Fundamentals PrepU: Chapter 24

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

"Help me understand your thoughts about vaccinations."

A client 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 these antibiotics?" What is the appropriate response by the nurse?

"We are giving you broad spectrum antibiotics because they are active for many types of bacteria."

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?

"When your sputum culture is negative."

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

Bacteria

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

Escherichia coli in the intestinal tract

A nurse 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.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective

Incentivizing health care workers to utilize hand hygiene

Personal protective equipment (PPE) is used in health care facilities to protect the staff from potentially infected clients.

True

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?

airborne precautions

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman

Which client would require a negative flow room?

an 81-year-old man with active tuberculosis and a productive cough

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room

The most common infection in children is:

respiratory.

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

Airborne

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

Discard the sterile field and the supplies and start over.

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips.

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

Place a surgical mask on the client and transport to the CT department at the specified time.

A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. Which would be the appropriate action to take to maintain a sterile field?

Stop the procedure, remove damaged gloves, perform handwashing, and put on new sterile gloves.

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

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

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?

Virus

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

When hands are visibly soiled

Surgical asepsis is defined as:

absence of all microorganisms.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?

changing the soiled dressing

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

decreased cellular immunity.

The process of phagocytosis involves:

digestion of microbes by white blood cells.

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

health care-associated infection (HAI)

A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is:

it is a vaccine given to booster antibodies towards the tetanus pathogen.

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:

stable

A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the priority nursing action the nurse must perform before leaving the client's room?

thorough handwashing

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift

A team of nurses is caring for a client with tuberculosis. They have not been fitted for N95 respirators. How will the team proceed with care?

utilize a powered air purifying respirator (PAPR)

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

"These barriers help prevent the transmission of infection to you or other people."

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

1) Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2) With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3) Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4) Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

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.

1) The nurse carries soiled items away from the body. 2) The nurse moves soiled equipment away from the body when cleaning it. 3) The nurse cleans least soiled areas first and then moves to more soiled ones

A new perioperative 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.

1) The nurse's back is facing the sterile field. 2) The nurse touches an unsterile object to the instrument tray. 3) The nurse is talking with the scrub nurse over the sterile field.

The nurse administered an antipyretic drug to a client with high-grade fever of 101.4°F (38.6°C). Which intervention should the nurse perform next?

Reassess temperature after 1 hour and document results in the chart.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

WBC of 25,000 mcL

In which situation is an alcohol-based rub not the appropriate option for hand hygiene?

When the nurse's hands are visibly soiled