Chap. 24: asepsis and infection control

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

"All visitors who enter the room must wear special masks."

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 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."

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 client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

"This antibiotic is the best choice since the causative organism is not known."

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:

"You may have infection in your birth canal that you are unaware of."

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 nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply.

- Pain with redness and swelling - Localized heat - Purulent or malodorous drainage

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

- airborne precautions - droplet precautions - contact precautions

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply.

- infectious disease - communicable disease - contagious disease

The nurse is monitoring a student who is performing surgical hand asepsis. Which student actions indicate the need for further education from the nurse? Select all that apply.

- wearing a gold wedding band - using at least five strokes for cleansing in each area - dropping hands to side when the wash is complete

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 1300. 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?

1500

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.

A nurse's gloves became soiled while providing morning care for a client. Which action best demonstrates that the nurse applied principles of infection control?

After removing the glove on the non dominant hand, hold the removed glove in the remaining gloved hand.

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

After the nurse has set up a sterile field for a dressing change, the nurse realizes that an essential item has been forgotten. How should the nurse proceed?

Ask another staff member to bring the forgotten item.

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

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

Discard the sterile field and the supplies and start over.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

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

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?

Hold sterile objects above waist level to prevent inadvertent contamination.

The nurse is caring for an older adult with pneumonia. What action by the nurse will help the client prevent further pulmonary infections?

Immunize the client with the pneumococcal vaccination once in a lifetime

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 hand washing, and document the exposure according to protocol.

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?

MRSA in the wound

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes 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 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.

Which should be documented by the nurse?

The fact that sterile technique was used for a given procedure

Personal protective equipment (PPE) is used in health care facilities for primarily which reason?

To protect both the staff and clients from becoming infected by one another

The nurse is caring for a postoperative client in contact isolation. Which actions should the nurse employ to reduce the spread of disease? Select all that apply.

Wash hands after removing gloves before leaving the client's room. Place used syringes and uncapped needles in a puncture-resistant container after use.

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.

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?

airborne

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

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?

avoid contact with mosquitoes

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

bacteria

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 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 an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact

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

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?

contact precautions

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

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gowns and gloves

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 lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

hand washing before leaving the client's room

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

has manicured nails that are 1-in. (2.5-cm) long

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?

health care-associated infection (HCAI)

To eliminate needlesticks as potential hazards to nurses, the nurse should:

immediately deposit uncapped needles into a puncture-proof plastic container

The nurse is admitting a client who has been receiving prescribed antibiotics for pneumonia. The client reports experiencing loose, watery stools for the past 4 days. What would be the initial action for the nurse to take?

implementing contact isolation

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

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

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

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 client care and interaction

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 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