Chapter 24- Aspesis
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?
"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."
Routine nasal and rectal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized with MRSA. The client is surprised at this finding, since he enjoys generally robust health. What should the client's nurse teach him about this diagnostic finding?
"This means that this organism in present on your skin, but it doesn't necessarily mean you will become sick."
A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask?
"What are your expectations about bathing at this time?"
The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?
A=Assessment
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?
Airborne
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
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81 year old client who has been recieving 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 observes a colleague performing the action above while preparing to care for a client with bacterial meningitis. What is the nurse's most appropriate statement to the colleague?
Don't forget to put on your gloves
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
The nurse instructs a mother of young children how to properly use a nonmercury glass thermometer. Which statement made by the client indicates a need for further instruction?
I will clean the thermometer in the dishwasher
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
The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?
Remove the thermometer and assess the blood pressure and heart rate
The most common infection in children is:
Respiratory
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 clients room to adjust settings on the intravenous pump The nurse has just completed documentation and is entering another clients room
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
This is an auscultatory gap
What is the primary purpose for the demonstrated glove application?
To cover the exposed wrist skin
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
What is the most common client site for development of healthcare-associated infections (HAI)?
Urinary tract
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 25,000 mcL
A client is diagnosed with hepatitis B. Which recommendation(s) will the nurse include when teaching the client about how to prevent the spread of viral infections? Select all that apply.
Wash hands frequently Practice safe and protected sex Cover all open sores Avoid sharing sharp objects like razors and nail clippers
The nurse is providing an in-service educational program for the interprofessional health care team about infection control precautions. What teaching will the nurse include? Select all that apply.
Wear PPE Practice hand hygiene Keep clients environment clean
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
An older adult client tells the nurse, "I do not understand why I have had so many epsides of infection lately." How should the nurse respond?
"As we age, our immune system does not function as well."
A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate?
"I am placing the new linens under the rolled, soiled linens to avoid contamination
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 form the staff and wash my hands before touching my family member."
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?
"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."
A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection?
18,000 cells/mm
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
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
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 HF
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
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
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 colleagues to remove the glove by grasping the cuff
Which condition will lead to an increase in cardiac output?
Exercise
A nurse is reviewing laboratory test results and finds that a client's neutrophil levels are elevated. The nurse understands that these cells are important for:
Generation of a fever response
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?
Hand hygiene is needed with objects near the client
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 long
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?
Healthcare-associated infections
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 reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?
Immediately
What is the second line of defense in microbial invasion?
Inflammation
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
The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?
Keeping sterile field above waist level
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 ago. What should the nurse do?
Obtain a new bottle of sterile saline
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?
Over the clients thigh
A nurse is providing care for a client who has had gall bladder surgery. It is the first postoperative day and the client is exhibiting a fever. The nurse suspects what as the most likely cause?
Physiologic Stress
A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor?
Pumping the blood pressure cuff up to 200 mm Hg rountinely
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?
Reaches down to the bed to pick up a sterile drape
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
Nursing students are learning about infection control and its impact on society as a whole. Which infections contribute to this concern? Select all that apply.
TB Multridrug resistant organisms Extended spectrum beta lactamases Resistant C. diff VRE
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 PPE appropriately
A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?
The client should be placed in a side lying position to prevent aspiration
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 postsurgical procedure
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?
The important of completely finishing the prescribed treatment
A client reports having a history of gingivitis. The nurse correctly recognizes that this condition may be caused by which? Select all that apply.
Thermal extremes poor oral hygiene adverse reaction to meds bacteria
A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement?
Those are senile lentigines and are common in older adults
A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?
Wear PPE when entering the room for all interactions that may involve contact with the client
The process of phagocytosis involves:
digestion of microbes by white blood cells
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 receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?
into a private room
