INFECTION & HYGIENE

mucus

Boogers

Which type of immunity will clients acquire through immunization with live or killed vaccines? Natural active immunity (when there is a natural contact with antigens through a clinical infection) Artificial active immunity (immunization with live or killed vaccines) Natural passive immunity (transfer of colostrum from mother to child) Artificial passive immunity (injecting serum from an immune human)

Artificial active immunity

Chain of Infection - Transmission

From one person to another - By contact - Airborne - by air - Droplet - cough

passive immunity

From one person to another Example: Mother to Baby

oral cavity

Gingivitis- Inflammation of gums Halitosis - bad breath

Cilia

Hair lining nasal passage, help move trapped particles to throat

alopecia

Hair loss

sebaceous glands

In dermis, oily substance that keep skin and hair soft

Chain of Infection - Portal of Exit

Leaving the body by coughing, urine, stool, drainage

Hand hygiene practices are ________ for health care workers. Mandatory

Mandatory

mucous membrane

Open area in body

The nurse manager appointed a RN to provide hospice care for a client and explained the tasks for be performed. Which tasks has the nurse manager delegated to the RN? Providing total client care Performing all the hygiene tasks Teaching the client and family members Teaching the client about personal hygiene Assisting the client in performing daily activities

Providing total client care Teaching the client and family members Teaching the client about personal hygiene

The nurse if caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient a. private room b. private, neg airflow room c. mask worn by the staff when entering the room d. mask worn by the staff and the patient when leaving the patient's room

a

Which statement made by the client indicates understanding after teaching about measures to decrease the risk for antibiotic-resistance infection? Select all that apply "I should wash my hands frequently" "I should skip doses when I am completely well" "I should avoid taking antibiotics to treat common cold" "I should save unfinished antibiotics for later emergency use" "I should avoid taking antibiotics without asking the primary health care provider"

"I should wash my hands frequently" "I should avoid taking antibiotics to treat common cold" "I should avoid taking antibiotics without asking the primary health care provider"

Which statement made by the nurse will be most significant when teaching strategies to reduce the risk for developing antibiotic-resistance infection? "Wash your hands frequently with warm soapy water" "Do not skip any prescribed doses of your antibiotics" "Do not save unfinished antibiotics for later use" "Do not stop taking the antibiotics when you feel better"

"Wash your hands frequently with warm soapy water"

Droplet precautions

- MASK & GOOGLES - single room

Airborne precautions

- N95 MASK, GLOVES, EYE SHIELD, GOWN - negative pressure room

Nursing Interventions to reduce risk of infection

- follow hand hygiene - never recap used needles - patient education - using PPE

The recommended duration for lathering hands is at least ________ seconds.

15 seconds

Lines of defense

1st Defense - Normal Flora (live in or on body, skin is entry) 2nd Defense - Inflammation (WBC fighting infection, WBC count: 5 - 1000) 3rd Defense - Immune Response (comes inside body)

A patient has a diagnosis of Clostridium difficile. What is most important for the nurse to convey to the NAP regarding this patient's care? A. To wash hands with soap and water before and after caring for patients with C. difficile. B. To use an alcohol-based hand rub after removing gloves. C. To wear an N95 mask when in the patient's room. D. To avoid caring for other patients with C. difficile to prevent cross contamination.

A

One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is cause for concern? A. Temperature of 102.5° F (39.2° C). B. Incisional area light pink in color. C. White blood cell count at 6500 per mm3. D. Absence of purulent drainage.

A

The nurse is caring for four individuals. Which patient would be most at risk for infection? A. The patient who is receiving immunosuppressive medication. B. The patient who is unable to shower without assistance. C. The patient with a history of a latex allergy. D. The patient who exercises daily in a swimming pool.

A

The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: A. Surgical asepsis (sterile technique). B. Medical asepsis (clean technique). C. Droplet precautions. D. Standard precautions.

A

The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? A. Following standard precautions. B. Using medical asepsis. C. Using surgical asepsis. D. Infection control to prevent a health care-acquired infection.

A

Under which circumstance(s) should hand washing be repeated? (Select all that apply.) A. Hands touch the sink during hand washing. B. Areas under fingernails remain soiled. C. Cracked areas are noted on the nurse's hands. D. Hands are free of visible soiling. E. Hands are lowered below waist level.

A B

When are sterile gloves necessary? A. When performing a sterile procedure. B. If blood or body fluids are present. C. If the patient is placed on isolation. D. When performing postmortem care.

A

Why are the hands rinsed with the fingertips held lower than the wrist? A. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. B. To keep the sleeves from getting wet. C. It is necessary to ensure that all surfaces of the hands, including under the nails, are cleansed. D. To loosen and remove dirt and bacteria.

A

The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) A. Standard precautions are used to protect you from potential contact with blood and body fluids. B. Standard precautions should be observed in every patient encounter. Correct C. Standard precautions refer only to the use of gloves, not to the use of masks, eye protection, or gowns; these refer to other types of precautions. D. To follow standard precautions, you must wear sterile gloves. E. Standard precautions are used once the type of infection is identified.

A B

The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? (Select all that apply.) A. Some of the sterile normal saline spills onto the sterile barrier. B. Nonsterile items are added to the sterile field. C. The nurse prepares the sterile field and leaves the room to get more sterile supplies. D. The nurse prepares the sterile field immediately before the procedure. E. When a sterile item falls off the sterile field, the nurse opens a new sterile item.

A B C

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following should be included in the discussion? (Select all that apply.) A. When preparing a sterile field, unwrap the commercial tray by beginning with the outermost flap and unfolding it in the direction away from the sterile kit toward the top of what will be the sterile field. B. If there is any question or doubt of an item's sterility, the item is considered to be nonsterile. C. When using a sterile barrier, touch only the outer 2 inches (5 cm) of the border because this is considered nonsterile. D. When using a sterile drape, position the bottom half of the sterile drape over the top of the intended sterile field. E. When pouring a solution, if some spills onto the sterile barrier, cover the spill with sterile gauze.

A B D

When is it acceptable to use antiseptic hand rub rather than soap and water? (Select all that apply.) A. After adjusting a nasal cannula on a patient. B. After removing gloves after changing a wound dressing. C. When the nurse's hands are cracked from frequent hand hygiene. D. After moving patient's belongings on the bedside table. E. After the patient develops a skin tear and blood is on the nurse's hand. F. When the patient has been diagnosed with C. difficile.

A B D

A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) A. A sterile barrier that has been permeated by moisture must be considered contaminated. B. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. C. A sterile field or object cannot become contaminated by air. D. If there is any doubt about an item's sterility, the item is considered to be unsterile. E. All items used within a sterile field must be sterile. Correct

A B D E

Which of the following are symptoms of latex allergy? (Select all that apply.) A. Skin redness. B. Itching. C. Purulent drainage. D. Edema. E. Difficulty breathing. F. Elevated temperature.

A B D E

When should you perform hand hygiene? (Select all that apply.) A. Before applying gloves to insert an IV. B. After documenting in the patient's electronic medical record. C. After moving a patient up in bed. D. Before assessing a patient's vital signs. E. Before touching clean linens.

A C D

which statement are correct concerning bathing a hospitalized patient select all that apply A. A complete bed bath is for patients who are bedridden B. All hospitalized patients need a complete bed bath C. Bathing removes dead skin, bacteria, and body fluids D. Male personnel must always perform male perineal care E. Keeping skin clean and dry helps prevent breakdown

A C E

A nurse reads the following documentation in a patient's electronic health record: 92-year-old female complains of frequent nonproductive cough. States has been taking PO steroids as prescribed. Denies having received pneumonia vaccine. B. Jones, R.N. Based on this information, what factors place this patient at risk for being a susceptible host? (Select all that apply.) A. Hospitalized. B. Nutritional status. C. Age. D. Gender. E. Vaccination status. F. Medical therapy.

A C E F

A new quality assurance program has been instituted on the unit because of a higher than average infection rate. Which of the following could be factors responsible for this increase? (Select all that apply.) A. Nurse A wears artificial nails. B. Nurse B performs hand hygiene between patients. C. Nurse D has fingernails less than ¼ inch long. D. Nurse E has open cuts on her hand. E. Nurse F has chipped nail polish.

A D E

The NAP complains of his hands hurting and skin being chapped. What would be appropriate suggestions for the NAP? (Select all that apply.) A. Use hand lotion from an individual use container. B. Decrease the frequency of hand hygiene until healed. C. Wear clean latex-free gloves at all times. D. Be sure to rinse and dry hands thoroughly. E. Avoid excessive amounts of soap or antiseptic.

A D E

Which of the following patients are at risk for developing an infection? (Select all that apply.) A. A patient receiving chemotherapy. B. A patient who has an early discharge from the hospital. C. A patient in a private room. D. A patient with an IV. E. A patient with a chronic respiratory disease receiving steroid therapy.

A D E

Which statement indicates the need for further learning after the nurse teaches a client self-management care in preventing and spreading methicillin-resistant Staphylococcus aureus (MRSA)? Select all that apply A. "I can share athletic equipment" B. "I can participate in contact sports" C. "I should sit on upholstered furniture" D. "I should use antibacterial soaps for bathing" E. "I should wash all infected skin areas before covering those areas"

A. "I can share athletic equipment" B. "I can participate in contact sports" C. "I should sit on upholstered furniture"

The nurse is providing colostomy care to a client with methicillin - resistance Staphylococcus aureus (MRSA) infection. Which personal protective equipment (PPE) would the nurse use? A. Gloves B. Gown C. Mask D. Googles E. Shoe covers F. Hair bonnet

A. Gloves B. Gown D. Googles

You are assigned to a postoperative patient who underwent knee replacement surgery and had an ankle pinned. You must perform a dressing change and provide pin care, which requires creating and maintaining a sterile field. What would be evidence of the patient meeting the expected outcome 24 hours after the procedure? (Select all that apply.)

Absence of tenderness or edema at surgical sites Afebrile WBC within normal limits of 5000 to 10,000 per mm3

Which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis? A. Place the client on airborne precautions B. Notify the client's health care provider C. Auscultate the client's breath sound D. Notify the public health department

A. Place the client on airborne precautions

Which type of immunity would a 4-year-old child develop during the course of an infection with varicella? Active natural immunity Active artificial immunity Passive natural immunity Passive artificial immunity

Active natural immunity

You are evaluating the cleanliness of your hands after performing hand hygiene with an antiseptic hand rub. You feel your hands stinging and notice that they are very chapped. What action should you take?

After hand hygiene, use a small amount of lotion/barrier cream from a single-use container.

Chain of Infection - Infection

Agent/ Pathogen - bacteria - antibacterial medication can be given to treat - viruses - cannot be treated - Fungi - Mold & Yeast, live in dark-moist areas (underarms, under large breast) - Parasites - bedbugs, hair lice

Which intervention will be beneficial for the safe and effective care of a hospitalized immunosuppressed client? Select all that apply Advise the client to eat raw fruits daily Avoid using supplies from common areas Encourage activity at an appropriate level Use alcohol-based hand rubs before touching the client Change gauze-containing wound dressing on alternate days

Avoid using supplies from common areas Encourage activity at an appropriate level Use alcohol-based hand rubs before touching the client

A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the patient's bladder. What link in the chain of infection is the nurse breaking by doing so? A. Portal of exit. B. Portal of entry. C. Reservoir. D. Host susceptibility.

B

A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the needle using the scoop method, the nurse accidentally touches the table with the uncovered needle. What is the nurse's best action? A. Discard the needle, syringe, and medication and start over. B. Discard the needle and replace with a new one before administration. C. Wipe the needle with an alcohol swab and recap for use. D. Transfer the medication to a new syringe.

B

A nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? A. Washing hands with soap and water is the only effective means for stopping the spread of germs. B. Immunizations help protect children from being susceptible hosts. C. Large containers of hand sanitizer should be made available for use when there is visible soiling. D. Toys are typically the reservoir of pathogen growth.

B

A nursing instructor is reviewing medical asepsis with a group of nursing students. Which comment, if made by a student, indicates that further teaching is needed? A. "Performing hand hygiene is an example of breaking the transmission link in the chain of infection." B. "Alcohol-based hand rubs should be used often when caring for patients with Clostridium difficile." C. "Health care-associated infections are most likely to develop in the urinary and respiratory tract." D. "Reducing the number of organisms and preventing their transfer is the goal of medical asepsis."

B

A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise, nausea, and vomiting. What might you suspect? A. The patient probably has the flu. B. The patient may now have a systemic infection. C. The patient is displaying signs of a localized infection. D. The patient is experiencing an allergic response to his medication.

B

A patient was hospitalized for surgical repair of a fractured hip. Upon admission her lungs were clear to auscultation and she was afebrile. Her discharge was delayed because she developed a fever and respiratory distress. A chest x-ray confirmed left lower lobe pneumonia. Which type of infection best describes what this patient has? A. A drug-resistant infection. B. A health care-associated infection. C. A systemic infection. D. A local infection.

B

The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? A. The nurse discards the entire sterile field, all items on it, and starts over. B. The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. C. Once sterile gloves are applied, the nurse moves the sterile gauze dressing to the center of the sterile field. D. The nurse continues with the procedure adding supplies to the sterile field and using each of them as needed.

B

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? A. Keep your intended work surface above waist level. B. Place the drape so the top half of the drape is over the top half of the work surface. C. You may grasp the outer 1-inch border of the drape without wearing sterile gloves. D. Place sterile items onto the sterile field at an angle.

B

The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction? A. "Be sure to select appropriate size gloves. Gloves that are too small can tear more easily." B. "Once sterile gloves are applied, the inside of the glove is still considered sterile." C. "Be sure to select appropriate size gloves. Gloves that are too large can impede your ability to pick up items and perform your task." D. "If you touch a nonsterile item with your sterile gloved hands, you should remove the gloves and obtain a new pair."

B

To apply sterile gloves, the nurse applied the first glove on the right hand. Where should the nurse pick up the remaining glove? A. At the top edge of the cuff. B. Underneath the second glove's cuff. C. Anywhere, because the entire glove is sterile. D. You should pick it up with your ungloved hand.

B

What is the best nursing practice to reduce the potential transmission of microorganisms within the health care setting? A. Bagging all linen. B. Performing hand hygiene. C. Keeping catheter bags empty. D. Wearing gloves.

B

The nurse is performing hand hygiene. Which would be an inappropriate action? (Select all that apply.) A. Keeping the hands and forearms lower than elbows. B. Using friction for 10 seconds in a vertical motion. C. Using hot water to rinse the hands after lathering. D. Turning the faucet off with a clean, dry paper towel. E. Drying hands from wrists to fingers with a paper towel.

B C E

An elderly patient is admitted for back surgery. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She requires a cane to ambulate. Which factors would be considered high-risk factors for latex allergy? (Select all that apply.) A. Her age. B. History of multiple surgeries as a child. C. Allergy to morphine and penicillin. D. Occupation. E. Use of a cane.

B D

The patient reports an allergy to latex. What alterations should be made in the patient's care? (Select all that apply.) A. Have a nurse who is also allergic to latex provide the patient's care. B. Use latex-free or synthetic gloves when gloves are necessary. C. Avoid wearing gloves unless absolutely necessary and only for short periods. D. Remove items that contain latex in the care of the patient. E. Avoid use of alcohol-based hand rubs. F. Determine whether syringes, IV tubing, and catheters contain latex.

B D F

The nurse is preparing a sterile field. The nurse opens the sterile commercial kit by pulling the outermost flap toward his body, followed by opening the remaining flaps. The nurse touches only the outer edge of the sterile field with his hands. The nurse adds sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? (Select all that apply.) A. The nurse correctly prepared the sterile field. B. Opening the outermost flap. C. Touching the outer edge of the sterile field. D. Adding sterile items to the field. E. Pouring a sterile solution.

B E

You are washing your hands in a sink with hand faucets. You first turn on the water and regulate the temperature to warm. You increase the water pressure to create a strong spray. You wet your hands, apply 1 teaspoon (5 mL) of soap, and rub your hands together vigorously, creating lather. You interlace your fingers and rub the palms and backs of the hands with a circular motion at least 5 times each. You keep your hands positioned with fingertips down and rinse the hands and wrists thoroughly. You turn off the faucet. You dry your hands with a paper towel. Which step(s) are incorrect? (Select all that apply.) A. The temperature of the water. B. The force of the water. C. The amount of soap used. D. The technique used in lathering. E. The position of your hands. F. The method used to turn off the faucet.

B F

An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse? a. "Do you have friends or family nearby?" b. "Can you raise your arms up to brush your teeth?" c. "Do you become short of breath during your shower?" d. "Are you able to get in and out of your bed at home?"

C

The nurse has delegated care of a patient's dentures to unlicensed assistive personnel. Which statement by the assistive personnel indicates a good understanding of denture care? A. It is not necessary to use a toothbrush in the patient's mouth since the patient does not have teeth B. I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside table C. I will out on clean gloves and brush the dentures gently with a toothbrush and toothpaste D. I will soak the dentures in the skin and then place them in a denture cup labeled with the patient's name

C

The nurse has prepared a sterile field and added the necessary sterile items to the field. The nurse has applied sterile gloves and is waiting to assist the health care provider in performing a surgical procedure. The nurse keeps the sterile field in view and holds her hands down at her side, away from her clothing. While waiting, the nurse instructs the patient to avoid touching the sterile field and for the need to lie still. Which action made by the nurse is incorrect? A. The patient teaching. B. Failing to cover up the sterile field with a sterile drape while waiting. C. Holding gloved hands at her side. D. All actions are appropriate.

C

The nurse is observing the NAP perform hand washing. During which step should the nurse intervene and provide further instruction? A. The NAP pushes his wristwatch and long uniform sleeves above the wrists. Standing in front of the sink, the NAP keeps his hands and uniform away from the sink surface. B. The NAP turns on the water and regulates the flow of water so that the temperature is warm and the force of the spray will not cause splashing. C. The NAP wets his hands and wrists thoroughly under the running water and keeps his hands and forearms higher than the elbows during washing. D. The NAP applies 3 to 5 mL of detergent and rubs the hands together vigorously, lathering thoroughly. The NAP performs hand hygiene for at least 15 seconds, interlacing the fingers and rubbing the palms and back of hands with a circular motion at least 5 times each. E. The nurse rinses the hands and wrists thoroughly, dries the hands, and uses a dry paper towel to turn off the hand faucet.

C

Which of the following is a correct description of glove removal? A. You pull the gloves off by the fingertips and discard them in a proper receptacle. B. You grasp the inside of one glove with the other gloved hand, pull the glove off, and discard it in a proper receptacle. The remaining glove is removed by placing the fingers of the bare hand outside the cuff, pulling the glove off, and discarding it in a proper receptacle. C. You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. D. You slide the gloved fingers of the dominant hand under the inside cuff of the nondominant hand and pull the glove off and discard. Then you slide the fingers of the nondominant hand under the cuff of the dominant hand and pull the glove off and discard.

C

The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? (Select all that apply.) A. Use sterile gloves if anticipating contact with nonintact skin. B. Artificial nails should be no longer than 0.625 cm (1/4 inch). C. If worn, fingernail polish should not be chipped. D. Cough hygiene practices should be followed. E. Gown and gloves are sufficient PPE for a splash risk. F. Always know a patient's susceptibility to infection.

C D F

Which of the following are symptoms of a systemic infection? (Select all that apply.) A. Redness. B. Edema. C. Fatigue. D. Fever. E. Pain or tenderness. F. Nausea and vomiting.

C D F

The nurse is observing the NAP perform hand hygiene. Which of the following, if performed by the NAP, requires intervention by the nurse? (Select all that apply.) The NAP: A. Washes her hands before and after removing clean gloves. B. Applies 3 to 5 mL of antimicrobial soap to hands wet with warm water. C. Takes the patient's blood pressure and leaves the room to document. D. Washes hands with plain soap and water when visibly dirty. E. Puts the patient's socks on, then begins to feed the patient. F. Moves the patient's IV pole by the bed and uses hand sanitizer. G. Has an uncovered cut on the back of the nondominant hand.

C E G

Determine which tasks indicate hand hygiene should be performed. (Select all that apply.)

Changing the dressing on a wound Administering an IV push medication into a patient's IV with a needleless system Checking the patient's blood pressure

The nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which personal protective equipment (PPE) would the nurse wear? Mask Clean gloves Sterile gloves Shoe covers

Clean gloves

Medical Asepsis

Clean techniques Hand washing Wearing gloves Gown Disinfecting

Which nursing interventions require the nurse to wear gloves? Select all that apply Giving a back rub Cleaning a newborn immediately after delivery Emptying a portable wound drainage system Interviewing a client in the emergency department Obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)

Cleaning a newborn immediately after delivery Emptying a portable wound drainage system

Which actions by a client who lives with family and has a upper respiratory infection indicates that the home health nurse's teaching about infection control has been effective? Select all that apply Covering mouth with a forearm when coughing or sneezing Putting tissues in a plastic bag after using them to cough Avoid talking or spending time with family members Asking the health provider for an antibiotic prescription Using an alcohol-based hand sanitizer to wash the hands

Covering mouth with a forearm when coughing or sneezing Putting tissues in a plastic bag after using them to cough

A nurse is obtaining a patient's medical history when he states, "I am HIV positive because I shared needles with a friend who is also HIV positive." The friend would be considered: A. The susceptible host. B. The vehicle or route of transmission. C. The infectious agent. D. The reservoir.

D

An NAP asks what an example would be of using standard precautions. The nurse is correct to respond: A. Placing an "isolation precautions" sign on the patient's door to alert any visitors. B. Wearing gloves and a mask whenever it is known that a patient has a communicable illness. C. Collecting a sputum specimen to determine if an infection is present. D. Wearing clean gloves when emptying a bedpan.

D

An ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails. The patient's toenails are long and thick. What is the next step the nurse should take? a. Soak the patient's feet, and trim her toenails using clippers. b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP). c. Assess the patient's self-care status. d. Ask for a referral to a podiatrist.

D

The most common methods of microorganism transfer from one person to another in a hospital is prevented by A. disinfecting instruments in special solutions B. Filtering the air in the hospital C. changing bed linens daily D. performing hand hygiene thoroughly and frequently

D

The nurse changes the dressing of your first patient with methicillin-resistant Staphylococcus aureus of the wound. The nurse discards the gloves and goes into the next room, where the nurse suctions a second patient's airway. According to the chain of infection, the mode of transmission is: A. Methicillin-resistant Staphylococcus aureus. B. The first patient. C. The first patient's wound. D. The nurse. E. The second patient's respiratory tract. F. The second patient.

D

The nurse is applying sterile gloves. Which series of steps would require correction? A. Perform hand hygiene. Examine glove package to determine if it is dry and intact. Open sterile gloves by carefully separating and peeling open the adhered package edges. Identify right and left glove. B. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. C. Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands. D. Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure.

D

The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? A. The nurse reviews documentation to see what supplies will be needed. B. The nurse asks the patient to rate his pain on a pain scale. C. The nurse asks the patient if he needs to use the bathroom. D. The nurse asks the patient if he has ambulated in the hall today.

D

Which hygienic care instructions by the nurse should be given to a patient who is being discharged on an anticoagulant? (Select all that apply.) a. Use an electric razor for shaving. b. Brush teeth with a soft toothbrush. c. Trim beard with double blade safety razor. d. Use caution when trimming nails with clippers. e. Deeply massage unused muscles while bathing.

D

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give? A. "You developed an infection that requires antibiotics" B. "This is a highly contagious infection requiring isolation" C. "An infection you had before beginning treatment has flared up" D. "Your infection occurred because of exposure to a health care facility"

D. "Your infection occurred because of exposure to a health care facility"

Of the following patients, which patient is at a higher risk of infection? A. 27 year old female who is athlete B. 60 year old male with osteoarthritis C. 12 year old female with a sprained ankle D. 36 year old female with HIV

D. 36 year old female with HIV

Under which circumstances would the nurse wear a gown? A. Client's hygiene is poor B. The nurse is assisting with medication administration C. The client has acquired immunodeficiency syndrome (AIDS) or hepatitis D. Blood or body fluid may get on the nurse's clothes from a task they plan to perform

D. Blood or body fluid may get on the nurse's clothes from a task they plan to perform

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to? A. Primary B. Secondary C. Superinfection D. Nosocomial

D. Nosocomial

A nurse is caring for an overweight 60-year- old woman with a reddened area over the coccyx. The priority nursing diagnosis for this patient is A. imbalanced Nutrition: More than body requirements related to immobility B. Impaired Physical Mobility related to pain and discomfort C. Chronic pain related to overweight D. Risk for infection related to altered skin integrity

D. Risk for infection related to altered skin integrity

Which nursing intervention would the nurse implement for a client with active tuberculosis who is walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions? Ensure regular visits by staff members to meet the client needs Explore what the airborne precautions mean to the client. Report the situation to the infection control nurse immediately Reteach the concepts of airborne precautions to the client

Explore what the airborne precautions mean to the client.

adaptive immunity

Exposed to antigen Example: COVID Getting flu shot

Malaise

Feeling tire

Taking off PPE

GLOVES GOWN HAND WASH GOGGLES MASK

Putting on PPE

GOWN MASK GOOGLES GLOVES

Chain of Infection - Portal of Entry

Going inside another person - can be prevented by hand washing

The nurse is teaching unlicensed assistance personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority. A. Hand washing before and after providing client care B. Cleaning all equipment with an approved disinfectant after use C. Wearing personal protective equipment (PPE) when providing care D. Using medical and Surgical aseptic techniques at all time

Hand washing before and after providing client care

A patient is discharged home with a follow-up plan for continued weekly chemotherapy treatments on an outpatient basis. Three days later, the patient has increased weakness and refuses to eat. Concerned, the patient's family brings the patient to the hospital. It is a busy Friday night in the emergency room, and the patient sits in an overcrowded waiting room for 3 hours before being seen by a physician. An intravenous line (IV) is started to improve the patient's fluid and electrolyte status, and blood is drawn for further testing. Identify risk factors for this patient developing an infection. Select all that apply. The use of standard precautions is determined by the patient's likelihood of carrying a communicable illness. TRUE or FALSE

Having chemotherapy being malnourished overcrowded health care facility IV insertion and blood sampling FALSE

pediculosis

Head lice

Active Natural Immunity

Illness

Chain of Infection

Infectious Source Portal of exit Transmission Portal of entry Susceptible host

Which room assignment would the nurse select for a child hospitalized with newly diagnosed tuberculosis? Private room Isolation room Four bed room Semiprivate room

Isolation room

Which action would the nurse encourage a client with obsessive-compulsive disorder who has red, raw, slightly bleeding hands from washing them 70 to 80 times a day to do? Understand that the hands are not dirty. Gain insight into the emotional problems Stop washing the hands so the skin will heal Limit the number of times hand washing occurs

Limit the number of times hand washing occurs

chronic infection

Long term

You include performing hand hygiene in your nursing care to help break the chain of infection. At which link in the chain of infection is hand hygiene primarily effective?

Mode of transmission

Passive Natural Immunity

Mother to Baby

decreased sensation

Not able to feel hot or cold

localized infection

One area

The nurse is caring for a client who underwent a hysterectomy and is admitted to a general medical-surgical unit. Which task can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. Oral hygiene Assistance with bathing Oral medication administration Intravenous fluid administration Providing treatments with supervision

Oral hygiene Assistance with bathing

Chain of Infection - Susceptible Host

Person exposed to the infectious disease Older people, people under medical treatment, with chronic illness are more at risk

The nurse changed a dressing on a client's wound with vancomycin resistant enterococci (VRE). Which steps would the nurse take to ensure proper disposal of the soiled dressing? Place the dressing in the bedside trash can. Place the dressing in a red bag/hazardous materials bag Contact environmental services personnel to pick up the dressing Transport the dressing to the lab to be placed in the in incinerator

Place the dressing in a red bag/hazardous materials bag

Excoriation

Red, loss of skin tissue (patient exposed to bodily fluids such as stool, urine) In areas where skin rests ion skin (armpits )

Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Pouring warm water over the perineum Ensuring the patency of the catheter Removing the catheter within 24 hours Cleaning the catheter insertion site

Removing the catheter within 24 hours

acute infection

Short term

integumentary system

Skin Nails Hair Sweat glands Sebaceous (oil) glands

Resistance Organisms and Nosocomial Infection

Someone in the hospital gets an infection that they did not come in with

According to the basic rules of creating and maintaining a sterile field, which of the following is correct?

The sterile field is within your view.

You are preparing a sterile field when you realize you will need more sterile gauze for the dressing change. What action should you take?

Turn on the call light and request more sterile gauze from the person that responds.

surgical asepsis

Using sterile techniques - used in surgical procedures - example: catheterization, in blood stream, break in skin, dressing change, wound care

Which action would be included in an organization's policy for hand hygiene? Select all that apply Wash hands before applying sterile gloves Wash hands before touching any client's personal items Wash with either soap and water or alcohol based hand rub (ABHR) before client contact Wash with soap and water when hands are visibly soiled with blood Wash with ABHR if hands are not visibly soiled Wash hands, between fingers, and under nails for 60 seconds

Wash hands before applying sterile gloves Wash hands before touching any client's personal items Wash with either soap and water or alcohol based hand rub (ABHR) before client contact Wash with soap and water when hands are visibly soiled with blood

Which action would the nurse teach an older adult to take to prevent frequent colds (viral rhinitis)? Taking antihistamines as soon as symptoms begin Spending more time indoors during the cold season Wearing extra layers whenever going outside in the winter Washing hands before putting them near the nose or mouth

Washing hands before putting them near the nose or mouth

Chain of Infection - Source

Where did it come from? Contaminated equipment, medications, air, food, water, human, animals

Asepsis

absence of pathogenic microorganisms - reduce risk of infection

systematic infection

all over the body

the nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. which agent is most likely the cause of the infection? a. virus b. bacteria c. fungus d. spore

b

Maceration

breakdown of the skin caused by fluid

A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient? a. Airborne precautions b. Droplet precautions c. Contact precautions d. Protective isolation

c

During normal patient care that does not soil hands, effective hand hygiene between patients requires a. at least a 20-second soap and water scrub. b. at least a 23-minute scrub with antimicrobial soap. c. use of an alcohol-based antiseptic handrub. d. a mask must be worn while scrubbing is occurring.

c

which during action is necessary for the patient safety during a bed bath? a. all four sides are always kept in the raised position during the bath. b. the bed is always in the low and locked position while bathing the patient c. the top side rail is raised opposite the side where the nurse is standing d. the bed is always kept in a flat position with a pillow under the patient head

c

which procedure is correct when making an occupied bed? a. the bed is left in the low and locked position for patient safety. b. the bed is made starting at the head and working toward the feet c. soiled linen is loosened on one side of the bed and rolled under the patient d. making an occupied bed cannot be delegated to unlicensed assistive personnel

c

Which statement is most accurate about hearing aid and ear care for hospitalized patients who are hard of hearing? a. heard if hearing patient should wear hearing aids at all times while hospitalized b. hearing aids should be cleansed daily with soap and water before reinsertion. c. hearing aids should be cleansed daily with soap and water before reinsertion d. hearing aids are cleansed with a dry cloth and stored in a labeled container.

d

which area of the body is most likely to be excoriated a. elbows b. facial skin c. cervical spine d. perineum

d

passive acquired immunity

given antibiotics in blood stream

Chain of Infection

infection agent - (Bacteria, viruses, Fungi, Protozoa) reservoir - pathogen growth (from a person) portal of exit - from reservoir (person coughs) mode of transmission - hands of health care workers, equipment, droplets in air portal of entry - to host (to the other person) susceptible host - the other person

active

long term

Two types of Aseptic Techniques

medical-surgical

anticoagulant

prevents blood clotting Patients should only use electric razor

passive

short term

surgical asepsis

sterile gloves using sterile cup to obtain a specimen for culture using sterile syringe for an injection autoclaving instruments common in operating rooms, labor & delivery area, major diagnostic areas, used at bedside

Medical Asepsis

using clean disposable gloves perform hadn't hygiene common in health care and home environment

active acquired immunity

vaccine

Cerumen

wax (ear)

The most effective way to prevent transmission of infection is performing hand hygiene and ________. Wearing gloves

wearing gloves