asepsis and infection control prep u
The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team?
"Avoid touching the outside of your gown when removing it."
The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?
"I have set up this sterile field for your procedure, so please do not touch anything around the tray."
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 obtain a mask from the staff and wash my hands before touching my family member."
Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?
"These barriers help prevent the transmission of infection to you or other people."
A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?
"Your white blood cells have increased in the area."
The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options
- Turn on the faucet and adjust force and temperature of the water. - Wet the hand and wrists. - Apply soap. - Wash the palms and backs of the hands for at least 20 seconds. - Pat the hands dry with a paper towel. - Turn the faucet off with a paper towel.
A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.
- exposure to the pathogen - nonspecific symptoms - positive laboratory tests - return of appetite
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.
- gloves - gown - mask with face shield
Nursing students are reviewing information about healthcare-associated infections (HAI). What would the students expect to find as a possible risk factor? Select all that apply.
- use of steroid therapy - insertion of invasive devices - multiple wounds - use of antibiotic therapy
A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:
3 days.
The nurse is caring for four clients. Which client presents the most susceptibility for infection?
46-year old with a foley catheter following anesthesia
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?
A commercially packaged surgical item is not considered sterile if past expiration date.
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
Which term describes foreign particles that enter a host and stimulate the body's immune response?
Antigen
When providing care to a incontinent client with a history of methicillin-resistant Staphylococcus aureus (MRSA), what is the priority goal for the nurse's observable intervention?
Avoiding the introduction of microorganisms to the nurse's uniform
When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?
Discard the bottle and get a new one because the saline has expired.
A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?
Early infection treatment is needed to prevent the spread of infection.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract
Which mask should the nurse don when caring for a client with tuberculosis?
Filtered respirator
Which piece of personal protective equipment (PPE) should be removed first?
Gloves ( The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.)
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
Hold sterile objects above waist level to prevent inadvertent contamination.
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 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).
A nurse is inserting a male client's indwelling urinary catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he has brought the wrong-sized catheter to the bedside. What is the nurse's best action?
Illuminate the client's call light and have a colleague bring the correct catheter to the bedside.
Infection control is foremost for all health care providers. Which example best interferes with the chain of infection?
Inform the family to avoid visiting the client while they are sick
A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?
Inform the physician about this finding.
A nurse has put on personal protective equipment (PPE) to perform the dressing change of a client's surgical wound. While the nurse is cleansing the incision, the client begins bleeding and blood hits the nurse's wrist, running down under the cuff of her glove. What is the nurse's best action?
Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol.
A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumoniae, which is particularly prone to cause infections, also referred to as what?
Pathogenic
The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?
Remove fresh fruit from the room.
The nurse is caring for a client that is suspected of having a latex allergy. What item of personal protective equipment should the nurse use with caution?
Surgical masks
A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?
T-lymphocytes
A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?
The client's immune system became further weakened
Which should be documented by the nurse?
The fact that sterile technique was used for a given procedure
Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?
These barriers help prevent the transmission of infection to you or other people."
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?
Use a sterile cotton-tipped applicator to apply the prescription to the site
Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?
Virus
A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?
Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.
Surgical asepsis is defined as:
absence of all microorganisms.
Since older adults do not always have a fever with an infection, the extended-care facility personnel should observe client for:
agitation.
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
airborne
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?
an older adult client with a history of heart failure
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria
The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:
bacterial infection.
The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?
be sure that there are gloves of various sizes and gowns for use
The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?
changing the soiled dressing
After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:
decreased cellular immunity
The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?
handwashing
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?
handwashing before leaving the client's room
A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?
indwelling catheter
The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?
into a private room
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?
noncommunicable disease(A noncommunicable disease is caused by food or environmental toxin.)
The most common infection in children is:
respiratory.
An infection or the products of infection carried throughout the body by the blood is called:
septicemia
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?
surgical asepsis
The nurse observes a member of the care team removing a gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?
teach the colleague to let the gown fall away rather than pulling on the sleeves
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?
urinary catheter
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift
Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?
wearing a particulate respirator for all care and interaction with this client
The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:
within normal limits