ch.24 Asepsis and Infection Control
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. -Usually when a client is being screened for a parasitic infection, stool specimens are collected daily for 3 days. Parasites lay eggs in the GI tract that can be detected on examination. Moving organisms can easily be detected in fresh specimens.
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.
What is the primary goal of the observable action associated with the removal of contaminated gloves?
- Prevent contamination of ungloved hand The outside of gloves are considered contaminated and care must be take to prevent contamination of the ungloved hand during the glove removal process. Sliding fingers of the ungloved hand under the remaining glove at the wrist helps avoid contact with the contaminated outer surface of the remaining glove. While proper removal of the contaminated glove does preserve the cleanliness of the ungloved hand, contamination and not general cleanliness, is the primary focus of the ungloving process. Neither speed nor tearing is the focus of this process.
signs and symptoms of infection.
- fever, increased respiratory rate, lymph node enlargement
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. 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?
Airborne
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 -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?
Avoid contact with mosquitoes
Deficient Knowledge related to prescribed antibiotic therapy.
The client will state how to safely take the prescribed antibiotic.
The charge nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction?
The new nurse slides the item from the wrapper into the side of the sterile field
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?
Use a sterile intravenous catheter.
In which situation is an alcohol-based rub not the appropriate option for hand hygiene?
When the nurse's hands are visibly soiled
Which client would require a negative flow room?
an 81-year-old man with active tuberculosis and a productive cough
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 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. -t 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.
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. -As a person ages, there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to infection.
The process of phagocytosis involves:
digestion of microbes by white blood cells -Many leukocytes function as phagocytes, digesting and destroying microbial invaders.
A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?
helps to determine prescribed antibiotic therapy
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?
migration of leukocytes to the area of the wound
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
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.
an indwelling urinary catheter inserted. precaution procedure?
surgical asepsis technique
Which of the following are considered the building blocks of the immune system?
t lymphocytes T and B lymphocytes are the building blocks of the immune system, accumulate in lymph nodes along lymphatic vessels, and are exposed to all antigens except those that enter the bloodstream directly.
The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response? You Selected:
encourage the colleague to remove the glove by grasping the cuff (한쪽 장갑의 소매부분을 잡아 당기면서 벗는다)
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day 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 -Hand hygiene is the most important way to prevent transmission of infection.
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.
The local high school has be exposed to methicillin-resistant Staphylococcus aureus (MRSA) infection and the school nurse is preparing an education plan on prevention of MRSA. Which steps should the nurse include? Select all that apply.
20-second handwashing online research on MRSA keep draining wounds covered use of hand sanitizer when necessary
Which term describes foreign particles that enter a host and stimulate the body's immune response?
Antigen Antigens are foreign particles, such as microbes, that enter a host.
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
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
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.
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 -If you realize a supply is missing after setting up the sterile field, you should call for help. Leaving the sterile field unattended renders it contaminated
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. (IPFC)
Incubation period Prodromal stage Full stage of illness Convalescent period
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?
Perform hand hygiene
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 -Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.
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
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 touches an unsterile object to the instrument tray. The nurse's back is facing the sterile field.
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
To eliminate needlesticks as potential hazards to nurses, the nurse should:
immediately deposit uncapped needles into a puncture-proof plastic container. -All uncapped needles should be placed in a puncture-proof plastic unit immediately after use.
A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.
increased respiratory rate lymph node enlargement fever -Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, and lymph node enlargement
A nurse is working with a young woman, age 15, in a community health clinic. It is early October, and the young woman is worried that she will become ill and miss school, stating "I am always getting sick this time of year." What health promotion activities are appropriate to include in the nurse's teaching today? Select all that apply.
information on sleep hygiene administration of influenza immunization proper handwashing techniques -It is not necessary for the client to shower with harsh soaps. This may actually lead to drying of the skin and decreased skin integrity, which is the first barrier to infection.
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? (taste, smell, vision, hearing, and touch.)
move the bed and furnishings to a different place in the room
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
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 : the nonspecific symptoms that occur before the body temperature rises. onset or invasion phase : an elevation in body temperature, as well as symptoms stationary phase : when the fever is sustained. the resolution or defervescence phase : the returns to the child's baseline temperature
The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?
remove gloves, remove gown, wash hands
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
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
The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?
staff education on utilizing hand hygiene -Hand hygiene is the most effective way to decrease the transmission of infections or pathogens in the health care setting. Educating staff on hand hygiene would be the best intervention to implement. Providing alcohol-based hand sanitizer to all clients will encourage hand hygiene, but will not decrease transmission from health care providers. Restricting visitors to those older than 12 years of age will not decrease transmission. Having visitors with a cough or cold wear a mask will decrease transmission to the clients, but will not decrease health care associated infections.
A nurse is palpating the cervical lymph nodes of a client with a suspected upper respiratory infection. Which finding would help to support the suspicion of an infection?
tenderness -Normally, cervical lymph nodes are smaller than 1 cm in diameter, soft, and mobile. Tenderness on palpation would suggest a problem, such as infection.
The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?
-Perform hand hygiene 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.
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 T-lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.
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 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?
contact
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
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? -staphy aureus : direct contact with an infected person, by using a contaminated object, or by inhaling infected droplets dispersed by sneezing or coughing
removes gloves and walks out of the room
The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.
"If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus to my child during pregnancy and childbirth." "I may transmit the virus if I share needles with another person." -The client has demonstrated that an understanding of the transmission of the virus may occur through exposure to blood, during pregnancy and childbirth, and through sharing of needles. Transmission of the virus does not occur through sweat or by exposure on a toilet seat. The virus is fragile and does not live on inanimate objects.
The nurse is getting ready to change the client's saturated, infected leg dressing. The client requests that the nurse delay it until the night shift. Which response would the nurse provide this client?
"Saturated dressings increase the risk of the spread of infection." -Stagnant secretions in the body provide a warm, moist environment that fosters bacterial growth. Normal defense mechanisms prevent stasis of body fluids, but these can be altered. It is not advisable to change the dressing at a later date or just tell the client to not worry as these are not appropriate responses. Waiting for the incoming nurse and waiting until later delays the needed dressing change and can lead to infection.
The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?
"The way you are doing it helps to minimize contamination of the non-waterproof side." -The sterile drape is to be positioned with the drape on work surface with the moisture-proof side down. It is important that only a sterile object touch another sterile object. Unsterile touching results in contamination of the sterile field. If this occurs, the procedure should be started again with new supplies. It is not okay to turn the drape on the other, non-waterproof side. This action will increase the risk for contamination.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?
The nurse keeps fingernails less than 1/4 in (0.63 cm) long. -The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood. The nurse could use a hospital sanctioned hand moisturizer after hand hygiene, but this is not the best answer.