Chapter 25 Asepsis and Infection Control

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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. Explanation: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

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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? "Washing the hands with soap and water is not necessary." "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." "We only wash our hands when they are visibly soiled."

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." Explanation: By explaining that alcohol-based hand rubs are effective in preventing the spread of microbes, the nurse directly addresses the client's concern. While washing with soap and water may not be necessary, it doesn't address the client's concern. Alcohol-based hand rub is an appropriate method for hand hygiene even when you plan to touch the client.

Which client presents the most significant risk factors for the development of Clostridioides difficile infection? 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis 30-year-old client who has recently contracted human immunodeficiency virus (HIV) 44-year-old client who is paralyzed and whose pressure injury on the coccyx required a skin graft 56-year-old client with acute kidney injury who receives hemodialysis three times weekly

81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Explanation: Two common factors that increase a client's risk of becoming infected with Clostridioides difficile are age greater than 65 and current or recent use of antibiotics. The client who is 81 years of age and received recent, long-term antibiotic therapy is at significant risk C. difficile infection. These risk factors supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.

The nurse determines that which client is at greatest risk for a wound infection? A two-day postoperative client An older adult client with dry skin An infant with intact skin A client with a urinary catheter

A two-day postoperative client Explanation: The client at greatest risk for a wound infection is the two-day postoperative client, as the surgery disrupted the integrity of the skin, thereby increasing the risk for wound infection. Although older adult clients are at greater risk for infection, this client's skin is dry (versus having an open or surgical wound); thus, this client is at less risk than the postoperative client. An infant with intact skin is not at risk for a wound infection. A client with a urinary catheter is at risk for a urinary tract infection versus a wound infection.

The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first? Educate the client of the importance of infection prevention. Assess client's pain level and manage pain accordingly. Inform the client that these exercises must be done at regular intervals. Inform the health care provider of the client's noncompliance

Assess client's pain level and manage pain accordingly. Explanation: Encouraging clients to cough, breathe deeply, blow the nose, and move the body promotes clearance of respiratory secretions, which may become infected if allowed to pool in the lower respiratory tract. Retained secretions prevent adequate gas exchange at the alveolar level and reduce oxygen available to the tissues to combat infection, heal injured tissues, and meet metabolic needs. Secondary infections are commonly associated with impaired respiratory tract function. Timing is an important consideration when administering analgesics. To time analgesics appropriately, know the average duration of action for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense. For example, an analgesic would be offered before ambulating a client postoperatively.

The laboratory calls the nurse to report the client's white cell differential reveals a shift to the left. The nurse will assess the client for signs and symptoms of what medical diagnosis? Viral infection Bacterial infection Protozoal infection Autoimmune disorder

Bacterial infection Explanation: If the infection is severe or prolonged, the body cannot manufacture neutrophils quickly enough, resulting in the release of immature granulocytes into the blood. This increase in the number of immature cells is called a shift to the left or leftward shift in the granulocyte differential count. A leftward shift is considered a strong indication of bacterial infection; the greater the leftward shift, the more worrisome the infection appears. It is not associated with viral or protozoal infections or autoimmune processes.

The nurse is assigned to four clients who have varying risks for infection and who each have elevated temperature. Which client should the nurse see first? Client who is postoperative day 1 following left hip replacement Client who received a unit of packed red blood cells yesterday for the treatment of anemia Client who undergoing chemotherapy for the treatment of lung cancer Client who recently underwent colostomy reversal surgery

Client who undergoing chemotherapy for the treatment of lung cancer Explanation: Patients who are neutropenic after chemotherapy experience a predictable drop in neutrophils. In this immunocompromised state, a fever could constitute a medical emergency. All of the students should be assessed promptly, but an immunocompromised client would be a short-term priority.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene? Decontaminate hands using an alcohol-based hand rub. Do not wash hands; apply clean gloves. Wash hands with soap and hot water. Wash hands with soap and water, followed by an alcohol-based hand rub.

Decontaminate hands using an alcohol-based hand rub. Explanation: Alcohol-based hand rubs can be used if hands are not visibly soiled. If the hands are visibly soiled, the nurse should wash hands with soap and hot water. The nurse should wash their hands. The nurse does not need to wash their hands AND use an alcohol-based hand rub.

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. Explanation: Equipment such as stethoscopes, sphygmomanometers, and other assessment tools that are used for clients on contact precautions should be cleaned and disinfected before use on other clients. The other answers are incorrect.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing sending a VRE-positive client to the radiology department for a chest X-ray without a face mask delivering a meal tray to a VRE-positive client without first donning gloves and a gown

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. Explanation: Direct client contact between a VRE-positive client and another client without handwashing carries a significant risk of infection, especially when contact includes body fluids. Handwashing is necessary before a procedure such as staple removal, but foregoing this infection control measure is less likely to spread VRE unless the nurse failed to handwash after the procedure. VRE does not normally require droplet or airborne precautions. Delivering an item to a client without gloves or a gown is less of a risk than failing to wash the hands after such contact.

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 Tuberculosis HIV

Hepatitis B Hepatitis C HIV Explanation: Tuberculosis would be a significant respiratory exposure, but it is not transmitted by blood.

A nurse is administering a client's prescribed insulin subcutaneously. To reduce the risk of a needlestick injury after administration, which action should the nurse perform? Securely place the uncapped needle on a tray and carry it to the medicine room for safe disposal Immediately deposit the uncapped needle into a puncture-proof plastic container. Carefully recap the needle using only one hand and deposit it in a plastic container. Slide the needle into the cap and deposit it in a puncture-proof plastic container.

Immediately deposit the uncapped needle into a puncture-proof plastic container. Explanation: All uncapped needles should be placed in a puncture-proof plastic unit immediately after use. Needles should not be manually recapped.

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. Explanation: Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms.

The nurse is assigned to clean a client's wound before applying a sterile dressing. Which action by the nurse demonstrates maintaining a sterile field? Pouring the sterile solution slowly from 6 in (15 cm) above the container. Opening the flaps of the sterile field toward oneself. Dropping sterile gauze onto the field from 1 in (2.5 cm) above. Turning the back on the field to retrieve the package of sterile gloves.

Pouring the sterile solution slowly from 6 in (15 cm) above the container. Explanation: The nurse must never turn the back on the sterile field. Any additional items needed must be dropped or poured onto the sterile field from a height of at least 6 in (15 cm). The flaps of the sterile field must be opened away from the nurse.

The school nurse performs frequent assessments of young school-aged children. Due to their high incidence and prevalence, the nurse should prioritize assessment for what types of infections? Respiratory Gastrointestinal Integumentary Genitourinary

Respiratory Explanation: The most common infections in early childhood are respiratory infections. For this reason, assessment of respiratory system would be a priority over integumentary, GI and GU assessment because these are less common.

A client is scheduled for an inguinal hernia repair and is concerned about the possibility of developing a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? Surgical asepsis Administration of monoclonal antibodies Appropriate use of antibiotics Increased vitamin C

Surgical asepsis Explanation: Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment. These measures supersede the importance of reactive treatment, vitamin intake or the use of targeted therapies like monoclonal antibodies.

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 Explanation: Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter. Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

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. Explanation: Principles of surgical asepsis include never turning one's back on a sterile field. The nurse should avoid talking, coughing, or sneezing over the field and keep sterile objects above waist level. Sterile objects may only be touched by other sterile objects. Most solutions are considered sterile for 24 hours after they are opened.

The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this nurse's action? To protect the integrity of the nurse's immune system To prevent the nurse from developing disease To remove disease-producing organisms from the nurse's skin To sterilize the nurse's hands to prevent infection or transmission of microorganisms

To remove disease-producing organisms from the nurse's skin Explanation: The purpose of hand hygiene is to protect clients from infection by removing microorganisms from the skin. Hand hygiene protects the nurse from infection but the primary purpose is to protect clients. Hand hygiene greatly reduces the number of microorganisms on the skin but does not result in sterile skin surfaces.

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation? -After completing a wound dressing -Before direct contact with clients -After direct contact with clients -When hands are visibly soiled

When hands are visibly soiled Explanation: Alcohol-based hand rubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, except when the health care worker's hands are visibly soiled.

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 Explanation: Standard precautions apply to blood and all body fluids, secretions, and excretions except sweat. Transmission-based precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as is the case in answers A, B, and D.

The client sustained a large skin tear to his arm while getting out of bed. He is concerned that it is now infected. Which manifestation shows infection? temperature of 98.2°F white blood cell count of 6,000 mcL serosanguineous drainage from the wound enlarged axillary lymph nodes

enlarged axillary lymph nodes Explanation: During an infection, the lymph nodes that drain an infected area may become enlarged and easily palpable ("swollen glands"). As the swelling increases, the nodes may also become tender. During inflammation, the lymphatic capillaries dilate as excess interstitial fluid, proteins, and invading microorganisms enter the lymphatic system. The swelling indicates that lymphocytes and macrophages in the lymph node are fighting the infection and trying to limit its spread.

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 Explanation: Hand hygiene is the most important way to prevent transmission of infection.

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? -washes hands for 20 seconds with soap and water -picks up the glove at the folded edge with the thumb and forefinger -stretches the glove over the hand without touching the unsterile area -reaches down to the bed to pick up a sterile drape

reaches down to the bed to pick up a sterile drape Explanation: The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully.

The nurse notes that the client's temperature is 101.2°F (38.4°C) at 8 a.m. Elevated temperature may be due to several factors. What could be the reason for this? very hot coffee recent bed bath respiratory infection loose stool

respiratory infection Explanation: Assess vital signs frequently to detect infection or to monitor its progress. The accuracy of such assessment is important in determining if infection is present. In client with an infection, look for elevations in temperature (above 38.4°C [101°F]), pulse rate, and respiratory rate.

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 Explanation: The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare.

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

the client who is 48-hours postsurgical procedure Explanation: Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between clients, the nurse should see clients from the "clean" to "dirty." The nurse should see the client who has no signs of infection first. Among these clients, the nurse should begin with the client who is postoperative, then see the other clients who have symptoms of infections.

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 wearing a face mask when entering and staying at a distance from the client wearing protective eye wear for contact with this client placing the client in a regular, private room

wearing a particulate respirator for all care and interaction with this client Explanation: To prevent the transmission of TB, the National Institute for Occupational Safety and Health recommends the use of a particulate air filter respirator that fits snugly to the face for all client care and interaction. A face mask does not block small TB particles effectively. Protective eyewear is only needed if contact with bodily fluids is expected. The client would be placed in a negative pressure room to prevent the potential spread of TB.

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." Explanation: There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992. The virus cannot be contracted or spread through a toilet seat.

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." Explanation: The nurse should explain that during the aging process, the immune system decreases in function and the older adult client is at greater risk for becoming infected. Other risk factors for the older adult client include poor nutrition and fluid intake. Although washing hands is an important part of the prevention of infection, there are other methods such as airborne and droplet transmission that may be unavoidable. When it comes to visitation, the only limitation that should be set is that those who are ill or possibly infected should refrain from visiting the client. Informing the client that nothing can be done is not accurate, as there are preventative measures that may be taken to avoid exposure.

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

Gloves Explanation: The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.

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

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 Explanation: Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have pre-existing illnesses, appear to be more vulnerable to infection. School-age children are exposed to potential infections, but immunizations protect the child. An adolescent with a fracture or middle-aged adult taking medication to control blood pressure could develop an infection, but these clients are not at the highest risk.

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection? -describing each step verbally to the client before performing the dressing change -checking that the sterile dressing packages are intact before opening -applying a new dressing with the gloves that were used to remove the old dressing -ensuring that the surface where the sterile field will be set up is dry

applying a new dressing with the gloves that were used to remove the old dressing Explanation: Gloves should be changed after removing the old dressing prior to putting on a sterile dressing, because the microorganisms from the old dressing can be transferred to the new dressing. The nurse should explain the procedure to the client before beginning and not during. The nurse should avoid talking over a sterile field as well as turning his or her back on sterile field to discuss the procedure with the client. The nurse should check that the packages are intact, ensure that the surface is dry, and open all packages before donning sterile gloves.

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection? describing each step verbally to the client before performing the dressing change checking that the sterile dressing packages are intact before opening applying a new dressing with the gloves that were used to remove the old dressing ensuring that the surface where the sterile field will be set up is dry

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. Explanation: As a person ages, there is a decline in cellular and humoral immunity, decreased effectiveness of phagocytosis, and an increased susceptibility to infection.

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? airborne droplet contact none

droplet Explanation: Whooping cough is transmitted through droplets; therefore droplet precautions are appropriate.

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 Explanation: The colleague should grasp the outside of one glove with the opposite gloved hand and peel the glove off, turning it inside out while peeling it off. The glove should not be pulled by the fingers, because this is unlikely to remove the glove and it may snap back. Personal protective equipment should normally be removed while inside the room, and there is no need to maintain a wide distance from the colleague.

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts? exit route vehicle of transmission infectious microorganism susceptible host

exit route Explanation: The nurse should provide special attention to the respiratory and gastrointestinal tracts as potential exit routes.

Which nursing action is a component of medical asepsis? handwashing after removing gloves insertion of an indwelling urinary catheter insertion of an intravenous catheter drawing blood from a central line

handwashing after removing gloves Explanation: Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood).

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 with a client with pneumonia with a client with a myocardial infarction with another client with a draining wound

into a private room Explanation: The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

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

use of one gown per person per shift Explanation: A new gown should be used by the nurse each time the nurse enters the client's room.

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."

A client who thinks he has an infection has come to the clinic. During the assessment, which question would the nurse most likely ask first? "Do you have any pain or swelling?" "Do you have a fever?" "How long have you had the infection?" "Are you having any general aches or fatigue?"

"How long have you had the infection?" Explanation: When an infection is the reason for seeking health care, the nurse needs to focus the assessment questions on the client's specific reports. It would be important for the nurse to first determine when the infection started and also what symptoms occurred first. Asking about pain, swelling, fever, or other general problems does not narrow the reason for the client's visit.

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? "Any staff who enters my room will be wearing personal protective equipment (PPE)." "I can leave my room any time I want as long as I wear a mask." "I will tell my visitors to keep their distance from me." "My personal belongings should remain in the room until I am discharged."

"I can leave my room any time I want as long as I wear a mask." Explanation: The client on droplet precautions should only leave the room when necessary and wear a mask. The nurse should limit the client's movement outside the room. Visitors should remain 3 feet (1 meter) from the client. Anything that enters the isolation room should remain until discharge. Any staff who enters the room will wear PPE.

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 causes body fluids to accumulate, which leads to bacterial growth." -"Stress leads to increased secretion of cortisol, which suppresses your immune response." -"Stress causes the body's normal immune response to turn on itself." -"Stress leads to a deterioration in the skin's barrier line of defense."

"Stress leads to increased secretion of cortisol, which suppresses your immune response." Explanation: Physical or emotional stress causes the body to release cortisol, which can increase the risk of infection by suppressing the immune response. Stress has no effect on body fluid collection. Inadequate nutrition depresses almost every normal body defense against infection. The use of invasive devices or any break in the skin or mucous membranes leads to a disruption in the skin's barrier function against infection.

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? -"Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it." -"If you do not wear gloves you will also get the infection." -"Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." -"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 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." Explanation: Contact precautions, which are not optional, block transmission of pathogens by direct or indirect contact. Explaining that the loved-one understands is not teaching information. Educating the visitor about drug-resistant infections is important but does not explain how to prevent transmission of the infection. Telling the visitor that he or she will get the infection if the visitor does not wear gloves is incorrect, the visitor is at a greater risk of getting and spreading the infection. Wearing gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing.

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." Explanation: Contact precautions block transmission of pathogens by direct or indirect contact Wearing a gown and gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing or even to others the visitors may come in contact with. While wearing gloves and gown may prevent sharing additional microorganisms with the client, that is not the reason for contact precautions. Agreeing that wearing the gown and gloves is not pleasant doesn't educate the family member.

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 that you will become sick." "This finding becomes part of your medical record, but it is not a threat to the health of yourself or others." "You may not develop any symptoms, but you will likely be given a round of antibiotics to eliminate these bacteria." "It's very fortunate that this was detected early, since this had the potential to make you very sick."

"This means that this organism in present on your skin, but it doesn't necessarily mean that you will become sick." Explanation: MRSA colonization does not necessarily mean that an individual will become sick, but it does pose a threat of passing on MRSA to others. The MRSA documentation is part of the laboratory section but does not allow for the client and others to get the MRSA infection. Colonization does not necessitate antibiotic therapy. MRSA is present and does not always cause an infection.

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." Explanation: Many bacteria are susceptible to broad-spectrum antibiotics and prior to the diagnosis of a specific bacteria, a broad-spectrum antibiotic will be prescribed to help eradicate the present bacteria until a culture result is returned. A client may be admitted to the hospital with pneumonia without receiving antibiotics, although it is likely that an antibiotic will be given at some point during hospitalization. Antibiotics do not boost the immune system and may destroy normal healthy flora. Antibiotics are used to treat bacterial infections, not viral infections; antibiotics do not kill viruses.

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."

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? "I will always wash my hands thoroughly and often." "It is important to refrain from recapping needles." "Masks, gloves, and gowns should be used to protect from infectious agents." "Wearing an N95 respirator is critical when I care for clients in droplet precautions."

"Wearing an N95 respirator is critical when I care for clients in droplet precautions." Explanation: N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.

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? When a sterile item touches something that is not sterile, it may not be contaminated. Any partially uncovered sterile package need not be considered contaminated. A commercially packaged surgical item is not considered sterile if past expiration date. Sterility may not be preserved even when one sterile item touches another sterile item.

A commercially packaged surgical item is not considered sterile if past expiration date. Explanation: When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

What is an accurate guideline for removing soiled gloves after client care? Use the nondominant hand to grasp the opposite glove, near the cuffed end on the outside exposed area. Remove the glove on the nondominant hand by pulling it straight off, keeping the contaminated area on the outside. After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. After removing the first glove, slide the fingers of the ungloved hand between the remaining glove and the wrist and pull the glove straight off, with the contaminated area on the outside.

After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. Explanation: When removing gloves, the dominant hand is used to grasp the opposite glove near the cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated area on the inside. The removed glove is held in the remaining gloved hand. Then, the fingers of the ungloved hand are slid between the remaining glove and the wrist, and the glove is pulled off and inverted.

A nursing instructor is describing humoral immunity and the complement system. What would the instructor include as a function of this system? Select all that apply. Make bacteria more susceptible to phagocytosis. Aid in the lysis of the bacterial cell wall. Neutralize the underlying causative virus. Enhance phagocytosis of the microbes. Encourage the inflammatory response.

Aid in the lysis of the bacterial cell wall. Enhance phagocytosis of the microbes. Encourage the inflammatory response. Explanation: The complement system enhances phagocytosis of microbes, helps in the lysis of bacterial cell walls, and encourages the inflammatory response. Antibodies act to make bacteria more susceptible to phagocytosis and, when a virus is the cause, help to neutralize the virus.

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 Explanation: The nurse should implement airborne precautions for clients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). Droplet precautions should be used for clients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Contact precautions should be used for clients who are infected or colonized by a multidrug-resistant organism (MDRO).

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? -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. -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. Explanation: Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening. Lipping the opening of the bottle and pouring the saline into a sterile container by holding it 6 in (15 cm) above the container would be appropriate, but contents in the bottle are expired. The nurse should discard the bottle and get a new one.

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. Explanation: Prevention of infections in early childhood requires good hygienic care of children and their food, adequate vaccinations, early infection treatment to prevent spread or complications and isolation of both healthy and those infected from infected people.

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 Clostridioides difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection? Exogenous healthcare-associated Endogenous healthcare-associated Iatrogenic Antibiotic-resistant

Exogenous healthcare-associated Explanation: The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and Clostridioides difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.

Which mask should the nurse don when caring for a client with tuberculosis? Low-efficiency particulate air (LEPA) Filtered respirator Surgical mask No mask is needed

Filtered respirator Explanation: When caring for a client with tuberculosis, the nurse should don a filtered respirator mask to filter the inspired air. A surgical mask, also known as a procedure mask, is intended to be worn by health care professionals during surgery and during nursing to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose. Low-efficiency particulate air (LEPA) masks are not used in health care.

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 Explanation: Leukocytes, also called white blood cells (WBCs), and the inflammatory response make up the second line of defense to microbial invasion. A normal WBC count is 5,000 to 10,000 cells/mm3. A count above this range is indicative of infection.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? Fungi Rickettsiae Protozoans Helminths

Fungi Explanation: Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes.

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 Explanation: A temperature greater than 40.5°C is referred to as hyperpyrexia. A low-grade fever is a temperature that is slightly elevated, 37.1°C to approximately 38.2°C. A temperature elevation above 38.2°C is considered a high-grade fever. A temperature between 35°C and 36.8°C is a subnormal temperature.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student? The use of gloves eliminates the need for hand hygiene. The use of hand hygiene eliminates the need for gloves. Hand hygiene is needed after contact with objects near the client. Hand lotions should not be used after hand hygiene.

Hand hygiene is needed after contact with objects near the client. Explanation: Hand hygiene must be performed when moving from a contaminated body site to a clean body site during client care and after contact with inanimate objects near the client. Using gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still be used after hand hygiene. Lotions may be used to prevent irritation.

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 Explanation: Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. Revising the agency's infection control protocols is not nursing centered. Encouraging visitors to adhere to isolation precautions is important but does not affect the immediate surroundings and personal space that can cause a contaminated work environment. Limiting visitors to family members over the age of 18 is not client-centered care and will not decrease transmission of pathogens.

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 health care provider 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 health care provider about this finding. Explanation: The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare. Chemical composition aids these physical barriers further. For example, the acidic nature of the skin and vagina helps to kill potential invaders before they enter the body. Certain illness or treatments can interfere with the body's delicate balance, causing overgrowth of Candida fungus.

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.

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client? Vancomycin-resistant enterococci and urinary tract infection Clostridioides difficile and colitis Coronary artery bypass grafting MRSA in the wound

MRSA in the wound Explanation: In many situations, clients with like infections can be placed together. The presence of similar causative microorganisms negates the risks of cross-contamination. Each of the other listed clients would encounter a risk for MRSA.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? Migration of leukocytes to the area of the wound Constriction of the small blood vessels near the wound Release of histamine Production of antibodies

Migration of leukocytes to the area of the wound Explanation: During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation. Antibody production is characteristic of the immune response to infection.

Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process? Select all that apply. Nurses limit the spread of microorganisms by directing the chain of infection. Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use personal protective equipment (PPE), which is the most effective way to help prevent the spread of organisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.

Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection. Explanation: Limiting the spread of microorganisms is accomplished by breaking the chain of infection, not by directing the chain. The practice of asepsis includes all activities to prevent infection or break the chain of infection. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Surgical asepsis, or sterile technique, includes practices used to render and keep objects and areas free from microorganisms. Hand hygiene is the most effective way to help prevent the spread of organisms. The use of Standard and Transmission-Based Precautions is an important part of preventing infection.

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply. Pain with redness and swelling Localized heat Purulent or malodorous drainage Inside edges of the ulcer appear to be drawing together Scabs forming over the ulcer

Pain with redness and swelling Localized heat Purulent or malodorous drainage Explanation: Signs of infection of the client's foot ulcer that the nurse includes in discharge teaching include redness, swelling, and pain; localized heat; and purulent or malodorous drainage. If the inside edges of the ulcer appear to be drawing together and/or if scabs are forming over the ulcer, the ulcer is likely to be healing.

An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client? Wash hands with soap or detergent. Perform hand antisepsis using a designated bleach solution. Perform surgical hand scrub using detergent. Apply alcohol-based handrub up to the mid-forearm

Perform surgical hand scrub using detergent. Explanation: The nurse should perform a surgical hand scrub using detergent when caring for a client undergoing surgery. Bleach solutions are not used and a basic handwash is not sufficient. Alcohol-based rubs may be used in many situations that do not involve surgery.

A nurse at the health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action(s) is appropriate by the nurse when using masks? Select all that apply. Position the mask so that it covers the nose and mouth. Avoid touching the mask once it is in place. Change the mask if it becomes damp. Discard used masks into a regular wastebasket. Touch only the strings of the mask during removal.

Position the mask so that it covers the nose and mouth. Avoid touching the mask once it is in place. Change the mask if it becomes damp. Touch only the strings of the mask during removal. Explanation: The nurse should avoid touching the mask once it is in place because touching the mask transfers microorganisms to the hands. The mask should be changed every 20 to 30 minutes or when it becomes damp, to preserve its effectiveness. The nurse should touch only the strings of the mask during removal to prevent transfer of microorganisms to the hands. The mask should be positioned over the nose and the mouth to provide a barrier to nasal and oral ports of entry. The nurse should discard used masks into a lined or waterproof waste container and not a regular wastebasket.

A client is having an open cholecystectomy and requires a saline irrigation. What action will reduce the spread of pathogens to the client and other clients? Pour a small amount of solution out of the container prior to pouring it into the sterile basin. After pouring the solution into the sterile basin, recap the solution for use later. Pour the solution below the level of the waist while the surgical technician holds the sterile basin. Have the surgical technician take the bottle of solution and pour directly into the open abdomen.

Pour a small amount of solution out of the container prior to pouring it into the sterile basin. Explanation: When using a sterile solution, the circulating nurse should pour the solution from above the waist level and avoid splashing the solution onto the sterile field and avoid touching any sterile areas within the field. The nurse should pour and discard a small amount of solution to wash away airborne contaminants. The unused solution should be discarded and not used in the future either for the surgical client or any other client.

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. Explanation: The solution container should be held outside the edge of the sterile field and poured steadily from a height of 4 to 6 inches into a sterile container previously added to the sterile field and positioned at the side of the sterile field. This assures minimal splashing, as moisture contaminates the sterile field, and maintains sterility of the bottle and solution.

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? Place the client in a private room that has monitored negative air pressure. Keep visitors 3 feet (1 m) from the client. Use respiratory protection when entering the room. Wear gloves whenever entering the client's room.

Wear gloves whenever entering the client's room. Explanation: Contact precautions are used for clients who are infected or colonized by a microorganism that spreads by direct or indirect contact, such as MRSA, vancomycin-resistant enterococci (VRE), or vancomycin-intermediate Staphylococcus aureus (VISA). Gloves should be worn when entering the client's room. Use of negative air pressure and respiratory protection are appropriate with airborne precautions. Keeping visitors 3 ft (1 m) away from the client is a droplet precaution.

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? -Clostridioides difficile and diabetic ketoacidosis -Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) -Tuberculosis and pneumonia -Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Explanation: Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together. Clostridioides difficile requires contact isolation and is contagious. Diabetic ketoacidosis is considered a medical diagnosis and requires standard precautions. A surgical incision from an appendectomy is considered clean. A draining leg ulcer can transmit an infection to a client with a clean surgical incision. In both of these cases, rooming these clients together violates infection control standards. Tuberculosis requires airborne precautions and pneumonia requires standard precautions. Based on the mode of transmission of tuberculosis, these clients cannot room together.

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 Explanation: T-lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.

What assessment finding most clearly suggests that a client is experiencing the second line of defense to microbial invasion? -The client is experiencing inflammation -The client's mucous membranes are intact -All of the client's skin surfaces are intact -The client has been prescribed immune system stimulators

The client is experiencing inflammation The inflammatory response makes up the second line of defense to microbial invasion. Intact mucous membranes and skin constitute the first line of defense. Use of immune stimulators is an exogenous process that is independent of the body's own line of defenses.

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 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. Explanation: Alcohol-based handrub is preferred in situations when hands are not visibly soiled; before and after touching a client; before handling an invasive device for client care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; and after removing sterile or nonsterile gloves. Use of an alcohol-based handrub does not replace the need for gloves or for handwashing, however. After performing catheter care and assisting with changing a colostomy, gloves are worn and handwashing should take place.

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. Explanation: The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood. The nurse could use a hospital sanctioned hand moisturizer after hand hygiene, but this is not the best answer.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding confirms the client has developed an infection? -Urine culture is positive for vancomycin-resistant enterococci (VRE). -The client reports nausea and vomiting. -The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C). -The nurse notes the client's urine is dark yellow with sediment.

Urine culture is positive for vancomycin-resistant enterococci (VRE). Explanation: Infections result from pathogens that produce illness after invading body tissues and organs. The client with the indwelling urethral catheter is at risk for developing an infection. The finding that confirms an infection would be a positive result on culture. Nausea and vomiting, a fever, and dark yellow urine with sediment are possible signs of an infection, but each of these findings alone does not confirm an infection.

The nurse is preparing to insert a peripheral 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 asterile water Use a sterile intravenous catheter. Wear a mask and gown for the procedure.

Use a sterile intravenous catheter. Explanation: Any item entering sterile tissues or the vasculature must be sterile. Therefore, an IV catheter must be sterile. It should not be dipped in an antiseptic before use. The nurse would clean the IV site with an antiseptic, not water, before insertion. An IV insertion does not require the nurse to wear a mask and gown.

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism? Direct contact Vehicle Droplet Airborne

Vehicle Explanation: Vehicle transmission involves the transfer of microorganisms by way of vehicles or contaminated items that transmit pathogens; for example, food can carry Salmonella. Direct contact transmission involves body surface-to-body surface contact causing the physical transfer of organisms between an infected or colonized person and an infected host. Droplet transmission occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. Airborne transmission occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens

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 Explanation: A reservoir is a place where microbes grow and reproduce. A soiled dressing can be a reservoir for microbes to breed. Changing the soiled dressing reduces the microbes at the wound. Wearing gloves, isolating client's belongings, and applying a face mask decrease the transmission of infection.

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection? airborne droplet contact reverse isolation

contact Explanation: Any multidrug resistant organism requires contact precautions to help prevent the spread of the organism to others. This will include MRSA. Airborne precautions can be utilized with diseases in which the causative organism is passed through the air after the infected person has coughed, sneezed, or talked. Tuberculosis is an example. Droplet precautions are warranted when the disease is spread through large particle droplets such as rubella and mumps. Reverse isolation is used to protect the client from any new infectious organisms. This can be utilized for client's who may be immunocompromised or already have a serious infection and the nursing team is trying to prevent further infections from complicating the client's health.

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. endogenous. exogenous. antibiotic resistant.

iatrogenic. Explanation: An infection is referred to as iatrogenic when it results from a treatment or diagnostic procedure. There is not enough information to determine if the infection was exogenous (causative organism is acquired from other people) or endogenous (causative organism comes from microbial life harbored in the person). An antibiotic-resistant organism is an organism against which most common antibiotics are ineffective.

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

increased respiratory rate lymph node enlargement fever Explanation: Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, and lymph node enlargement.

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 -with a client with pneumonia -with a client with a myocardial infarction -with another client with a draining wound

into a private room. Explanation: The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan? signs and symptoms of infection intravenous antibiotic administration hand hygiene measures vital sign monitoring

intravenous antibiotic administration Explanation: The discharge education plan would most likely include teaching the client and caregivers about the signs and symptoms of infection, hand hygiene measures, and vital sign monitoring. Because the client's infection has resolved, the client would probably not require intravenous antibiotic administration.

The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as: fungus. parasite. virus. bacteria.

parasite. Explanation: Lyme disease is spread through the bite of an infected tick, an arthropod, which is classified as a parasite. The bacteria Borrelia burgdorferi causes Lyme disease in humans. Viruses cause numerous infections but are not associated with Lyme disease. Fungi also cause disease in humans but are not associated with Lyme disease.

Any microorganism capable of disrupting normal physiologic body processes is a: bacterium. fomite. pathogen. virus.

pathogen. Explanation: Microorganisms that are capable of harming people are called pathogens or pathogenic.

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing? prodromal invasion stationary resolution

prodromal Explanation: Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature.

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 Explanation: Urinary catheters account for the highest percentage (26%) of hospital-associated infections. The four most common types of HAIs are related to invasive devices or surgical procedures: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated events (VAEs). A peripherally inserted catheter is an invasive line. Nasogastric tubes and endotracheal tubes are not associated with HAIs.

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse? -wash the area with soap and water -fill out a risk management form -find out who left the scalpel blade on the procedure tray -go to employee health for testing

wash the area with soap and water. Explanation: The first action by the nurse should be to wash the hands gently with soap and water to reduce exposure of blood or pathogens to the wound. Filling out a risk management form is required but should be done after first aid care is performed. Finding out who left the blade on the tray is not relevant at this time, but further education for the unit may be required at a later time. Going to employee health is the step that will be taken after immediate first aid.

The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: decreased elevated within normal limits stable

within normal limits Explanation: A normal white blood cell count is 5,000 to 10,000 cells/mm3.

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