Chapter 24: Asepsis and Infection Control

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate? "Stress leads to increased secretion of cortisol, which suppresses your immune response." "Stress causes body fluids to accumulate, which leads to bacterial growth." "Stress leads to a deterioration in the skin's barrier line of defense." "Stress causes the body's normal immune response to turn on itself."

"Stress leads to increased secretion of cortisol, which suppresses your immune response."

The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?

*gloves and gown picture 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.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? Limiting visitors to family members over the age of 18 Encouraging visitors to adhere to isolation precautions Incentivizing health care workers to utilize hand hygiene Revising the facility's infection control protocols

Incentivizing health care workers to utilize hand hygiene

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? Fomite Contact Airborne Droplet

airborne

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

airborne

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? contact airborne none droplet

airborne

For which client would the use of standard precautions alone be appropriate? a client with TB who needs medications administered a child with chickenpox who is treated in the emergency room a client with diphtheria who needs p.m. care an incontinent client in a nursing home who has diarrhea

an incontinent client in a nursing home who has diarrhea

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? infectious disease contagious disease noncommunicable disease communicable disease

noncommunicable *A noncommunicable disease is caused by food or environmental toxin.

The most common infection in children is: gastrointestinal. respiratory. neurologic. urinary.

respiratory

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor? picks up the glove at the folded edge with the thumb and forefinger stretches the glove over the hand without touching the unsterile area washes hands for 20 seconds with soap and water reaches down to the bed to pick up a sterile drape

reaches down to the bed to pick up a sterile drape

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 microbial precautions contact precautions body fluid precautions respiratory precautions droplet precautions

airborne contact droplet

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? placing the client in a regular, private room wearing a particulate respirator for all care and interaction with this client wearing a face mask when entering and staying at a distance from the client wearing protective eye wear for contact with this client

wearing a particulate respirator for all care and interaction with this client

The nurse is caring for a client admitted with tuberculosis. The client asks why the nurse wears a respirator, gown, and gloves whenever they are in the room. How should the nurse respond? "This equipment is just standard precautions for all clients." "The droplet precautions are to protect me from the tuberculosis." "Because of the tuberculosis, I need to follow airborne precautions for protection." "I wear the equipment to protect you from anything I could give you."

"Because of the tuberculosis, I need to follow airborne precautions for protection."

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." "Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." "If you do not wear gloves you will also get the infection." "Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it."

"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 educating a client with human immunodeficiency virus (HIV) on a new antiviral medication. Which client statement indicates a need for further teaching? "This medication will limit the viral load in my body." "I will need to take the medication every day." "This medication will cure me of this virus." "The medication will stop the virus from multiplying."

"This medication will cure me of this virus."

A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse? "You cannot be admitted to the hospital with pneumonia without receiving some sort of antibiotics." "We give antibiotics to treat the virus that are causing your the pneumonia." "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." "The antibiotics we are giving you will boost your immune system and help fight off whatever pathogen is present."

"We are giving you broad spectrum antibiotics because they are active for many types of bacteria."

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 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. The nurse is exiting a room after completed indwelling urinary catheter care. The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has assisted a client with changing and caring for a new colostomy.

-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. -The nurse is going from one room to another to introduce themself at the start of the shift.

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. Place used syringes and uncapped needles in a puncture-resistant container after use. Use sealed items from the client's room when caring for other clients. Wear clean gloves when performing a sterile dressing change. Instruct the client to ambulate in the hall several times a day. Wash hands after removing gloves before leaving the client's room.

-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 assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply. absence of pain increased respiratory rate decreased pulse rate fever lymph node enlargement

-increased respiratory rate -fever -lymph node enlargement

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? Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container. Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening. Discard the bottle and get a new one because the saline has expired. Since the bottle has been open, previously used, and unexpired, "lip" it by pouring a small amount into a waste container or waste cup.

Discard the bottle and get a new one because the saline has expired. *Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening.

The nurse is preparing to help mobilize a client with an abdominal wound that is colonized by methicillin-resistant Staphylococcus aureus (MRSA). Which of the shown actions should the nurse perform before assisting the client?

Drug-resistant wounds normally require contact precautions. This necessitates the use of gloves and a gown but not a mask, goggles, or face shield.

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? There is really nothing that can be done to prevent childhood illness. It is recommended that infection in children be allowed to run its course to build immunity. Early infection treatment is needed to prevent the spread of infection. Grouping infectious children together helps to prevent future infection.

Early infection treatment is needed to prevent the spread of infection.

The student nurse observes another nurse wash her hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium Difficile (C diff). Why is this behavior incorrect? The nurse must make sure that the bathroom has been cleaned recently before washing her hands. The bathroom is highly contaminated with the Clostridium difficile bacteria. The behavior is not a problem as long as the nurse uses gloves in the room. Clostridium difficile bacteria is eradicated by the use of hand sanitizer only.

The bathroom is highly contaminated with the Clostridium difficile bacteria.

A nurse has identified the client's lack of knowledge regarding their prescribed antibiotic therapy. Which outcome is appropriate for the nurse to include in the client's care plan based on this nursing concern? The client demonstrates the proper technique for hand hygiene. The client will verbalize measures appropriate to minimize infection transmission. The client will identify signs and symptoms of worsening infection. The client will state how to safely take the prescribed antibiotic.

The client will state how to safely take the prescribed antibiotic.

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 top flap of the package is opened away from the new nurse's body. The sterile field is set up at waist level. The new nurse touches 1.5 in (4 cm) from the outer edges. Direct visualization of the sterile field is maintained.

The new nurse touches 1.5 in (4 cm) from the outer edges. *Only the outer 1 in (2.5 cm) of the sterile package is safe to touch

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? endotracheal tube PICC line Salem sump nasogastric tube urinary catheter

Urinary catheter

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 a school-age child who is current with immunizations an adolescent who has a right radial fracture a middle-aged adult who takes prescribed medication to control blood pressure

an older adult client with a history of heart failure

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? fold soiled side to the inside and roll with inner surface exposed fold soiled side to the outside and roll with inner surface exposed fold soiled side to the outside and roll with outer surface exposed fold soiled side to the inside and roll with outer surface exposed

fold soiled side to the inside and roll with inner surface exposed

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? wear a mask and gown in the client's room avoid direct contact with the client perform hand hygiene before and after entering the client's room wear gloves when touching the client

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 is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse? placing the cap on the table with edges down pouring the sterile solution from a height of 5 in. (13 cm) discarding any unused sterile solution touching the tip of the bottle to the sterile container to avoid splashing

pouring the sterile solution from a height of 5 in. (13 cm) *Sterile solutions can be poured onto a sterile field from a height of 4 to 6 in. (10 to 15 cm). The tip of the bottle should not touch the sterile container on the field. The cap should always be placed with edges up to maintain sterility. Unused solution can be labeled with date and time and stored for up to 24 hours.

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? performs hand hygiene before donning gloves applies a mask with face shield asks the client to state name and date of birth removes gloves and walks out of the room

removes gloves and walks out of the room *forgot hand hygiene

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? slight bleeding noted while old dressing is removed blanching over elbow area noted skin is dry and intact redness size over sacral area is with minimal increase

skin is dry and intact

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 admitted with diarrhea who tested positive for Escherichia coli (E. coli) the client admitted with a rash who reports recent exposure to measles the client who is 48-hours postsurgical procedure the client placed in contact isolation who was admitted with a draining abdominal wound

the client who is 48-hours postsurgical procedure

Which is not appropriate regarding the use of gowns as PPE? use of a new gown each time the nurse enters the room use of paper or cloth gowns donning a gown when splashing use of one gown per person per shift

use of new gown each time the nurse enters the room