N360 Test 1

The nurse is caring for a postpartum mother who delivered her second child yesterday. The mother states her older child has just been diagnosed with chickenpox. She is concerned her newborn will develop the disease. How will the nurse likely respond?

"Have you had chickenpox?"

The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?

"Help me understand your perspective about vaccinating."

A client who has been diagnosed with a cold is upset that antibiotic therapy was not prescribed. Which nursing response is most appropriate?

"The common cold is a virus and will not respond to antibiotics."

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?

"This antibiotic is the best choice since the causative organism is not known."

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 pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds

"You may have infection in your birth canal that you are unaware of."

Which nursing actions will the nurse perform to assist in the prevention of health care-associated infections (HCAIs)? (Select all that apply.) You Selected:

1.Wash hands between caring for clients. 2.Recommend vaccinations to clients. 3.Educate clients regarding why antibiotics are not used for viral illnesses.

Which practice is a correct application of infection control practices?

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

Which patient would the nurse consider the most infectious?

A patient who is in the prodromal stage

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

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

A nursing student is alarmed to learn that the patient whom she has been assigned to provide care is positive for HIV. What infection control strategy should the student apply when caring for this patient?

Apply routine precautions in the same manner as when caring for other patients.

A nurse observed a colleague enter a patient's room to respond to a call bell. The nurse believes that the colleague did not perform hand hygiene prior to giving care. What is the nurse's most appropriate action?

Ask the colleague if he performed hand hygiene before giving care.

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?

Before entering the client's room

Which of the following clients should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?

Client with a urinary catheter

A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply.

Clostridium difficile Norovirus

When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?

Contact

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub.

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

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?

Don another pair of sterile gloves.

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

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair

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

Which of the following masks should the nurse don when caring for a client with tuberculosis?

Filtered respirator

A nurse is caring for a client with ringworm. Which microorganism c

Fungi

Unbeknown to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.

Incubation period Prodromal stage Full stage of illness Convalescent period

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?

Indwelling catheter

A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter?

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

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today 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?

Perform hand hygiene before and after entering the client's room.

The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders 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.

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?

Remind the student that a fitted N95 respirator is required.

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from the room.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

Surgical asepsis

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure

Surgical asepsis technique

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of

Survival adaptation

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:

Survival adaptation

A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated?

The nurse is caring for a client with a C. difficile infection

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 monitored negative air pressure.

A nurse has finished providing morning care for a patient and is now planning to perform hand hygiene. Alcohol-based hand rub would be inappropriate in which of the following circumstances?

The nurse's hands are visibly soiled.

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

True

The nurse is caring for a client with tuberculosis who has been placed in airborne precautions. The nurse has not yet been fitted with an N95 respirator. Which nursing action is appropriate? You Selected:

Use a powered air purifying respirator (PAPR).

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 handrub is appropriate in which of the following situations?

When hands are visibly soiled

Surgical asepsis is defined as

absence of all microorganisms

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

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 reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

an older adult client with a history of heart failure

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

bacteria.

The nurse is caring for a client with a acute viral conjunctivitis. Which precautions will the nurse begin?

contact

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?

diligent handwashing practices

Which of the following are names of the transmission-based precautions defined by the Centers for Disease Control (CDC)? Select all that apply.

droplet precautions airborne precautions contact precautions

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

has manicured nails that are 1-in (2.5-cm) long

What is the most common reason people contact health care providers?

infectious disease

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

into a private room

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen.

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor

reaches down to the bed to pick up a sterile drape

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

semen

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

septic

An infection or the products of infection carried throughout the body by the blood is called

septicemia.

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

stethoscope that remains in the client's room

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 post-surgical procedure

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?

to eliminate disease-producing organisms from the nurse's skin Explanation:

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is:

universal precautions.