Ch. 23 (Asepsis and Infection Control)
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.
To eliminate needlesticks as potential hazards to nurses, the nurse should:
Immediately deposit uncapped needles into puncture-proof plastic container.
The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
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
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in (4 cm) from the outer edges.
The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority iintervention can the nurse include that is a first line of defense?
intact skin and mucous membranes.
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 home health nurse is completing a health history for a client. What is one question that is important to ask to identify a latex allergy for this client?
"Have you had any unusual symptoms after blowing up balloons?"
The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?
"Help me understand your perspective about vaccinating."
The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?
"When your sputum culture is negative."
A nurse at health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action is appropriate by the nurse when using masks?.
-Avoid touching the mask once it is in place. -Position the mask so that it covers the nose and mouth. -Touch only the strings of the mask during removal. -Change the mask every 20 or 30 minutes.
Which clients are at a heightened risk for infection? Select all that apply
-Client with an IV catheter -Client with an indwelling catheter -Client with gastric tube feeding
Unbeknown to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.
-Incubation Period -Prodromal Period -Full Stage of Illness -Convalescent Period
The nurse is preparing to perform hand washing. Arrange the steps in the correct order.
-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 20 seconds. -Pat hands dry with a paper towel. -Turn the faucet off with a paper towel
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 practice is a correct application of infection control practices?
A nurse performs hand washing each time she removes a pair of gloves
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 caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a non-particulate (N-95) respirator when entering the room.
A client with HIV is the:
Carrier
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?
Change to airborne precautions.
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
The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin?
Contact
The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?
Disinfect it with alcohol swabs.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract.
Which of the following masks should the nurse don when caring for a client with tuberculosis?
Filtered Respirator
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?
Fungi
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?
Hand Washing
A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter?
Keep hands lower than elbows to allow water to flow toward fingertips.
The nurse is caring for a client who has a colonized infection. What assessment data does the nurse anticipate collecting?
No signs or symptoms
A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection?
Older adult
When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. Which of the following is the appropriate action by the nurse?
Perform hand hygiene after removing the glove
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?
Perform hand hygiene before and after entering the client's room.
The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?
Remove fresh fruit from the room.
A client has a systemic infection that resulted from an untreated urinary tract infection. The client has malaise and is confused. The client is:
Septic
An infection or the products of infection carried throughout the body by the blood is called:
Septicemia
The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?
Sterile field is kept above waist level.
The student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains:
Stress causes the body to release cortisol, which can increase the risk of infection.
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 planning to insert an indwelling urinary catheter into a client should utilize which of the following techniques?
Surgical asepsis
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:
Survival adaptation
The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?
The client who is 48-hours post-surgical procedure
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the appropriate use of hand hygiene?
The nurse keeps fingernails less than 1/4 inch long
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
Standard precautions apply to blood; all body fluids, secretions, and excretions; intact and nonintact skin and mucous membranes.
True
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
A nurse who has finished cleansing and dressing the wound of a young client now needs to change the dressings of a client in the burn unit. Which action should the nurse perform, keeping in mind the importance of asepsis and client comfort?
Wash hands thoroughly and then wear sterile gloves.
The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based handrub is appropriate in which of the following situations?
When hands are visibly soiled
Surgical asepsis is defined as:
absence of all microorganisms.
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?
an older adult client with a history of heart failure
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?
gown and gloves
Which nursing action is a component of medical asepsis?
hand washing after removing gloves
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
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease
An infection-control nurse is discussing needle stick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needle stick injuries result from:
recapping a needle.
A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is:
semen.
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift
