Chapter 24: Asepsis and Infection Control

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be mostappropriate? "It results from the swelling caused by the pain of the inflammation. "Your white blood cells have increased in the area." "It's just a sign that your wound is infected." "Metabolism in your wound tissues is increased."

"Your white blood cells have increased in the area."

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? "I can't transmit the virus other people if I shake their hands." "I probably got the virus when I sat on the toilet seat in a dirty bathroom." "I received a blood transfusion in 1989, which could be a factor in contracting the disease." "I may have gotten the virus when I got a tattoo while I was in prison."

"I probably got the virus when I sat on the toilet seat in a dirty bathroom."

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 A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft A client with renal failure who receives hemodialysis three times weekly

An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

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 Don a new pair of gloves to dispose of materials Wrap all used materials together and discard in biohazard container Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

Perform hand hygiene

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? contact vehicle droplet airborne

contact

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 sterile technique putting on gloves signs of healing

hand washing

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 Escherichia coli in the urinary tract Shigella in the intestinal tract Shigella in the urinary tract

Escherichia coli in the intestinal tract

A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.

exposure to the pathogen nonspecific symptoms positive laboratory tests return of appetite

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

ncreased respiratory rate lymph node enlargement fever

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

respiratory.

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? Avoid touching the outer surfaces of the gown. Remove the gown before removing gloves. Remove the gown immediately after exiting the room. Perform hand hygiene before removing the gown.

Avoid touching the outer surfaces of the gown.

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? Dip the IV catheter into an antiseptic before use. Clean the site with a disinfectant. Use a sterile intravenous catheter. Wear a mask and gown for the procedure.

Use a sterile intravenous catheter.

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from: viral infection. bacterial infection. chickenpox. hepatitis.

bacterial infection.

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? "It is possible that you are not washing your hands well enough." "As we age, our immune system does not function as well." "You will have to limit who comes to visit since they may be exposing you." "There are a lot of infectious processes around and there is nothing that can be done."

"As we age, our immune system does not function as well."

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response? "Vaccinations prevent disease." "Help me understand your thoughts about vaccinations." "Has your child received any previous vaccinations?" "Transmission of certain diseases is halted with vaccination."

"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? "Do not touch this, or I will have to start over. " "Everything is ready, I will leave the tray here for the provider." "I have set up this sterile field for your procedure, so please do not touch anything around the tray." "It is alright if you want to look at the supplies. Just be careful not to touch them."

"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 not visit my family member in the first 3 days of my cold." "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." "I will obtain a mask from the staff and wash my hands before touching my family member." "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."

"I will obtain a mask from the staff and wash my hands before touching my family member."

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? "I understand; wearing these items is not pleasant but it really isn't optional." "If you don't come into contact with anything with your body, you may wear gloves only, as long as you wash your hands after removing the gloves." "These barriers help prevent the transmission of infection to you or other people." "Wearing the gloves and gown prevents sharing additional microorganisms with the client."

"These barriers help prevent the transmission of infection to you or other people."

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." "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." "Drug resistance can develop when the wrong antibiotic is used for pneumonia." "Pneumonia is usually caused by multiple organisms."

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

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? "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." "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." "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 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? Discard it in the waste can. Do nothing; it can be used again immediately. Disinfect it with alcohol swabs. Sterilize it by placing it in the autoclave.

Disinfect it with alcohol swabs.

Which piece of personal protective equipment (PPE) should be removed first? Gloves Respirator Gown Goggles

Gloves

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely: Between 37.1°C and 38.2°C Above 38.2°C Greater than 40.5°C Between 35°C and 36.8°C

Greater than 40.5°C

To eliminate needlesticks as potential hazards to nurses, the nurse should: place the uncapped needle on a tray and carry it to the medicine room for disposal. immediately deposit uncapped needles into a puncture-proof plastic container. stick the uncapped needle into a Styrofoam block and deposit it in a plastic container. slide the needle into the cap and deposit it in a puncture-proof plastic container.

Immediately deposit uncapped needles into a puncture-proof plastic container.

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? Incentivizing health care workers to utilize hand hygiene Revising the facility's infection control protocols Encouraging visitors to adhere to isolation precautions Limiting visitors to family members over the age of 18

Incentivizing health care workers to utilize hand hygiene

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next? Inform the physician about this finding. Encourage the client to brush his teeth 3 times a day. Assess for the expiration dates of the antibiotics being administered. Inform the client that the antibiotics will resolve this problem.

Inform the physician about this finding.

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. Notify the CT department in advance so other clients and staff can be removed from the area. Question the need for the examination, because the client must remain under airborne precautions. Request that the examination be done at the bedside.

Place a surgical mask on the client and transport to the CT department at the specified time.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? Surgical asepsis Medical asepsis Universal precautions Contact precautions

Surgical asepsis

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? Neutrophils Eosinophils T-lymphocytes Monocytes

T-lymphocytes

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern? WBC of 7,500 mcL WBC of 25,000 mcL WBC of 5,500 mcL WBC of 10,500 mcL

WBC of 25,000 mcL

Surgical asepsis is defined as: absence of all virulent microorganisms. absence of all microorganisms. slowed growth of microorganisms. use of hand washing, gowning, and gloving.

absence of all microorganisms.

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

an incontinent client in a nursing home who has diarrhea

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

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: increased humoral immunity response. decreased cellular immunity. increased effectiveness of phagocytosis. decreased susceptibility to infection.

decreased cellular immunity.

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? encourage the colleague to remove the glove by grasping the cuff teach the colleague why the gloves should be removed outside the room maintain a distance of at least 5 ft (1.5 m) from the colleague take no action at this time

encourage the colleague to remove the glove by grasping the cuff

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? permits selection of antibiotic concentration helps in reducing proliferation of multidrug-resistant organisms narrows the therapeutic range to avoid prolonged use helps to determine prescribed antibiotic therapy

helps to determine prescribed antibiotic therapy

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

noncommunicable disease

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? adult child older adult pregnant woman

older adult

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 gloves when touching the client 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

perform hand hygiene before and after entering the client's room

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the mostimportant factor to prevent this infection? surgical asepsis increased T cells decreased antibiotics increased vitamin C

surgical asepsis

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 shortened length of stay strong cough reflex use of steroid therapy insertion of invasive devices multiple wounds

use of steroid therapy insertion of invasive devices multiple wounds use of antibiotic therapy

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

removes gloves and walks out of the room

When explaining the inflammatory response to nursing students, the instructor describes a series of events. Place the events in the order in which the instructor would describe them. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. phagocytosis tissue injury dilation of blood vessels plasma flow out of capillaries white blood cell migration to the area

tissue injury dilation of blood vessels plasma flow out of capillaries white blood cell migration to the area phagocytosis

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 PICC line Salem sump nasogastric tube endotracheal tube

urinary catheter

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor? "You should not visit your friend if you have an infection of any kind because your friend may also get sick." "If you wash your hands before coming in contact with your friend you will prevent infection during your visit." "As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend." "Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

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 Airborne Droplet Contact

Airborne

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? Avoid contact with mosquitoes Use hand sanitizer after touching any public surface Self-quarantine yourself for 2 weeks if you feel ill Use a face mask when in crowds

Avoid contact with mosquitoes

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. Grouping infectious children together helps to prevent future infection. Early infection treatment is needed to prevent the spread of infection.

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

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.

Incubation period Prodromal stage Full stage of illness Convalescent period

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 sterile field is set up at waist level. Direct visualization of the sterile field is maintained. The top flap of the package is opened away from the new nurse's body.

The new nurse touches 1.5 in (4 cm) from the outer edges.

A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply. The nurse carries soiled items away from the body. The nurse places soiled bed linen on the floor. The nurse moves soiled equipment away from the body when cleaning it. The nurse opens a window and dusts the room in the direction of the window. The nurse cleans least soiled areas first and then moves to more soiled ones. The nurse pours discarded liquids into a basin then pours them into the drain.

The nurse carries soiled items away from the body. The nurse moves soiled equipment away from the body when cleaning it. The nurse cleans least soiled areas first and then moves to more soiled ones.

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. The nurse is exiting a room after completed indwelling urinary catheter care. The nurse has assisted a client with changing and caring for a new colostomy.

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.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene? The nurse uses gloves in place of hand hygiene. The nurse keeps fingernails less than 1/4 in (0.63 cm) long. The nurse uses hand hygiene instead of gloves when in contact with blood. The nurse refrains from using hand moisturizer following hand hygiene.

The nurse keeps fingernails less than 1/4 in (0.63 cm) long.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? The nurse performs hand hygiene after touching the client's surroundings. The nurse removes her gown and then removes her gloves. The nurse performs hand hygiene before putting on gloves. The nurse applies nonmedicated hand cream after performing hand hygiene.

The nurse removes her gown and then removes her gloves.

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? Apply a 1-in (2.5-cm) layer of the ointment to the site using the index finger Use a sterile cotton-tipped applicator to apply the prescription to the site Place sterile 4 × 4 gauze on the wound and secure the dressing with dressing with paper tape Put soiled dressing change supplies in the client's bathroom garbage and double bag

Use a sterile cotton-tipped applicator to apply the prescription to the site

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? changing the soiled dressing wearing clean unsterile gloves when changing the dressing isolating the client's belongings applying a face mask with shield

changing the soiled dressing

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

skin is dry and intact

When explaining the inflammatory response to nursing students, the instructor describes a series of events. Place the events in the order in which the instructor would describe them.

tissue injury dilation of blood vessels plasma flow out of capillaries white blood cell migration to the area phagocytosis

What is the primary purpose for the demonstrated glove application? Help adjust for glove size Anchor gown sleeves Cover exposed wrist skin Minimize risk of a glove tear

Cover exposed wrist skin

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? Drop the item from 6 in (15 cm) above the sterile field. Lay the item in an open package on the 1-in (2.5-cm) border. Remove the gauze from the package with one sterile hand. Extend the sterile field by laying the open package beside it.

Drop the item from 6 in (15 cm) above the sterile field.

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's back is facing the sterile field. The nurse keeps hands above waist level while donning sterile gloves. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. The nurse disposes of an opened container of sterile saline after 24 hours.

The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field.

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

contact precautions

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter? Use an alcohol-based hand rub to decontaminate the hands. Remove all jewelry, including wedding bands, before hand washing. Keep hands lower than elbows to allow water to flow toward fingertips. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips.

Keep hands lower than elbows to allow water to flow toward fingertips.

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection? Helminth Protozoa Healthcare-associated infection (HAI) Virus

Healthcare-associated infection (HAI)

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? Pour the liquid onto gauze on the sterile field until the gauze is moist. Pour the liquid into the cap of the bottle and dip the gauze as needed. Pour the liquid into a sterile container within the sterile field. Pour the liquid into the palm of a sterile gloved hand for use.

Pour the liquid into a sterile container within the sterile field.

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 LPN should put on goggles prior to putting on the mask. The LPN should don personal protective equipment inside the client's room. Gloves should be worn while putting on a mask and goggles.

The LPN is donning personal protective equipment appropriately.

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate? The client will state how to safely take the prescribed antibiotic. The client will identify signs and symptoms of worsening infection. The client will verbalize measures appropriate to minimize infection transmission. The client demonstrates the proper technique for hand hygiene.

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