ch. 24 PrepU Fundamentals
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?
"As we age, our immune system does not function as well."
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."
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."
The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?
"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a nonparticulate (N-95) respirator when entering the room.
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 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. Saline expires after 24 hours of opening.
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.
The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?
Open a new sterile dressing kit
The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?
Perform hand hygiene.
Which of the following are considered the building blocks of the immune system?
T lymphocytes
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 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
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 hand rub is appropriate in which situation?
When hands are visibly soiled
The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?
applying a new dressing with the gloves that were used to remove the old dressing
The process of phagocytosis involves:
digestion of microbes by white blood cells.
Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.
droplet precautions contact precautions airborne precautions
Which nursing action is a component of medical asepsis?
handwashing after removing gloves
To eliminate needlesticks as potential hazards to nurses, the nurse should:
immediately deposit uncapped needles into a puncture-proof plastic container.
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 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
The most lethal infection in an older adult client is:
urinary.
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 postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?
Assess client's pain level and manage pain accordingly.
The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?
Create an area for sterile field and opening packages
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.
The nurse is providing care for a client with varicella. What action should the nurse perform?
Ensure the client is housed in a negative pressure room.
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
Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process? Select all that apply.
Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.
The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?
Putting on gloves. A draining abscess poses an infection control risk that is sufficiently addressed with contact precautions. Because there is no obvious risk of airborne or droplet transmission, masks, goggles, and face shields are not warranted.
An operating room (OR) nurse on the facility's infection control team notices that a coworker in the OR is wearing artificial nails. What is the appropriate action/response by the nurse?
Remind coworker that artificial nails increase infections
What is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled.
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
The nurse is caring for a client with a cough and copious secretions. Before providing care, the nurse observes the licensed practical nurse (LPN) standing outside the client's room and donning personal protective equipment as shown above. How should the nurse best interpret the LPN's actions?
The LPN is donning personal protective equipment appropriately.
The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply.
The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room.
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 is talking with the scrub nurse over the sterile field. The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
A nurse instructs a new mother on immunizations. An immunization produces:
active immunity
When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:
an older adult can have an infection without a fever.
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 tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?
change to airborne precautions
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?
prodromal
Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care?
skin is dry and intact
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
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 antibiotic therapy multiple wounds use of steroid therapy insertion of invasive devices
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 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.
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?
contact precautions
A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?
intravenous antibiotic administration
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.
What is the primary purpose for the demonstrated glove application?
Cover exposed wrist skin