Prep U- Ch. 24: Asepsis and Infection Control

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? "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." "It is important to refrain from recapping needles." "I will always wash my hands thoroughly and often."

"Wearing an N95 respirator is critical when I care for clients in droplet precautions." Explanation: 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.

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? contact airborne none droplet

droplet Explanation: Whooping cough is transmitted through droplets; therefore droplet precautions are appropriate.

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. -Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse. -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. -Nurses need only apply clean gloves when performing or assisting with invasive client procedures. -Nurses may use a waterproof gown more than one time. -To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.

-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. Explanation: Several examples represent the proper use of personal protective equipment in a health care agency. First, 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. The nurse should remove a gown by unfastening ties, if at the neck and back, and allow the gown to fall away from the shoulders. The nurse would apply clean gloves for most care activities, not just when assisting or performing an invasive client procedure. A waterproof gown is to be used only once. Nurses cannot wear a mask around the neck when not being worn nor can it be brought back over the nose and mouth for reuse.

A client has a diagnosis of HIV. Which statement would concern the nurse? My dog likes to roam the neighborhood and often eats from garbage cans. I enjoy preparing meals for my family. I use the same bathroom as the rest of my family. I often spend time with and hug my young nieces and nephews.

My dog likes to roam the neighborhood and often eats from garbage cans. Explanation: HIV is a viral infection that impairs the immune system, making individuals with the virus more likely to acquire infectious diseases. A dog who roams the neighborhood and eats from garbage cans is likely to pick up a bacterial infection, which can easily be spread to the individual with HIV. The virus is spread through exposure to blood and body fluids of an infected person. Using the same bathroom as family members, preparing their meals, or hugging them does not place them at risk for being infected with the virus.

A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply. Tuberculosis Hepatitis B HIV Hepatitis C

Hepatitis B Hepatitis C HIV Explanation: Tuberculosis would be a significant respiratory exposure, but it is not transmitted by blood.

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? -"We only wash our hands when they are visibly soiled." -"I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." -"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." -"Washing the hands with soap and water is not necessary."

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." Explanation: By explaining that alcohol-based hand rubs are effective in preventing the spread of microbes, the nurse directly addresses the client's concern. While washing with soap and water may not be necessary, it doesn't address the client's concern. Alcohol-based hand rub is an appropriate method for hand hygiene even when you plan to touch the client.

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

"All visitors who enter the room must wear N95/surgical masks." Explanation: 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.

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." "Transmission of certain diseases is halted with vaccination." "Has your child received any previous vaccinations?" "Vaccinations prevent disease."

"Help me understand your thoughts about vaccinations." Explanation: Seeking to understand the caregiver's perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. The nurse could then collect assessment data regarding past vaccines and provide appropriate teaching.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? -"I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." -"I will obtain a mask from the staff and wash my hands before touching my family member." -"I will not visit my family member in the first 3 days of my cold." -"If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."

"I will obtain a mask from the staff and wash my hands before touching my family member." Explanation: Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is elderly or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.

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? -"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." -"Drug resistance can develop when the wrong antibiotic is used for pneumonia."

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

A nurse has finished giving care to a client who has a communicable respiratory infection. In which order should the personal protective equipment (PPE) be removed? 1. Gloves 2. Respirator 3. Gown 4. Goggles -1, 2, 4, 3 -4, 2, 3, 1 -4, 2, 1, 3 -1, 4, 3, 2

1, 4, 3, 2 Explanation: The order for removal of PPE is gloves, goggles, gown, and respirator.

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse? -Discard the supplies and field and prepare a new sterile field. -Educate the client on sterile fields and continue preparing for the procedure. -Remove the supplies from the field and replace with new supplies. -Give the client the water pitcher and continue preparation.

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. Explanation: The correct order of putting on sterile gloves is as follows. First, the nurse should open the package, taking care not to touch the inner surface of the package or gloves. Then, the nurse should pick up the glove at the folded cuff with the thumb and forefinger and insert fingers while pulling the glove over the hand. Next, the nurse should place the finger of the gloved hand inside the cuff of the remaining glove, taking care not to touch outside of the folded cuff. Once both gloves are on, the nurse adjusts the gloves touching only sterile areas. If gloves are donned not following this order, there is an increased risk for contamination of the sterile gloves.

After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter? -Soap and water hand washing technique -Alcohol-based hand rub -Mixture of soap and alcohol-based hand rub techniques -Scrubbing hands with soap, water, and brush

Alcohol-based hand rub Explanation: Alcohol-based hand rubs 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. Indications for washing hands with soap and water include visibly dirty hands, hands visibly soiled with body fluids, or after using the toilet. Concomitant alcohol-based hand rub and soap and water use is not recommended. Surgical hand hygiene is reserved for sterile procedures.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection? -Place water-soluble lubricant on catheter tip prior to insertion -Wash the perineal area with soap and water -Ensure opening port of the catheter is closed -Create an area for sterile field and opening packages

Create an area for sterile field and opening packages Explanation: Pathogens require a portal of entry to cause infection. Insertion of an indwelling urinary catheter is a sterile technique; any contamination could cause a portal of entry. Using water-soluble lubricant on catheter tip prior to insertion is correct but will not prevent an infection nor will closing the opening port. Likewise, washing the perineal area with soap and water will reduce microorganisms but will not prevent infection alone.

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. Notify the primary care provider. Complete a sentinel event report. No action is needed.

Don another pair of sterile gloves. Explanation: If the nurse realizes that the sterile field is broken, the most appropriate response is to stop and don another pair of sterile gloves. A sentinel event has not occurred, and calling the PCP is unnecessary. Doing nothing and moving forward with foley insertion places the client at greater risk of infection and is not an appropriate action.

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? Extend the sterile field by laying the open package beside it. Lay the item in an open package on the 1-in (2.5-cm) border. Remove the gauze from the package with one sterile hand. Drop the item from 6 in (15 cm) above the sterile field.

Drop the item from 6 in (15 cm) above the sterile field.

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

Filtered respirator Explanation: 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.

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply. Nonsterile gloves Mask Hand hygiene Gown Sterile gloves

Nonsterile gloves Hand hygiene Explanation: When taking vital signs on a client after surgery, the nurse should practice hand hygiene. There is no need to use a gown or mask unless the client is diagnosed or suspected to have a transmittable infection. Since it is an aseptic versus sterile procedure, the nurse should use nonsterile gloves.

An older adult client from a long-term care facility is being admitted to the hospital with an infected wound on the left foot. What action should the nurse perform upon admission related to the client's residential occupancy? -Perform a nasal swab to identify colonization with methicillin-resistant Staphylococcus aureus (MRSA). -Insert an indwelling urinary catheter. -Ask the client if any other clients in the facility have infected wounds. -Give the client a complete bath to make sure the pathogens from the wound are decreased.

Perform a nasal swab to identify colonization with methicillin-resistant Staphylococcus aureus (MRSA). Explanation: Hospitals are now obtaining nasal cultures of clients to identify any that have been colonized with MRSA and placing them in contact isolation until the culture reports come back negative. This prevents the potential spread of the pathogen to other clients as well as health care providers. There is no indication that the client requires an indwelling catheter which could be another source of pathogen invasion. Other client wounds would not be a relevant question to ask, and the client is not likely to have the answer. Giving a bath does not reduce the pathogen spread from the infected wound.

A client is having an open cholecystectomy and requires a saline irrigation. What action will reduce the spread of pathogens to the client and other clients? -After pouring the solution into the sterile basin, recap the solution for use later. -Pour a small amount of solution out of the container prior to pouring it into the sterile basin. -Have the surgical technician take the bottle of solution and pour directly into the open abdomen. -Pour the solution below the level of the waist while the surgical technician holds the sterile basin.

Pour a small amount of solution out of the container prior to pouring it into the sterile basin. Explanation: When using a sterile solution, the circulating nurse should pour the solution from above the waist level and avoid splashing the solution onto the sterile field and avoid touching any sterile areas within the field. The nurse should pour and discard a small amount of solution to wash away airborne contaminants. The unused solution should be discarded and not used in the future either for the surgical client or any other client.

Which action is the best example of a nurse donning/removing protective equipment properly? -Removing respirator after leaving client's room -Removing gown after leaving client's room -Donning respirator inside of client's room -Donning gown after entering client's room

Removing respirator after leaving client's room Explanation: The best example of proper utilization of protective equipment is the removal of a respirator after leaving the client's room, as doing so prevents contact with airborne microorganisms. Gowns should be removed before leaving the client's room. Gowns and respirators should be donned prior to entering the client's room.

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

Stop and obtain appropriate PPE. Explanation: 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 nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? Medical asepsis Surgical asepsis Contact precautions Universal precautions

Surgical asepsis Explanation: Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter. Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

Which should be documented by the nurse? The fact that sterile technique was used for a given procedure The fact that the nurse donned gloves two different times during a procedure The specific items that the nurse transferred into a sterile field The fact that the nurse washed her hands before a procedure

The fact that sterile technique was used for a given procedure Explanation: The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

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

The nurse removes her gown and then removes her gloves. Explanation: 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 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 clients from becoming infected by staff members

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

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

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

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care? -Dip the IV catheter into an antiseptic before use. -Clean the site with a disinfectant. -Use a sterile intravenous catheter. -Wear a mask and gown for the procedure.

Use a sterile intravenous catheter. Explanation: Any item entering sterile tissues or the vasculature must be sterile. Therefore, an IV catheter must be sterile. It should not be dipped in an antiseptic before use. A chemical used on lifeless objects is called a disinfectant, whereas one used on living objects is an antiseptic. The nurse would clean the IV site with an antiseptic, not a disinfectant, before insertion. An IV insertion does not require the nurse to wear a mask and gown.

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

Wear personal protective equipment (PPE). Practice hand hygiene. Keep client's environment clean. Explanation: 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.

Surgical asepsis is defined as: -absence of all virulent microorganisms. -use of hand washing, gowning, and gloving. -slowed growth of microorganisms. -absence of all microorganisms.

absence of all microorganisms. Explanation: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

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

airborne Explanation: Pulmonary tuberculosis is transmitted via airborne mechanisms; therefore airborne contact precautions are appropriate.

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

an 80-year-old woman Explanation: 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 nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action? -continue with droplet precautions -change to standard precautions -change to airborne precautions -change to contact precautions

change to airborne precautions Explanation: Tuberculosis is transmitted via the air, so airborne precautions are required. The other answers are incorrect.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? isolating the client's belongings applying a face mask with shield changing the soiled dressing wearing clean unsterile gloves when changing the dressing

changing the soiled dressing Explanation: A reservoir is a place where microbes grow and reproduce. A soiled dressing can be a reservoir for microbes to breed. Changing the soiled dressing reduces the microbes at the wound. Wearing gloves, isolating client's belongings, and applying a face mask decrease the transmission of infection.

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? contact airborne droplet vehicle

contact Explanation: Contact may be either direct or indirect.

The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client? airborne contact respiratory droplet

droplet Explanation: Droplet precautions are appropriate, because microorganisms exit the body during coughing, sneezing, and procedures such as suctioning. Airborne precautions are not used, because droplets do not remain suspended in air.

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? fold soiled side to the outside and roll with outer surface exposed fold soiled side to the outside and roll with inner surface exposed fold soiled side to the inside and roll with inner surface exposed fold soiled side to the inside and roll with outer surface exposed

fold soiled side to the inside and roll with inner surface exposed Explanation: To dispose of the gown, the nurse will fold the soiled side to the inside and roll with the inner surface exposed. The other answers are incorrect.

A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to don PPE. Which would be appropriate? Select all that apply. gown respirator gloves mask with face shield

gloves gown mask with face shield Explanation: A respirator is typically reserved for clients with tuberculosis. A face shield is more appropriate for protection from influenza.

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? -sterile technique -signs of healing -hand washing -putting on gloves

hand washing Explanation: 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 student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene? washes hands for 15 seconds drains hands lower than the wrist has wedding band on ring finger has manicured nails that are 1-in. (2.5-cm) long

has manicured nails that are 1-in. (2.5-cm) long Explanation: Fingernails should be less than ¼-in. (0.625-cm) long, as this reduces the reservoir for flora to accumulate and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. A flat wedding band is acceptable. Allowing the hands to drain lower than the wrist promotes gravity drainage.

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? -intact skin and mucous membranes -low levels of flora -early intervention with antibiotics -the cell-mediated immune response -staying home when sick

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

Any microorganism capable of disrupting normal physiologic body processes is a: pathogen. fomite. virus. bacterium.

pathogen. Explanation: Microorganisms that are capable of harming people are called pathogens or pathogenic.

The nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent clients from getting the infection? -perform meticulous hand hygiene -perform meticulous hand hygiene and don a new mask with each client encounter -only accept clients who are not immune compromised and perform meticulous hand hygiene -wear a mask and don gloves with each client encounter until symptoms are completely gone.

perform meticulous hand hygiene and don a new mask with each client encounter Explanation: The nurse with a mild upper respiratory infection should don a new mask and practice meticulous hand hygiene with each encounter with a client. Hand hygiene alone will not control transmission of the infection. All clients are at risk for infection, not just those who are immune compromised. The window for being contagious varies dependent on the microorganism. The absence of a fever is not always an indication that the microorganisms can't be transmitted. Gloves are not specifically needed if hand washing procedures are followed with each contact.

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 -within normal limits -elevated -decreased

within normal limits Explanation: A normal white blood cell count is 5,000 to 10,000 cells/mm3.

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond? -"There are a lot of infectious processes around and there is nothing that can be done." -"As we age, our immune system does not function as well." -"It is possible that you are not washing your hands well enough." -"You will have to limit who comes to visit since they may be exposing you."

"As we age, our immune system does not function as well." Explanation: The nurse should explain that during the aging process, the immune system decreases in function and the older adult client is at greater risk for becoming infected. Other risk factors for the older adult client include poor nutrition and fluid intake. Although washing hands is an important part of the prevention of infection, there are other methods such as airborne and droplet transmission that may be unavoidable. When it comes to visitation, the only limitation that should be set is that those who are ill or possibly infected should refrain from visiting the client. Informing the client that nothing can be done is not accurate, as there are preventative measures that may be taken to avoid exposure.

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? "My personal belongings should remain in the room until I am discharged." "Any staff who enters my room will be wearing personal protective equipment (PPE)." "I will tell my visitors to keep their distance from me." "I can leave my room any time I want as long as I wear a mask."

"I can leave my room any time I want as long as I wear a mask." Explanation: The client on droplet precautions should only leave the room when necessary and wear a mask. The nurse should limit the client's movement outside the room. Visitors should remain 3 feet (1 meter) from the client. Anything that enters the isolation room should remain until discharge. Any staff who enters the room will wear PPE.

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." Explanation: 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 friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor? -"If you wash your hands before coming in contact with your friend you will prevent infection during your visit." -"As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend." -"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." -"You should not visit your friend if you have an infection of any kind because your friend may also get sick."

"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." Explanation: Visitors with respiratory infections need to wear a mask until their symptoms have subsided. The other options do not control transmission of airborne or droplet infections. Hand hygiene is appropriate and should be encouraged but used alone it won't prevent the spread of an airborne or droplet infection.

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? -"You cannot be admitted to the hospital with pneumonia without receiving some sort of antibiotics." -"We are giving you broad spectrum antibiotics because they are active for many types of bacteria." -"The antibiotics we are giving you will boost your immune system and help fight off whatever pathogen is present." -"We give antibiotics to treat the virus that are causing your the pneumonia."

"We are giving you broad spectrum antibiotics because they are active for many types of bacteria." Explanation: Many bacteria are susceptible to broad-spectrum antibiotics and prior to the diagnosis of a specific bacteria, a broad-spectrum antibiotic will be prescribed to help eradicate the present bacteria until a culture result is returned. A client may be admitted to the hospital with pneumonia without receiving antibiotics, although it is likely that an antibiotic will be given at some point during hospitalization. Antibiotics do not boost the immune system and may destroy normal healthy flora. Antibiotics are used to treat bacterial infections, not viral infections; antibiotics do not kill viruses.

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? -"Until you leave the hospital." -"For 2 days as you get settled onto the unit." -"When your sputum culture is negative." -"Only until you begin to feel better."

"When your sputum culture is negative." Explanation: The client will be on airborne precautions until a sputum culture is negative. The other answers are incorrect.

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. -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 lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse. -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. -Nurses may use a waterproof gown more than one time. -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. Explanation: Several examples represent the proper use of personal protective equipment in a health care agency. First, 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. The nurse should remove a gown by unfastening ties, if at the neck and back, and allow the gown to fall away from the shoulders. The nurse would apply clean gloves for most care activities, not just when assisting or performing an invasive client procedure. A waterproof gown is to be used only once. Nurses cannot wear a mask around the neck when not being worn nor can it be brought back over the nose and mouth for reuse.

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply. -Purulent or malodorous drainage -Scabs forming over the ulcer -Pain with redness and swelling -Localized heat -Inside edges of the ulcer appear to be drawing together

-Pain with redness and swelling -Localized heat -Purulent or malodorous drainage Explanation: Signs of infection of the client's foot ulcer that the nurse includes in discharge teaching include redness, swelling, and pain; localized heat; and purulent or malodorous drainage. If the inside edges of the ulcer appear to be drawing together and/or if scabs are forming over the ulcer, the ulcer is likely to be healing.

The nurse is caring for a client with full-thickness (third-degree) burns. What aseptic intervention(s) would the nurse implement for this client when admitted to the general medical unit? Select all that apply. -Instruct all staff, the client, and family members to practice strict and meticulous hand washing. -Allow the client to only ingest fresh fruits or vegetables, no canned or prepackaged food products. -Restrict visitors to family members who are not ill. -Place the client in a private room with protective isolation. -Permit flowers only if the containers have plastic wrapping around the base.

-Place the client in a private room with protective isolation. -Instruct all staff, the client, and family members to practice strict and meticulous hand washing. -Restrict visitors to family members who are not ill. Explanation: Clients with extensive burns are at high risk for infection. Such clients are placed in private rooms on protective isolation. To reduce the risk of infection, everyone practices strict and meticulous hand washing, including the client and his or her family. Visitors should be only family members who are not ill. Flowers, either in water or soil, are not permitted because soil harbors fungus and standing water supports the growth of microorganisms. All of these measures help to ensure that the client's environment stays as free from pathogens as possible, thereby decreasing the chance of infection. No fresh fruits or vegetables are allowed, only canned and cooked food.

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 pours discarded liquids into a basin then pours them into the drain. -The nurse cleans least soiled areas first and then moves to more soiled ones. -The nurse carries soiled items away from the body. -The nurse opens a window and dusts the room in the direction of the window. -The nurse moves soiled equipment away from the body when cleaning it. -The nurse places soiled bed linen on the floor.

-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. Explanation: The nurse would be following medical asepsis when the nurse carries soiled items away from the body, moves soiled equipment away from the body when cleaning it, and cleans least soiled areas first—then moves to more soiled areas. The nurse would not place soiled bed linen on the floor. The nurse would not open a window and dust the room in the direction of the window. The nurse would not pour discarded liquids into a basin before pouring them into the drain.

A nurse is preparing a sterile field for the health care provider to perform a biopsy on a client. Which actions follow recommended guidelines for maintaining the sterile field for this procedure? Select all that apply. -The nurse drops a sterile item on a sterile field from the height of 12 inches (30 cm). -The nurse holds an agency-wrapped item with the top flap opening toward the body. -The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. -The nurse discards a sterile field when a portion of it becomes contaminated. -The nurse places the cap of an opened solution on the table with edges down. -The nurse calls for help when realizing a supply is missing.

-The nurse considers the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. -The nurse discards a sterile field when a portion of it becomes contaminated. -The nurse calls for help when realizing a supply is missing. Explanation: The nurse practitioner would follow several recommended guidelines when performing a biopsy on a client. First, the nurse would consider the outer 1-inch (2.5-cm) edge of the sterile field to be contaminated. The nurse would discard a sterile field when a portion of it became contaminated. The nurse would call for help when realizing a supply is missing. The nurse would not place the cap of an opened solution on the table with edges down. The nurse would not drop a sterile item on a sterile field from the height of 12 in (30 cm), rather 6 in (15 cm). The nurse would hold a wrapped item with the top flap opening away from the body.

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. -The nurse's back is facing the sterile field. -The nurse keeps hands above waist level while donning sterile gloves. -The nurse disposes of an opened container of sterile saline after 24 hours. -The nurse is talking with the scrub nurse over the sterile field. -The nurse touches an unsterile object to the instrument tray.

-The nurse's back is facing the sterile field. -The nurse touches an unsterile object to the instrument tray. -The nurse is talking with the scrub nurse over the sterile field. Explanation: Principles of surgical asepsis include never turning one's back on a sterile field. The nurse should avoid talking, coughing, or sneezing over the field and keep sterile objects above waist level. Sterile objects may only be touched by other sterile objects. Most solutions are considered sterile for 24 hours after they are opened.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. -respiratory precautions -contact precautions -airborne precautions -microbial precautions -droplet precautions -body fluid precautions

-airborne precautions -droplet precautions -contact precautions Explanation: The CDC has three general precautions: contact, droplet, and airborne. Use contact precautions for clients with known or suspected infections that represent an increased risk for contact transmission. Use droplet precautions for clients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a client who is coughing, sneezing, or talking. Use airborne precautions for clients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster). Respiratory, microbial, and body fluid precautions are embedded in the three precautions.

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply. infectious disease health care-associated infection (HAI) communicable disease noncommunicable disease contagious disease

-infectious disease -communicable disease -contagious disease Explanation: Infections disease, communicable disease, and contagious disease describe this type of illness. A noncommunicable disease is caused by food or environmental toxin. Health care-associated infections are acquired within a healthcare facility.

Unbeknownst 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. Put in order 1.) Prodromal stage 2.) Incubation period 3.) Convalescent period 4.) Full stage of illness

1.) Incubation period 2.) Prodromal stage 3.) Full stage of illness 4.) Convalescent period Explanation: The correct sequence of the stages of infection are (1) incubation period, (2) prodromal stage, (3) full stage of illness, and (4) convalescent period.

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. Put in order 1.) Pat the hands dry with a paper towel. 2.) Wash the palms and backs of the hands for at least 20 seconds. 3.) Turn the faucet off with a paper towel. 4.) Turn on the faucet and adjust force and temperature of the water. 5.) Wet the hand and wrists. 6.) Apply soap.

1.)Turn on the faucet and adjust force and temperature of the water. 2.) Wet the hand and wrists. 3.) Apply soap. 4.) Wash the palms and backs of the hands for at least 20 seconds. 5.) Pat the hands dry with a paper towel. 6.) Turn the faucet off with a paper towel. Explanation: The correct steps to hand washing are as follows. Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrist areas. Apply soap product. Wash the palms and back of the hands for at least 15 seconds. Pat hands dry with a paper towel. Finally, turn the faucet off with a paper towel.

Which client would the nurse consider the most infectious? A client who is in the convalescent period A client who is in the prodromal stage A client who is in the full stage of illness A client who is in the incubation period

A client who is in the prodromal stage Explanation: The client is most infectious during the prodromal stage of the illness. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the client often is unaware of being contagious. As a result, the infection spreads. The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the client's general condition. The signs and symptoms disappear, and the person returns to a healthy state.

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

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

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

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

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? -Droplet -Fomite -Airborne -Contact

Airborne Explanation: The nurse should implement airborne precautions for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). Droplet precautions should be used for patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Contact precautions should be used for patients who are infected or colonized by a multidrug-resistant organism (MDRO).

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

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? Wear a protective gown and gloves with any direct contact. Apply a nonparticulate (N-95) respirator when entering the room. Wear a mask with face shield during invasive procedures. Have the client wear a mask during care.

Apply a nonparticulate (N-95) respirator when entering the room. Explanation: TB is an airborne infection, and the nurse should wear a nonparticulate mask (N-95) respirator. Gown and gloves would be indicated for infections that are transmitted via direct contact. A mask with a face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? -Self-quarantine yourself for 2 weeks if you feel ill -Avoid contact with mosquitoes -Use hand sanitizer after touching any public surface -Use a face mask when in crowds

Avoid contact with mosquitoes Explanation: Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate.

Standard precautions apply to which items? Select all that apply. Body fluid secretions Sweat Nonintact skin Blood Intact skin Mucous membranes

Blood Body fluid secretions Mucous membranes Nonintact skin Explanation: Standard precautions do not apply to sweat or intact skin, but do apply to all of the other items listed.

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse? -Discard the sphygmomanometer in the trash. -Cleanse and disinfect the sphygmomanometer. -Send the sphygmomanometer for sterilization. -Use the sphygmomanometer.

Cleanse and disinfect the sphygmomanometer. Explanation: The nurse should cleanse and disinfect the sphygmomanometer. A sphygmomanometer is another name for a blood pressure cuff. As this equipment is used on the outside of the arm versus entering a sterile body part, there is no need to have the equipment sterilized. It would be inappropriate for the nurse to use the visibly soiled blood pressure cuff or to throw it in the trash.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? -Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. -Don a second pair of sterile gloves over the first pair. -Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. -Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability.

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. Explanation: It is appropriate to adjust the gloves as long as the nurse only touches sterile surface to sterile surface. Leaving the thumb and finger in the thumb hole or only using the correctly gloved hand to perform the sterile procedure would not be appropriate, nor would donning a second pair of gloves, in this case.

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

Discard the bottle and get a new one because the saline has expired. Explanation: 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.

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? -Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening. -Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container. -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.

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

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. Explanation: 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.

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 Shigella in the intestinal tract Shigella in the urinary tract Escherichia coli in the intestinal tract

Escherichia coli in the intestinal tract Explanation: 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.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection? Antibiotic-resistant Iatrogenic Endogenous healthcare-associated Exogenous healthcare-associated

Exogenous healthcare-associated Explanation: The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? Helminths Rickettsiae Fungi Protozoans

Fungi Explanation: Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes.

The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection? Hand hygiene Good nutrition and getting enough rest How to properly wear a mask during flu season Avoid crowded areas and people who have the flu

Hand hygiene Explanation: Hand hygiene is the most effective way to control the spread of microorganisms. While it is true that the client may be less susceptible to illness when well rested, exposure to a pathogen can still result in influenza. Avoiding those with the flu is also appropriate; however, hand washing remains the best answer for prevention. Wearing a mask all season may or may not prevent the flu and is not the most reasonable choice.

A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step? -Hold the bottle inside the 1-inch edges of the sterile field with the label side facing the palm of the hand, then pour from a height of 2 to 4 in (5 to 10 cm). -Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm). -Touch the tip of the bottle to the sterile container to start the flow of the solution and pour it into the container directly from the top of the container edge. -"Lip" a new or old bottle of solution before pouring it and hold the solution with the label facing out from a height of 4 to 6 in (10 to 15 cm).

Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm). Explanation: Holding the bottle outside the edge of the sterile field with the label side facing the palm of the hand and preparing to pour from a height of 4 to 6 in (10 to 15 cm) is the correct step for adding a sterile solution. The tip of the solutions should never touch the container or dressing, and the label should face the palm when pouring the solution. Only a used bottle of solution needs to be lipped. The bottle should be held outside the edge of the sterile field.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? Release of histamine Constriction of the small blood vessels near the wound Migration of leukocytes to the area of the wound Production of antibodies

Migration of leukocytes to the area of the wound Explanation: During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation. Antibody production is characteristic of the immune response to infection.

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

Nonsterile gloves Hand hygiene Explanation: When taking vital signs on a client after surgery, the nurse should practice hand hygiene. There is no need to use a gown or mask unless the client is diagnosed or suspected to have a transmittable infection. Since it is an aseptic versus sterile procedure, the nurse should use nonsterile gloves.

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? -Give the client a meal, because the client may be hungry -Obtain a psychiatric consultation, because the client may be psychotic -Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection -Obtain a blood pressure reading, because the client may be hypertensive

Obtain a urine specimen, as ordered, because the client may have developed a urinary tract infection Explanation: 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? -Wrap all used materials together and discard in biohazard container -Don a new pair of gloves to dispose of materials -Perform hand hygiene -Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

Perform hand hygiene Explanation: 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 prepares for a sterile procedure. Of those listed, what action does the nurse perform first? -Put on personal protective equipment, if required. -Set up a work area at waist level. -Perform hand hygiene. -Check that the packaged kit is dry and unopened.

Perform hand hygiene. Explanation: When preparing for a sterile procedure, the nurse will perform hand hygiene followed by any personal protection equipment, if required. Next, the nurse confirm the client's identity with the order and explains the procedure to the client. Then, the nurse the will check that the sterile package or kit is dry and unopened as well as the expiration date. Next, the nurse will set up a work area at waist level or higher followed by opening the outside package and remove the kit.

The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first? Check that the packaged kit is dry and unopened. Set up a work area at waist level. Perform hand hygiene. Put on personal protective equipment, if required.

Perform hand hygiene. Explanation: When preparing for a sterile procedure, the nurse will perform hand hygiene followed by any personal protection equipment, if required. Next, the nurse confirm the client's identity with the order and explains the procedure to the client. Then, the nurse the will check that the sterile package or kit is dry and unopened as well as the expiration date. Next, the nurse will set up a work area at waist level or higher followed by opening the outside package and remove the kit.

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 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 the cap of the bottle and dip the gauze as needed

Pour the liquid into a sterile container within the sterile field. Explanation: 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.

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 -Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) -Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Explanation: 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.

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

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Explanation: 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 suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. Pain Swelling Exudate Redness Coolness

Redness Swelling Pain Exudate Explanation: Cardinal signs of infection include redness (heat), swelling, pain, and loss of function. As leukocytes and neutrophils enter the area, exudate made up of fluid, cells, and inflammatory by-products may be released by the wound. Warmth and heat at the site versus coolness are a sign of infection.

Which action is the best example of a nurse donning/removing protective equipment properly? Removing gown after leaving client's room Donning gown after entering client's room Donning respirator inside of client's room Removing respirator after leaving client's room

Removing respirator after leaving client's room Explanation: The best example of proper utilization of protective equipment is the removal of a respirator after leaving the client's room, as doing so prevents contact with airborne microorganisms. Gowns should be removed before leaving the client's room. Gowns and respirators should be donned prior to entering the client's room.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? -Surgical asepsis technique -Medical asepsis technique -Strict reverse isolation -Droplet precautions

Surgical asepsis technique Explanation: Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others.

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 nurse notes the client's urine is dark yellow with sediment. -The client reports nausea and vomiting. -Urine culture is positive for vancomycin-resistant enterococci (VRE). -The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C)

Urine culture is positive for vancomycin-resistant enterococci (VRE). Explanation: 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 Implement full isolation protocol while client is contagious Ensure all visitors wash their hands upon entering the room Use a gown when within 3 ft (1 m) of the client

Use a mask when within 3 ft (1 m) of the client Explanation: For droplet precautions, the nurse will need to make sure the client is in a private room or shares a room with a person who is infected with the same microorganism. Full isolation precautions are not required for this client as this limits visitors which is not necessary. The nurse will use a mask when working within 3 ft (1 m) of the client. Washing hands upon entering the room will not prevent a visitor from being at risk for droplet transmission as this mode of transmission is not by touching. Using a gown is not necessary when caring for a client on droplet precautions as droplets are airborne.

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

Vehicle Explanation: 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.

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? -Use respiratory protection when entering the room. -Place the client in a private room that has monitored negative air pressure. -Keep visitors 3 feet (1 m) from the client. -Wear gloves whenever entering the client's room.

Wear gloves whenever entering the client's room. Explanation: 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.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? -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. -Place client in a private room that has monitored negative air pressure. -Ensure that hard surfaces in the room are disinfected at least once per day.

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. Explanation: 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 preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection? -checking that the sterile dressing packages are intact before opening -describing each step verbally to the client before performing the -dressing change -ensuring that the surface where the sterile field will be set up is dry -applying a new dressing with the gloves that were used to remove the old dressing

applying a new dressing with the gloves that were used to remove the old dressing Explanation: Gloves should be changed after removing the old dressing prior to putting on a sterile dressing, because the microorganisms from the old dressing can be transferred to the new dressing. The nurse should explain the procedure to the client before beginning and not during. The nurse should avoid talking over a sterile field as well as turning his or her back on sterile field to discuss the procedure with the client. The nurse should check that the packages are intact, ensure that the surface is dry, and open all packages before donning sterile gloves.

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection? -droplet -contact -reverse isolation -airborne

contact Explanation: Any multidrug resistant organism requires contact precautions to help prevent the spread of the organism to others. This will include MRSA. Airborne precautions can be utilized with diseases in which the causative organism is passed through the air after the infected person has coughed, sneezed, or talked. Tuberculosis is an example. Droplet precautions are warranted when the disease is spread through large particle droplets such as rubella and mumps. Reverse isolation is used to protect the client from any new infectious organisms. This can be utilized for client's who may be immunocompromised or already have a serious infection and the nursing team is trying to prevent further infections from complicating the client's health.

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 contact precautions droplet precautions neutropenic precautions

contact precautions Explanation: Contact precautions should always be used when coming into contact with contaminated body fluids. Gown and gloves should be worn and protective eyewear if splashing may occur. Droplet precautions are used there is a risk of transmitting pathogens within a 3-foot (1-meter) radius of the client when sneezing, coughing, etc. Neutropenic precautions are for the protection of the client due to immunosuppression. Airborne precautions should be instituted when exposure to microorganisms are transmitted by airborne route may occur.

The school nurse is educating a group of teenagers about ways in which human immunodeficiency virus (HIV) can be transmitted. Which methods of infection transmission will the nurse educate the group about? Select all that apply. -contact with wound openings -via mucous membranes -contact with blood -via syringes shared between the client and others -contact with sweat -via sexual contact

contact with blood via sexual contact contact with wound openings via mucous membranes via syringes shared between the client and others Explanation: All of these (with the exception of sweat) can transmit HIV.

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

droplet Explanation: Streptococcal pneumonia is transmitted through droplets; therefore droplet contact precautions are appropriate. The other options are inappropriate.

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

droplet Explanation: Influenza is transmitted through droplets; therefore droplet contact precautions are appropriate.

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? airborne droplet none contact

droplet Explanation: Whooping cough is transmitted through droplets; therefore droplet precautions are appropriate.

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? none droplet contact airborne

droplet Explanation: Whooping cough is transmitted through droplets; therefore droplet precautions are appropriate.

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 handwashing before leaving the client's room make contact between two clean surfaces

handwashing before leaving the client's room Explanation: 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 teaching a client the correct procedure for pouring a sterile solution. Which client action indicates the need for further education from the nurse? placing the cap upside down on the table pouring the solution slowly pouring out a small amount of the solution and discarding holding the container off to the side

holding the container off to the side Explanation: 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 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? bath blanket indwelling catheter face shields specimen containers

indwelling catheter Explanation: Infections are often transmitted to older adult clients through equipment reservoirs (e.g., indwelling urinary catheters, humidifiers, and oxygen equipment) or through incisional sites, such as those for intravenous tubing, parenteral nutrition, or tube feedings. Use of proper aseptic techniques is essential to prevent the introduction of microorganisms. Bath blankets, face shields, and specimen containers are not part of the equipment reservoir that transmits infection easily, because they are disposed of immediately after one-time use.

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique? -inserting an arm within each sleeve while touching the outer surface of the gown -unfolding the gown while avoiding contact with the floor -holding the gown away from the body and other unsterile objects -picking up the gown at the sterile neckline

inserting an arm within each sleeve while touching the outer surface of the gown Explanation: To maintain sterile technique while donning the sterile gown, the gown should be picked up at the sterile neckline to preserve the sterility of the outer gown surface. Holding the gown away from the body and any unsterile surfaces or objects prevents contamination of the sterile gown. Allowing the gown to unfold and not touch the floor in the process will prevent contamination. The nurse should intervene and supply a new gown when observing the surgical technician touching the outer surface of the gown.

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique? unfolding the gown while avoiding contact with the floor inserting an arm within each sleeve while touching the outer surface of the gown picking up the gown at the sterile neckline holding the gown away from the body and other unsterile objects

inserting an arm within each sleeve while touching the outer surface of the gown Explanation: To maintain sterile technique while donning the sterile gown, the gown should be picked up at the sterile neckline to preserve the sterility of the outer gown surface. Holding the gown away from the body and any unsterile surfaces or objects prevents contamination of the sterile gown. Allowing the gown to unfold and not touch the floor in the process will prevent contamination. The nurse should intervene and supply a new gown when observing the surgical technician touching the outer surface of the gown.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? -keeping sterile field above waist level -opening the sterile package toward the nurse to prevent reaching over -putting on sterile gloves before opening sterile package -maintaining a 3-in. (7.5-cm) border around the sterile field

keeping sterile field above waist level Explanation: When setting up a sterile field, the correct technique is to keep the sterile field above the waist level. A nurse would open the sterile package away from him- or herself first. The sterile gloves are applied after the sterile container is opened. The sterile field is maintained with a 1-in. (2.5-cm) border.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? opening the sterile package toward the nurse to prevent reaching over putting on sterile gloves before opening sterile package keeping sterile field above waist level maintaining a 3-in. (7.5-cm) border around the sterile field

keeping sterile field above waist level Explanation: When setting up a sterile field, the correct technique is to keep the sterile field above the waist level. A nurse would open the sterile package away from him- or herself first. The sterile gloves are applied after the sterile container is opened. The sterile field is maintained with a 1-in. (2.5-cm) border.

The nurse is caring for a client who has been hospitalized and placed in airborne precautions for a week. Which nursing intervention is appropriate to provide sensory stimulation? -communicate with the client only through the intercom -encourage family and friends to visit more often -move the bed and furnishings to a different place in the room -take the client outside for fresh air

move the bed and furnishings to a different place in the room Explanation: To promote sensory stimulation, move the bed and furnishings around in the room. The client cannot be transported outside without risking infecting others. Family and friends may not be able to visit more without exposing themselves to infection or bringing further infection to the client. Communicating only through the intercom is not appropriate, as the client will still need hands-on care as well.

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

noncommunicable disease Explanation: A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe an illness that is contracted after eating food.

A nurse is caring for four clients. Which client has the highest risk of infection? woman in second trimester of pregnancy toddler with a benign heart murmur young woman with a history of scoliosis older male with an enlarged prostate

older male with an enlarged prostate Explanation: An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on infection.

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse? discarding any unused sterile solution placing the cap on the table with edges down pouring the sterile solution from a height of 5 in. (13 cm) touching the tip of the bottle to the sterile container to avoid splashing

older male with an enlarged prostate Explanation: An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on infection.

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds? one that remains in the client's room one that is the nurse's personal stethoscope one that the client has personally purchased for use one that remains directly outside the client's room

one that remains in the client's room Explanation: A dedicated stethoscope and blood pressure cuff should remain in the client's room. The other answers are incorrect.

The nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent clients from getting the infection? -perform meticulous hand hygiene and don a new mask with each client encounter -wear a mask and don gloves with each client encounter until symptoms are completely gone. -perform meticulous hand hygiene -only accept clients who are not immune compromised and perform meticulous hand hygiene

perform meticulous hand hygiene and don a new mask with each client encounter Explanation: The nurse with a mild upper respiratory infection should don a new mask and practice meticulous hand hygiene with each encounter with a client. Hand hygiene alone will not control transmission of the infection. All clients are at risk for infection, not just those who are immune compromised. The window for being contagious varies dependent on the microorganism. The absence of a fever is not always an indication that the microorganisms can't be transmitted. Gloves are not specifically needed if hand washing procedures are followed with each contact.

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? teach that a gown and shoe coverings must be worn in addition to gloves do nothing, as the precautions observed are appropriate remind the student that a fitted N95 respirator is required offer the student a mask

remind the student that a fitted N95 respirator is required Explanation: A fitted N95 respirator must be worn in addition to other precautions when caring for clients with pulmonary tuberculosis. The other answers do not recommend the appropriate precautions that must be used for this type of infection.

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 asks the client to state name and date of birth applies a mask with face shield performs hand hygiene before donning gloves

removes gloves and walks out of the room Explanation: The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used as barriers to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients. Asking the client to state his or her name and date of birth is important to make sure the specimen is collected with the correct laboratory label. To protect the UAP from direct contact with the urine, a face mask is indicated.

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: airborne precautions. standard precautions. droplet precautions. contact precautions.

standard precautions. Explanation: Standard or universal precautions relate to blood and certain body fluids to protect health care workers from clients possibly carrying HIV, hepatitis B virus, or other bloodborne pathogens. Reference:

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? -sterile drape positioned with the moisture-proof side facing up -sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field -sterile gloves, removed from the outer wrapping, 4 in (10 cm) away from the edge of the sterile field -sterile drape hanging off the work surface

sterile drape positioned with the moisture-proof side facing up Explanation: If the sterile drape is placed with the moisture-proof side up, it will become contaminated if it gets wet. It is acceptable to place gloves away from the field and to place gauze on the field. The edges commonly overhang the end of the table slightly, and this is acceptable.

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. body-substance isolation. droplet precautions. reverse precautions.

universal precautions. Explanation: Universal precautions protect health care workers from the blood and certain body fluids of clients who may be carrying HIV, hepatitis B virus, or other bloodborne pathogens.

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first? -PICC line -urinary catheter -endotracheal tube -Salem sump nasogastric tube

urinary catheter Explanation: Urinary catheters account for the highest percentage (26%) of hospital-associated infections. The four most common types of HAIs are related to invasive devices or surgical procedures: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated events (VAEs). A peripherally inserted catheter is an invasive line. Nasogastric tubes and endotracheal tubes are not associated with HAIs.

Which is not appropriate regarding the use of gowns as PPE? -use of one gown per person per shift -donning a gown when splashing -use of a new gown each time the nurse enters the room -use of paper or cloth gowns

use of one gown per person per shift Explanation: A new gown should be used by the nurse each time the nurse enters the client's room.

Which nursing action demonstrates safe injection practice? -recap needles if necessary -use sterile single-use disposable syringes for each injection -use multiple-dose vials when administering medication to multiple clients -clean injection equipment when dust becomes visible

use sterile single-use disposable syringes for each injection Explanation: Sterile single-use disposable syringes reflect safe injection practice. All the other actions are unsafe.

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse? fill out a risk management form wash the area with soap and water go to employee health for testing find out who left the scalpel blade on the procedure tray

wash the area with soap and water Explanation: The first action by the nurse should be to wash the hands gently with soap and water to reduce exposure of blood or pathogens to the wound. Filling out a risk management form is required but should be done after immediate first aid care. Finding out who left the blade on the tray is not relevant at this time, but further education for the unit may be required at a later time. Going to employee health is the step that will be taken after immediate first aid.

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? placing the client in a regular, private room wearing a face mask when entering and staying at a distance from the client wearing a particulate respirator for all care and interaction with this client wearing protective eye wear for contact with this client

wearing a particulate respirator for all care and interaction with this client Explanation: To prevent the transmission of TB, the National Institute for Occupational Safety and Health recommends the use of a particulate air filter respirator that fits snugly to the face for all client care and interaction. A face mask does not block small TB particles effectively. Protective eyewear is only needed if contact with bodily fluids is expected. The client would be placed in a negative pressure room to prevent the potential spread of TB.