delivering a meal tray to a VRE-positive client without first donning gloves and a gown sending a VRE-positive client to the radiology department for a chest X-ray without a face mask 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. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing

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. Direct client contact between a VRE-positive client and another client without handwashing carries a significant risk of infection, especially when contact includes body fluids. Handwashing is necessary before a procedure such as staple removal, but foregoing this infection control measure is less likely to spread VRE unless the nurse failed to handwash after the procedure. VRE does not normally require droplet or airborne precautions. Delivering an item to a client without gloves or a gown is less of a risk than failing to wash the hands after such contact. Reference:

A nurse is educating adolescents on how to prevent infections. The nurse determines which statement(s) by participants indicates more education is needed? "I do not need a flu shot because I am not considered a high-risk client" "Everyone coughs and sneezes during allergy season so it is better to be safe and take precautions." "I need to wash my hands before and after going to the bathroom, so I will not contaminate my food." "It is okay to share glasses and eating utensils with my family and friends because they are all pretty healthy."

"It is okay to share glasses and eating utensils with my family and friends because they are all pretty healthy."

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? "I will always wash my hands thoroughly and often." "It is important to refrain from recapping needles." "Wearing an N95 respirator is critical when I care for clients in droplet precautions." "Masks, gloves, and gowns should be used to protect from infectious agents."

"Wearing an N95 respirator is critical when I care for clients in droplet precautions." N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.

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

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.

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

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.

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. The nurse performs hand hygiene after touching the client's surroundings. The nurse performs hand hygiene before putting on gloves. The nurse applies nonmedicated hand cream after performing hand hygiene.

The nurse removes her gown and then removes her gloves. Gloves should be removed prior to a gown. Hand hygiene is necessary before applying gloves and after touching a client's surroundings. The use of moisturizers is acceptable.

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

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

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

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.

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

airborne

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? contact droplet airborne none

airborne

Which clients are at a heightened risk for infection? Select all that apply. client with gastric tube feeding client with an indwelling catheter client with hypertension client with an IV catheter client with hypothermia

client with gastric tube feeding client with an indwelling catheter client with an IV catheter

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin? airborne droplet contact none

contact

The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin? contact droplet airborne none

contact

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile? gown and gloves goggles and gloves mask and shoe covers respirator mask and gown

gown and gloves A client with Clostridium difficile requires contact isolation. Gown and gloves are the most appropriate options for this client; more so than goggles and gloves, respirator masks and gowns, and masks and shoe covers.

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? putting on gloves signs of healing sterile technique hand washing

hand washing Hand washing technique is the single most important procedure in reducing the spread of microorganisms from either the client to the surroundings or the surroundings to the client. A client does not need to learn a sterile technique for the abdominal incision. Most client procedures are related to clean handing and do not need gloves to be added to a dressing change. The nurse should review signs of infection and healing of the abdominal incision.

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? make contact between two contaminated surfaces remove the garments that are most contaminated make contact between two clean surfaces handwashing before leaving the client's room

handwashing before leaving the client's room The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath.

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?

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 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? wear a mask and gown in the client's room avoid direct contact with the client wear gloves when touching the client perform hand hygiene before and after entering the client's room

perform hand hygiene before and after entering the client's room

A client has a systemic infection that resulted from an untreated urinary tract infection. The client has malaise and is confused. The client is: toxic. septic. lethargic. contagious.

septic. Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.

What is the most common client site for development of healthcare-associated infections (HAI)? Urinary tract Bloodstream Surgical wound Respiratory tract

Urinary tract The urinary tract is the most common site for healthcare-associated infections (HAI).

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism? Direct contact Vehicle Airborne Droplet

Vehicle Vehicle transmission involves the transfer of microorganisms by way of vehicles or contaminated items that transmit pathogens; for example, food can carry Salmonella. Direct contact transmission involves body surface-to-body surface contact causing the physical transfer of organisms between an infected or colonized person and an infected host. Droplet transmission occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. Airborne transmission occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens.

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

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.

The client states his family has recently been exposed to a communicable disease. Despite all the family needing medical intervention for the illness, the client never developed the illness. The nurse explains: "Sometimes we develop immunity without showing signs of disease." "You were probably so busy caring for your family, you didn't notice it." "Maybe you had the disease a long time ago and you don't remember." "You will likely develop the disease soon."

"Sometimes we develop immunity without showing signs of disease."

The nurse is providing education to a senior circle group during an active flu season about the differences between viruses and bacteria. What statements made by the attendees indicates that the education has been effective? Select all that apply. "I can take an antibiotic to eradicate a viral infection ". "Viruses are not as harmful as bacteria." "The virus enters the host cell's metabolism and replicates itself" "There are some Immunizations that are available for select viruses. "There are some viruses that may be associated with cancers."

"There are some Immunizations that are available for select viruses. "There are some viruses that may be associated with cancers." "The virus enters the host cell's metabolism and replicates itself" A virus invades a living cell many times its size, uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup. Viruses cause AIDS, chickenpox, colds, cold sores, encephalitis, hepatitis, herpes, HPV, influenza, measles, mononucleosis, mumps, polio, rabies, shingles, pneumonia, and many other diseases. They have been associated with some cancers and leukemias and with many autoimmune diseases. Viruses may be just as harmful as bacteria since there is not an effective treatment for a virus.

The nurse determines that which client is at greatest risk for a wound infection? A two-day postoperative client A client with a urinary catheter An older adult client with dry skin An infant with intact skin

A two-day postoperative client The client at greatest risk for a wound infection is the two-day postoperative client, as the surgery disrupted the integrity of the skin, thereby increasing the risk for wound infection. Although older adult clients are at greater risk for infection, this client's skin is dry (versus having an open or surgical wound); thus, this client is at less risk than the postoperative client. An infant with intact skin is not at risk for a wound infection. A client with a urinary catheter is at risk for a urinary tract infection versus a wound infection.

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

"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 preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation? "Do not touch this, or I will have to start over. " "I have set up this sterile field for your procedure, so please do not touch anything around the tray." "Everything is ready, I will leave the tray here for the provider." "It is alright if you want to look at the supplies. Just be careful not to touch them."

"I have set up this sterile field for your procedure, so please do not touch anything around the tray." If the client touches the sterile field, the nurse will need to discard the supplies and prepare a new sterile field. When any portion of the sterile field becomes contaminated, all portions of the sterile field must be discarded. The nurse should call for help if a supply is needed. The nurse should not leave the sterile field unobserved.

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 can't transmit the virus other people if I shake their hands." "I probably got the virus when I sat on the toilet seat in a dirty bathroom." "I received a blood transfusion in 1989, which could be a factor in contracting the disease." "I may have gotten the virus when I got a tattoo while I was in prison."

"I probably got the virus when I sat on the toilet seat in a dirty bathroom." There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992. The virus cannot be contracted or spread through a toilet seat.

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

"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.

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? "Drug resistance can develop when the wrong antibiotic is used for pneumonia." "Pneumonia is usually caused by multiple organisms." "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." "This antibiotic is the best choice since the causative organism is not known."

"This antibiotic is the best choice since the causative organism is not known." Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness. The side effects of all antibiotics are similar. The antibiotic can cause resistance when used excessively in the absence of infection. Pneumonia may or may not be caused by multiple organisms; however, this isn't the best answer regarding the medication.

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,

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

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? When a sterile item touches something that is not sterile, it may not be contaminated. Sterility may not be preserved even when one sterile item touches another sterile item. A commercially packaged surgical item is not considered sterile if past expiration date. Any partially uncovered sterile package need not be considered contaminated.

A commercially packaged surgical item is not considered sterile if past expiration date. When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

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

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.

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? Remove the gown before removing gloves. Avoid touching the outer surfaces of the gown. Remove the gown immediately after exiting the room. Perform hand hygiene before removing the gown.

Avoid touching the outer surfaces of the gown. When removing a gown, it is important to touch only the inside of the gown. The gown should be removed inside the room and after removing gloves. Hand hygiene should be performed after removal.

A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control? Airborne precautions Contact precautions Droplet precautions Protective isolation

Contact precautions Contact precautions are used with organisms that can be transmitted by hand- or skin-to-skin contact (e.g., during client care activities or when touching the client's environmental surfaces or care items) such as with a client with impetigo. Airborne precautions are used to protect against microorganisms transmitted by small-particle droplets that can remain suspended and become widely dispersed by air currents, such as tuberculosis or measles. Droplet precautions are used for microorganisms transmitted by larger-particle droplets which disperse into air currents, such as H. influenzae or M. pneumoniae. Protective isolation is used to prevent infection for people whose body defenses are known to be compromised, such as those who are neutropenic secondary to chemotherapy.

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

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. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.

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

Escherichia coli in the intestinal tract Escherichia coli residing in the intestinal tract is typical normal flora. Escherichia coli in the urinary tract is indicative of a urinary tract infection. Shigella germs are a common cause of severe diarrhea and are contagious. Shigella in the urinary tract is indicative of a urinary tract infection.

A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take? Have all clients in the waiting room don face masks. Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes. Ask the child to stay at least 2 feet (0.6 meters) away from all other clients. Ask the parent to take the child home.

Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes. The nurse should educate clients and visitors to health care facilities to cover the mouth/nose with a tissue when coughing; to promptly dispose of used tissues; to use surgical masks on the coughing person when tolerated and appropriate; to use hand hygiene after contact with respiratory secretions; and to use spatial separation, ideally greater than 3 feet (1 meter), between people with respiratory infections in common waiting areas when possible. Having all clients in the waiting room don face masks would be inconvenient and unnecessary. Asking the parent to take the child home would be inappropriate.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique? Hold sterile objects above waist level to prevent inadvertent contamination. Consider the outside of the sterile package to be sterile. Open sterile packages so that the first edge of the wrapper is directed toward the nurse. Consider the outer 3-in. (8-cm) edge of a sterile field to be contaminated.

Hold sterile objects above waist level to prevent inadvertent contamination. Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 in. (2.5 cm) of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse.

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing? In the client's trash container In the sharps container With the double-bag technique In a bag marked "biohazards"

In a bag marked "biohazards" The nurse should dispose of a bloody dressing in a bag marked biohazards. In fact, all trash that contains liquid or semiliquid blood or potentially infective material should be disposed of in a bag marked "biohazards." A double-bagged technique should be used if the outside bag is tearing. Sharps containers are necessary for the disposal of used needles and syringes with medications. A client's trash container should be used for nonmedical trash such as cups, disposable utensils, and food wrappers.

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? Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. Keep hands lower than elbows to allow water to flow toward fingertips. Use an alcohol-based hand rub to decontaminate the hands. Remove all jewelry, including wedding bands, before hand washing.

Keep hands lower than elbows to allow water to flow toward fingertips. Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms.

The nurse is caring for an older adult client in a long-term care facility who has been previously alert and oriented. The client has become agitated and disoriented to time and place. The client is afebrile. What action by the nurse may assist with the determination of a causative factor in the client's condition? Obtain a blood pressure reading, because the client may be hypertensive Obtain a psychiatric consultation, because the client may be psychotic Give the client a meal, because the client may be hungry Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection

Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection Many older clients do not mount a febrile response to infection, and increasing agitation or confusion in response to infection may be dismissed as normal signs of aging. It is likely the client may have developed a urinary tract infection, which is a common cause of change in mental status in older adults. Hypertension generally does not cause a change in orientation or agitation, and the client with hypertension may not display any symptoms at all. Psychosis or delirium does not usually develop for no reason in a client who has been previously alert and oriented. Hunger does not result in behavior that is disoriented or agitated.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? Perform hand hygiene Wrap all used materials together and discard in biohazard container Don a new pair of gloves to dispose of materials Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

Perform hand hygiene Inverting the gloves into each other encloses the soiled surface and blocks a potential exit route for microorganisms. After removing gloves, the next step would be to perform hand hygiene which should be conducted before touching the loved one. Used materials are not always disposed of in biohazard containers. Donning new gloves should not be necessary as materials should have already been disposed of prior to removing the gloves. Lotions that work in conjunction with soaps and lotions should be used when applying lotion after performing hand hygiene but this is not the next step.

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

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.

Which intervention would the nurse implement to prevent infections in a client who is neutropenic as a result of chemotherapy and radiation therapy? Droplet precautions Contact precautions Airborne precautions Protective isolation precautions

Protective isolation precautions Protective isolation may be used in high-risk situations to prevent infection for people whose body defenses are known to be compromised. Clients who are neutropenic as a result of chemotherapy, radiation therapy, or immunosuppressive medications are prime candidates. Airborne precautions are used to protect against microorganisms transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents. Contact precautions are used with organisms that can be transmitted by hand or skin-to-skin contact, such as during client care activities or when touching the client's environmental surfaces or care items. Droplet precautions are used for microorganisms transmitted by larger particle droplets, which disperse into air currents.

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? Clostridium difficile and diabetic ketoacidosis Tuberculosis and pneumonia Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together. C. difficile requires contact isolation and is contagious. Diabetic ketoacidosis is considered a medical diagnosis and requires standard precautions. A surgical incision from an appendectomy is considered clean. A draining leg ulcer can transmit an infection to a client with a clean surgical incision. In both of these cases, rooming these clients together violates infection control standards. Tuberculosis requires airborne precautions and pneumonia requires standard precautions. Based on the mode of transmission of tuberculosis, these clients cannot room together.

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse? Leave PPE in the room. Stop and obtain appropriate PPE. Ask a colleague to perform the task. Complete the task, then obtain PPE.

Stop and obtain appropriate PPE. The nurse should stop the task and obtain the appropriate protective wear. Protective equipment should be left outside of the room so that it can be donned prior to entering. Completing the task without the appropriate equipment can contaminate the nurse, which can lead to cross-contamination on the unit. Asking a colleague to finish the task is inappropriate.

The student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains: Cortisol decreases the level of serum glucose, leading to infection. Stress causes the body to release cortisol, which can increase the risk of infection. Stress causes the body to increase insulin production and the resulting hypoglycemia predisposes the patient to infection. Stress is not considered a risk for infection.

Stress causes the body to release cortisol, which can increase the risk of infection. Physical or emotional stress causes the body to release cortisol, which can increase the risk of infection by suppressing the immune response. Cortisol increases the level of serum glucose, providing a good medium for bacterial growth

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 normal flora proliferated because of a nutritional deficit The client's immune system became further weakened The client's normal flora began producing spores The resident microorganisms mutated and became virulent

The client's immune system became further weakened Unless the supporting host becomes weakened, normal flora remains controlled. If the host's defenses are weakened, as in cases of HIV/AIDS, even benign microorganisms can cause opportunistic infections. This phenomenon is not due to mutations, spore production or the direct effects of a nutritional deficit.

A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply. The nurse opens a window and dusts the room in the direction of the window. The nurse places soiled bed linen on the floor. The nurse carries soiled items away from the body. The nurse cleans least soiled areas first and then moves to more soiled ones. The nurse moves soiled equipment away from the body when cleaning it. The nurse pours discarded liquids into a basin then pours them into the drain.

The nurse carries soiled items away from the body. The nurse moves soiled equipment away from the body when cleaning it. The nurse cleans least soiled areas first and then moves to more soiled ones.

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 uses gloves in place of hand hygiene. The nurse refrains from using hand moisturizer following hand hygiene. The nurse keeps fingernails less than 1/4 in (0.63 cm) long. The nurse uses hand hygiene instead of gloves when in contact with blood.

The nurse keeps fingernails less than 1/4 in (0.63 cm) long. The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood. The nurse could use a hospital sanctioned hand moisturizer after hand hygiene, but this is not the best answer.

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

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.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection? The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C) The client reports nausea and vomiting. The nurse notes the client's urine is dark yellow with sediment. Urine culture is positive for vancomycin-resistant enterococci (VRE).

Urine culture is positive for vancomycin-resistant enterococci (VRE). Infections result from pathogens that produce illness after invading body tissues and organs. The client with the indwelling urethral catheter is at risk for developing an infection. The finding that would most likely indicate an infection would be a positive result. Nausea and vomiting, a fever, and dark yellow urine with sediment are possible signs of an infection, but each of these findings alone does not confirm an infection.

The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. Which precautions should the nurse take? Use a mask when within 3 ft (1 m) of the client Ensure all visitors wash their hands upon entering the room Implement full isolation protocol while client is contagious Use a gown when within 3 ft (1 m) of the client

Use a mask when within 3 ft (1 m) of the client

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client? Keep visitors 3 feet (1 m) from the client. Wear gloves whenever entering the client's room. Place the client in a private room that has monitored negative air pressure. Use respiratory protection when entering the room.

Wear gloves whenever entering the client's room. Contact precautions are used for clients who are infected or colonized by a microorganism that spreads by direct or indirect contact, such as MRSA, vancomycin-resistant enterococci (VRE), or vancomycin-intermediate Staphylococcus aureus (VISA). Gloves should be worn when entering the client's room. Use of negative air pressure and respiratory protection are appropriate with airborne precautions. Keeping visitors 3 ft (1 m) away from the client is a droplet precaution. Reference:

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? Ensure that hard surfaces in the room are disinfected at least once per day. Place client in a private room that has monitored negative air pressure. Use a private room with the door closed at all times. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. The nurse should wear PPE upon entry into the room for all interactions that may involve contact with the client. The nurse should use a private room, if available, and the door may remain open. Placing a client in a private room that has monitored negative air pressure is appropriate for airborne infections. Frequent disinfecting is not indicated.

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. Use standard precautions only for clients with infection. Wear personal protective equipment (PPE). Practice hand hygiene. Use equipment repeatedly on clients with similar conditions. Keep client's environment clean.

Wear personal protective equipment (PPE). Practice hand hygiene. 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.

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

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 educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense? early intervention with antibiotics the cell-mediated immune response staying home when sick low levels of flora intact skin and mucous membranes

intact skin and mucous membranes The first line of defense against infection is intact skin and mucous membranes covering body cavities.

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

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.

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition? infectious disease communicable disease contagious disease noncommunicable disease

noncommunicable disease A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe food poisoning.

The nurse is preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply. prepare the transport stretcher with a clean sheet communicate about precautions with the health care team cover the client with a sheet during transport refuse to transport the client place a mask on the client

place a mask on the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

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? wear gloves and a gown when transporting the specimen place the specimens into plastic biohazard bags swab the outside of each specimen container with alcohol prior to transport place each of the three sealed specimens in a separate paper bag

place the specimens into plastic biohazard bags Specimens should be placed in sealed plastic bags to prevent them from becoming contaminated or causing the transmission of infective microorganisms. Paper bags are not used for this purpose, and it is not customary to swab the outsides of specimen containers. Standard precautions should be implemented, but this does not necessitate the use of a gown in all cases.

An infection or the products of infection carried throughout the body by the blood is called: viral illness. contamination. infectious disease. septicemia.

septicemia. Transport of an infection or the products of infection throughout the body by the blood is known as septicemia. Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement? having any visitor with a cough or cold wear a mask staff education on utilizing hand hygiene restricting visitors to those older than 12 years of age providing alcohol-based hand sanitizer to all clients

staff education on utilizing hand hygiene

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? the client who is 48-hours postsurgical procedure the client placed in contact isolation who was admitted with a draining abdominal wound the client admitted with a rash who reports recent exposure to measles the client admitted with diarrhea who tested positive for Escherichia coli (E. coli)

the client who is 48-hours postsurgical procedure Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. 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 infection first. Among these clients, the nurse should begin with the client who is postoperative, then see the other clients who have symptoms of infections.