Chapter 23

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."

Transient and resident bacterial flora can reside on the hands, so strict handwashing techniques are important. Where are resident bacteria most likely to reside?

In creases of the skin

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 is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

Surgical asepsis technique

An older adult patient has been diagnosed with a nosocomial respiratory infection and has been transferred to the intensive care unit. The nurse should understand what fact about the patient's illness?

The patient acquired the illness after he or she was admitted to the hospital.

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 gown, 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 appropriate nursing response?

These barriers help to prevent the transmission of infection."

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne

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

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 preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps, in the correct order, that the nurse should take when donning sterile gloves. All options must be used.

carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?

describing each step verbally to the client while performing the dressing change

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?

diligent handwashing practices

The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client?

droplet

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

health care-associated infection (HCAI)

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

The nurse manager is developing a plan to decrease the transmission of healthcare associated infections. What would be the best to implement?

staff education on utilizing hand hygiene

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 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 nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

Fungi

An infection or the products of infection carried throughout the body by the blood is called:

septicemia.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?

Review the current infection control protocols.

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?

contact

When is hand hygiene with an alcohol-based rub appropriate, as opposed to using handwashing?

when hands are not visibly soiled

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."

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 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.

An African-American international business traveler asks the public health nurse about his risks of acquiring malaria. The traveler states that he carries the sickle cell gene. The nurse explains:

Carrying the sickle cell gene prevents you from acquiring malaria."

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.

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

Which of the following clients should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?

Client with a urinary catheter

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.

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?

Exogenous healthcare-associated

Which of the following masks should the nurse don when caring for a client with tuberculosis?

Filtered respirator

The nurse is caring for a client with an active upper respiratory infection. How will the nurse dispose of the client's unconsumed beverages and used paper tissues?

Flush them down the toilet in the client's room.

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?

Indwelling catheter

When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days previous. What should the nurse do?

Obtain a new bottle of sterile saline

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 pneumonia, which is particularly prone to cause infections, also referred to as what?

Pathogenic

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?

Remind the student that a fitted N95 respirator is required.

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

The nurse is instructing a new mother on symptoms of infection in the newborn. Which of the following would the nurse include? Select all that apply.

Restlessness Poor feeding Lethargy

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.

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.

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse?

pouring the sterile solution from a height of 5 in (13 cm)

The nurse observes an unlicensed assistive personal (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 sexual intercourse with someone infected with HIV. The vehicle of transmission is:

semen

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