Ch. 23: Asepsis and Infection Control, NUR 209 Ch. 23 Asepsis (Fundamentals of Nursing), Chapter 23 PrepU, Taylor's Chapter 23: Prep U
A home health nurse is completing a health history for a patient. What is one question that is important to ask to identify a latex allergy for this patient? (page 548)
"Have you had any unusual symptoms after blowing up balloons?
A home health nurse is completing a health history for a patient. What is one question that is important to ask to identify a latex allergy for this patient?
"Have you had any unusual symptoms after blowing up balloons?"
A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1 p.m. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?
3pm
A nurse is preparing an operation theater for a surgical procedure. Which of the following points regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? (page 565)
A commercially packaged surgical item is not considered sterile if past expiry date.
Health care professionals are required to follow certain principles to ensure that nosocomial infections do not occur in the health care facility. Which of the following contributes to infections during health care?
A health care professional donning artificial nails
Which practice is a correct application of infection control practices? (page 542)
A nurse performs handwashing each time she removes a pair of gloves
Which patient would the nurse consider the most infectious?
A patient who is in the prodromal stage
Surgical asepsis is defined as (page 539)
Absence of all microorganisms
Which of the following is an accurate guideline for removing soiled gloves after client care?
After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.
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?
Alcohol-based handrubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, EXCEPT when the health care worker's hands are visibly soiled.
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? (page 537)
An 80-year-old woman
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room.
Nurses use medical asepsis in practice to reduce the number and transfer of pathogens. Which of the following are principles of this practice? Select all that apply.
Carry soiled items, including linens, equipment, and other used articles, away from the body to prevent them from touching the clothing. Do not place soiled bed linen or any other items on the floor, which is grossly contaminated; it increases contamination of both surfaces. Move equipment away from you when brushing, dusting, or scrubbing articles. Clean the least soiled areas first and then move to the more soiled ones. Use personal grooming habits that help prevent spreading microorganisms; shampoo your hair regularly. Do not shake linens. Dust and lint particles constitute a vehicle by which organisms may be transported from one area to another.
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.; Tuberculosis is transmitted via the air, thus airborne precautions are required. Other answers are incorrect.
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?
Cleanse and disinfect the sphygmomanometer
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? (page 546)
Cleanse and disinfect the sphygmomanometer
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission? (page 534)
Contact
A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control?
Contact precautions; Contact precautions are used with organisms that can be transmitted by hand- or skin-to-skin contact (e.g., during client care activities or when touching the client's environmental surfaces or care items) such as with a client with impetigo (a contagious bacterial skin infection forming pustules and yellow, crusty sores) Airborne precautions are used to protect against microorganisms transmitted by small-particle droplets that can remain suspended and become widely dispersed by air currents, such as tuberculosis or measles. Droplet precautions are used for microorganisms transmitted by larger-particle droplets which disperse into air currents, such as H. influenzae or M. pneumoniae. Protective isolation is used to prevent infection for people whose body defenses are known to be compromised, such as those who are neutropenic secondary to chemotherapy.
You are donning a pair of sterile gloves. You correctly don the first glove, but inadvertently insert the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which of the following actions is most appropriate?
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene? (page 542)
Decontaminate hands using an alcohol-based hand rub
When leaving the room of a client requiring contact precautions after helping an unlicensed personnel (UP) bathe the client, the nurse observes the unlicensed personnel taking gloves off by grasping the inside of one gloved hand with the opposite gloved hand and peeling it off. What is the proper action of the nurse?
Demonstrate proper glove removal to the unlicensed personnel: It is important for the unlicensed personnel to learn how to remove gloves correctly. The nurse should demonstrate proper glove removal to the unlicensed personnel. There is no need to report the unlicensed personnel to the unit manager. Reassigning the unlicensed personnel is not appropriate.
When a nurse picks up a client's contaminated tissue without gloves and fails to wash his hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?
Direct contact
A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? (page 534)
Escherichia coli in the intestinal tract
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
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli resides in the intestinal tract, is normal flora, and does not cause harm or infection in the client.
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? (page 544)
Exogenous healthcare-associated
A nurse is caring for a client with ringworm. Which of the following microorganisms causes ringworm in a client?
Fungi
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?
Fungi; 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 nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution(s) should the nurse use? (Select ALL that apply.) (page 548)
Hand hygiene Non-sterile gloves
A lead nurse is removing her personal protective equipment after dressing the infected wounds of a client. Which of the following is the highest priority nursing action? (page 542)
Handwashing before leaving the client's room
A nurse changing the linens of a patient bed is exposed to urine and performs hand hygiene. Which of the following is a guideline for performing this skill properly following this patient encounter?
Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms.
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 follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique? (page 553)
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? (Page 568)
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 inches (10 to 15 cm).
Which of the following is an accurate guideline for the use of PPE?
If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas.
To eliminate needlesticks as potential hazards to nurses, the nurse should
Immediately deposit uncapped needles into puncture-proof plastic container
To eliminate needlesticks as potential hazards to nurses, the nurse should: (pages 552)
Immediately deposit uncapped needles into puncture-proof plastic container.
To eliminate needlesticks as potential hazards to nurses, the nurse should:
Immediately deposit uncapped needles into puncture-proof plastic container.; All uncapped needles should be placed in puncture-proof plastic units immediately after use.
The nurse working with the hospital's infection control team is attempting to decrease the transmission of health care-associated pathogens. Which of the following will be most effective? (page 540)
Incentivizing health care workers to utilize hand hygiene
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? (page 535)
Indwelling catheter
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 of the following equipment can transmit infection to older adult clients?
Indwelling catheter: 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.
A nurse changing the linens of a patient bed is exposed to urine and performs hand hygiene. Which of the following is a guideline for performing this skill properly following this patient encounter? (page 559)
Keep hands lower than elbows to allow water to flow toward fingertips.
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?
Long-term care residents and older adult hospitalized clients are at increased risk for antibiotic-resistant infections. Pneumonia, influenza, urinary tract and skin infections, and TB are common in older people, especially residents of long-term care facilities. These infectious diseases are not commonly seen in young adults, children, or pregnant women admitted to health care facilities
Which nursing action is a component of medical asepsis?
Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary or intravenous catheters).
A patient has sought care because of a knee wound that appears to have become infected. Which of the following processes is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?
Migration of leukocytes to the area of the wound
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? (page 536)
Older adult
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; Pathogenicity is an organism's ability to cause infections.
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 of the following actions by the nurse is appropriate? (page 551)
Place a surgical mask on the client and transport to the CT department at the specified time
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 of the following actions by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time. Transport clients in Airborne Precautions out of the room only when necessary and place a surgical mask on the client, if possible
Which of the following is an accurate guideline for the use of PPE? (page 570)
Replace gloves if they are visibly soiled.
A nurse is caring for a client with urinary incontinence and acute diarrhea. What is the highest priority nursing diagnosis for this client?
Risk of infection: Risk of infection is an appropriate nursing diagnosis for this client. Delay in providing personal care for the client puts the client at risk of developing infectious diseases like pneumonia and urinary tract infection, among others. Risk of loneliness, social isolation, or impaired walking may not be applicable.
The nurse is preparing a sterile field for a dressing change. How would the nurse add paper- wrapped sterile items to the sterile field?
Separate the sealed flaps and drop contents onto field.; Once a sterile field is set up, only sterile items can be placed on the field. To add paper-wrapped sterile items, after performing hand hygiene, the nurse would open the items by separating the sealed flaps and dropping the contents onto the sterile field. Wearing sterile gloves to open the package would containment the gloves. Opening the package away from the field would containment the sterile field. It is not necessary to set up a separate sterile field.
A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which of the following precautions should the nurse take when transporting the specimens?
Specimens should be placed in sealed plastic bags to prevent their becoming contaminated or causing the transmission of infective microorganisms. Paper bags are not used for this purpose and it is not customary to swab the outside of specimen containers. Standard precautions should be implemented, but this does not necessitate the use of a gown in all cases.
For which of the following clients would the use of Standard Precautions alone be appropriate?
Standard Precautions apply to blood and all body fluids, secretions, and excretions, except sweat. Transmission-Based Precautions are used in addition to Standard Precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as is the case in answers A, B, and D.
An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate?
Standard; The nurse should implement standard precautions, as these precautions are appropriate for all hospitalized patients. There is no indication that additional precautions such as airborne, droplet, or contact precautions are needed at this time.
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? (page 540)
Surgical asepsis
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? (page 553)
Surgical asepsis technique
The nurse is caring for a client with a Clostridium difficile (C. difficile) infection who states that she has not been able to go out with friends due to having C. difficile. When planning care for this client, which of the following would be the most appropriate nursing diagnosis?
The most appropriate nursing diagnosis for this client would be social isolation related to presence of a communicable disease. The client stated that she is not able to go out with friends due to having C. difficile, a communicable disease, thereby indicating social isolation. There is no indication that the client has an imbalance in body temperature, altered skin integrity, or a lack of visitors at this time.
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. (page 539)
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
A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated?
The nurse is caring for a client with a C. difficile infection.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.; When a client is diagnosed with tuberculosis it is important for the nurse to remember that the client should be placed in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The nurse must wear the appropriate respirator when caring for the client, but visitors must wear masks. Simply being 3 feet away will not keep the visitor from being exposed to the client. The nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis.
The nurse is setting up a sterile field to perform a catheterization when the patient touches the end of the sterile field. What would be the nurse's next appropriate action?
The nurse's next appropriate action would be to discard the sterile field and the supplies and start over. The client touching the end of the sterile field contaminated the field and the items on the field. The nurse cannot reuse the sterile equipment because the items are no longer sterile. The nurse cannot proceed with the procedure since the items have been contaminated. Calling for help and asking for new supplies is not the best answer. The field has been contaminated also.
The use of alcohol-based hand rubs for hand hygiene in healthcare facilities is approved by the Centers for Disease Control (CDC), but The Joint Commission (TJC) discourages its use.
This is false
A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room?
Thorough handwashing
The nurse is preparing to perform handwashing. Arrange the following 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 15 seconds. Pat hands dry with a paper towel. Turn the faucet off with a paper towel.
The nurse is preparing to perform handwashing. Arrange the following steps in the correct order. (page 559)
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. Turn the faucet off with a paper towel.
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
Vehicle; 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 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.
A nurse is caring for a patient who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on the QSEN competency of safety?
When a client is diagnosed with tuberculosis it is important for the nurse to remember that the client should be placed in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The nurse must wear the appropriate respirator when caring for the client, but visitors must wear masks. Simply being 3 feet away will not keep the visitor from being exposed to the client. The nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis.
Surgical asepsis is defined as
absence of all microorganisms
Which client presents the most significant risk factors for the development of Clostridium difficile infection? (page 543)
an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
Which of the following patients 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 client would require a negative flow room?
an 81-year-old man with active tuberculosis and a productive cough
Which client would require a negative flow room?
an 81-year-old man with active tuberculosis and a productive cough; Active tuberculosis always requires a negative flow room.
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
For which client would the use of standard precautions alone be appropriate? (page 550)
an incontinent client in a nursing home who has diarrhea
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea; Standard precautions apply to blood and all body fluids, secretions, and excretions, except sweat. transmission-based precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes.
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria.; Bacteria may be transmitted through air, food, water, soil, vectors, or sexual activity.
A client with HIV is the: (page 534)
carrier
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact; Fluids from a draining abscess can transmit infection through contact; therefore, contact precautions are appropriate.
An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative? (page 545)
diligent handwashing practices
A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts? (page 534)
exit route
Which nursing action is a component of medical asepsis? (page 539)
handwashing after removing gloves
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease; A noncommunicable disease is caused by food or environmental toxin
An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from: (page 552)
recapping a needle.
A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is? (page 535)
semen
A client has a systemic infection that resulted from an untreated urinary tract infection. The client has malaise and is confused. The client is:
septic.; Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.
An infection or the products of infection carried throughout the body by the blood is called:
septicemia.; Transport of an infection or the products of infection throughout the body by the blood is known as septicemia. Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.
The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart?
stethoscope that remains in the client's room; A dedicated stethoscope and blood pressure cuff should remain in the client's room when a client has been placed in contact isolation.
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus infection. What is the most important factor to prevent this infection
surgical asepsis
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; Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between patients, the nurse should see clients clean to dirty. The nurse should see the client who has no signs of infection first. The nurse should see the client who is post-operative first before seeing the other clients who have symptoms of infections.
The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action? (page 540)
to eliminate disease-producing organisms from the nurse's skin
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift
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:
within normal limits; A normal white blood cell count is 5,000 to 10,000 cells/mm3.
The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution(s) should the nurse use? (Select ALL that apply.)
• Non-sterile gloves • Hand hygiene