Chapter 24 Week 2/ 01-25-21

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."

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 - contagious disease -communicable disease

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?

Discard the bottle and get a new one because the saline has expired.

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?

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

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

A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. Which would be the appropriate action to take to maintain a sterile field?

Stop the procedure, remove damaged gloves, perform handwashing, and put on new sterile gloves.

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?

The client's immune system became further weakened

Which should be documented by the nurse?

The fact that sterile technique was used for a given procedure

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?

handwashing before leaving the client's room

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

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 care and interaction with this client

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 in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

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.

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

airborne

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

Which piece of personal protective equipment (PPE) should be removed first?

Gloves

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 N95/surgical masks."

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?

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

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required?

"I can leave my room any time I want as long as I wear a mask."

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

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 is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?

"The way you are doing it helps to minimize contamination of the non-waterproof side."

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 nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator?

"Wearing an N95 respirator is critical when I care for clients in droplet precautions."

. The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding of this condition?

- "An infectious disease like pneumonia may not pose a risk to others." Infections are infectious and/or communicable. Infectious diseases may not pose a risk for transmission to others, although they are serious for the patient. Pneumonia is not a communicable disease—a disease that is transmitted directly from one individual to the next, so there is no need for isolation. A private negative-air pressure room is used for tuberculosis, not pneumonia. Clinical signs and symptoms are present in pneumonia. Frequently, patients with pneumonia do return home unless there are extenuating circumstances.

The nurse is admitting a patient with an infectious disease process. Which question willbe most appropriate for a nurse to ask about the patient's susceptibility to this infectious process?

- "Do you have a chronic disease?" Multiple factors influence a patient's susceptibility to infection. Patients with chronic diseases such as diabetes mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and nutritional impairment. Other factors include age, nutritional status, trauma, and smoking. The other questions are part of an admission assessment process but are not pertinent to the infectious disease process.

. When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate?

- "It must be difficult not to know what the surgeon will find. What can I do to help?" "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and asking relevant questions

A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy?

- "This must be hard news to hear." "This must be hard" is an example of empathy. Empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other.

A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority?

- "What medications are you currently taking?" Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowthof Candida albicans in that area. It is important to ask the patient about current medications to obtain information that may assist with diagnosis.

The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection?

- A patient who is recovering from a right total hip surgery The patient who is recovering from a right total hip surgery has a large incision from the surgery. This break in the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous membranes allows pathogens to enter and exit the body.

The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI?

- Allowing the drainage bag port to touch the graduated receptacle. Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once a shift. Patients should have their own receptacle for measurement to prevent cross-contamination. Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in reducing the risk.

The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient's cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is most appropriate for the nurse to take?

- Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. Completing the assessment while wearing gloves, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate.

A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection?

- Don gloves and other appropriate personal protective equipment. Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and other personal protective equipment as appropriate when examining or providing treatment to localized infected areas to create a protective barrier.

The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response?

- Edema, redness, tenderness, and loss of function The body's cellular response to an injury is seen as inflammation. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.

. A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication?

- Electronic communication to assess a patient in another city Electronic communication is the use of technology to create ongoing relationships with patients and their health care team. Intrapersonal communication is self-talk. Interpersonal communication is one- on-one interaction between a nurse and another person that often occurs face to face. Public communication is used to present information to an audience. Small group communication is interaction that occurs when a small number of persons meet. When nurses work on committees or participate in patient care conferences, they use a small group communication process.

The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care-associated infection will the nurse report?

- Exogenous An exogenous infection comes from microorganisms found outside the individual suchas Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras. A vector transmits microorganisms and is usually a type of insect or organism. Endogenous infection occurs when part of the patient's flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection.

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply.

- Hang hygiene - Nonsterile gloves

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for "B" when using SBAR?

- History of angina The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is the Recommendation (R).

The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure?

- Maintain surgical aseptic technique. You maintain surgical aseptic technique at the patient's bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and sterile dressing changes) because patients with disease processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious organism. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the procedure but are not the priority in the procedure since the patient already has a compromised immune response.

A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief?

- Mutuality Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses standards such as humility, self-confidence, independent attitude, and fairness. To be authentic (one's self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient.

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using?

- Narrative In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction

The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use?

- Nonverbal The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate, and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of a message. Vocabulary consists of words used for verbal communication.

A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient?

- Observe the patient for decreased activity tolerance. Systemic infection, like pneumonia, causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise; be alert for changes in the patient's level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason for the patient to be limited to ice. Maintaining the room temperature at 65° F is too cold.

A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take?

- Obtain an interpreter. Interpreters are often necessary for patients who speak a foreign language.

During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. Which phase of the helping relationship is the nurse in with this patient?

- Orientation Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase. Preinteraction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work together to solve problems and accomplish goals. Termination occurs during the ending of the relationship.

A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using?

- Personal Personal space is 18 inches to 4 feet and involves things such as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves things such as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. The socio-consultative zone is 9 to 12 feet and involves things such as giving directions to visitors in the hallway and giving verbal report to a group of nurses. The public zone is 12 feet and greater and involves things such as speaking at a community forum, testifying at a legislative hearing, or lecturing.

Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient?

- Preinteraction The time before the nurse meets the patient is called the preinteraction phase. This phase can involve things such as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve things such as setting the tone for the relationship by adopting a warm, empathetic, caring manner. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. The termination phase occurs during the ending of the relationship. This phase can involve things such as reminding the patient that termination is near.

A nurse wants to present information about flu immunizations to the older adults in the community. Which type of communication should the nurse use?

- Public Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. When nurses work on committees or participate in patient care conferences, they use a small group communication process. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Intrapersonal communication is a powerful form of communication that you use as a professional nurse. This level of communication is also called self- talk.

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R?

- Relax In SOLER, the R stands for relax. It is important to communicate a sense of being relaxed and comfortable with the patient.

Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response?

- Rest, ice, and elevation Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part.

6. The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information is most important for the nurse to include in the educational session?

- Smoking affects the cilia lining the upper airways in the lungs. A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of the lungs and normal mucus.

The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing and visualization. What is the primary rationale for the nurse's actions related to the teaching?

- Stress for long periods of time can lead to exhaustion and decreased resistance to infection. The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with pain, but they are not the primary reason. The teachings listed are not all standard interventions taught at every health care visit. There is no data to indicate the patient requested this information for the family.

The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?

- Teaching the patient to select nutritious foods A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing.

Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior?

- The nursing assistive personnel is calling the older-adult patient "honey." The nurse needs to intervene to correct the use of "honey." Avoid terms of endearment such as "honey," "dear," "grandma," or "sweetheart.

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

- droplet

A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding?

- The patient's affect is inappropriate. An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient's personal space was not violated. The patient's vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The patient's denotative meaning is correct for cough and deep breathe.

1. Which types of nurses make the best communicators with patients?

- Those who develop critical thinking skills Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques, and communication involves more than psychomotor skills. Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators.

A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse's action?

- To standardize communication SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others.

An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication?

- Turn off the television. Turning off the television will facilitate communication. Patients who are hearing impaired benefit when the following techniques are used: check for hearing aids and glasses, reduce environmental noise, get the patient's attention before speaking, do not chew gum, and speak at normal volume— do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired.

The nurse is caring for a patient in an intensive care unit who needs a bath. Which priorityaction will the nurse take to decrease the potential for a health care-associated infection?

- Use a chlorhexidine wash. The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water does not affect the cause of a health care-associated infection by, for example, decreasing microbial counts like a CHG bath.

Which nursing action will most likely increase a patient's risk for developing a health care- associated infection?

- Uses a clean technique for inserting a urinary catheter Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care-associated infection. Urinary catheters need to be inserted using sterile technique, which is also referred to as surgical asepsis. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Washing from clean to dirty (urinary meatus toward rectum) is correct for decreasing infection risk. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded.

The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5° F, and the WBC is 10,500/mm3. Which action should the nurse take first?

- Utilize SBAR to notify the primary health care provider. The nursing assessment indicates signs and symptoms of infection, requiring the primary health care provider to be notified of the patient's needs. SBAR—Situation, Background, Assessment, and Recommendation—can be utilized to organize thoughts and data and to provide a thorough explanation of the patient's current status. The reevaluation of temperature is a good choice, but it will take longer than 4 hours to make a change in the white blood cells. Changing the dressing may be a need during the shift but is not a first priority. Checking to see about the skin preparation used 2 days ago may or may not be useful information at this time.

. The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers?

- Wash their hands between each interaction with children. The single most important thing that individuals can do to prevent the spread of infection is to wash their hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose and between touching each individual child. It is important for preschool children to have a nutritious diet; a healthy individual can fight infection more effectively. A health care provider, along with the parent, makes decisions about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most important thing to do in this scenario.

The patient and the nurse are discussing Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission for this disease?

- When camping, I will wear insect repellent." Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks. Wearing a repellent that is designed for repelling ticks, mosquitoes, and other insects can help in preventing transmission of this disease. Drinking plenty of uncontaminated water, wearing sunscreen, and using alcohol-based hand gels for cleaning hands are all important activities to participate in while camping, but they do not contribute to or prevent transmission of this disease.

. A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the nurse in with this patient?

-Working The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Preinteraction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship.

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

Which client would the nurse consider the most infectious?

A client who is in the prodromal stage

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 determines that which client is at greatest risk for a wound infection?

A two-day postoperative client

What is an accurate guideline for removing soiled gloves after client care?

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

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?

Airborne

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, respiratory precautions

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

Avoid contact with mosquitoes

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.

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

Client receiving chemotherapy

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

Create an area for sterile field and opening packages

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?

Don another pair of sterile gloves.

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

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 mask should the nurse don when caring for a client with tuberculosis?

Filtered respirator

The nurse is caring for a client with human immunodeficiency virus (HIV) who currently has no signs or symptoms of the disease. Which important information about being an HIV carrier does the nurse teach the client?

HIV can be transmitted from an infected person to another person through blood, semen, vaginal fluids and breast milk.

A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply.

Hepatitis B Hepatitis C HIV

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

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 handwashing, and document the exposure according to protocol.

The nurse who is recovering from a very mild upper respiratory infection with no fever is assigned to care for four clients. What is the appropriate nursing action?

Perform meticulous hand hygiene and don a new mask with each client encounter

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 into a sterile container within the sterile field.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply.

Redness Swelling Pain Exudate

Which action is the best example of a nurse donning/removing protective equipment properly?

Removing respirator after leaving client's room

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.

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 removes her gown and then removes her gloves.

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?

The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.

What is the most common client site for development of healthcare-associated infections (HAI)?

Urinary tract

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection?

Urine culture is positive for vancomycin-resistant enterococci (VRE).

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?

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

The nurse is caring for a client with a draining abscess. 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

A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as:

iatrogenic

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense?

intact skin and mucous membranes

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 SUBMIT ANSWER

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

noncommunicable disease

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

A nurse is caring for four clients. Which client has the highest risk of infection?

older male with an enlarged prostate

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

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?

to eliminate disease-producing organisms from the nurse's skin

After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply.

• Used syringe with attached needle • Used fingerstick lancet