Chapter 25 "Asepsis and infection control" TB/coarse point questions
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." Tuberculosis is an airborne respiratory disease, which requires a HEPA-style respirator or N95 mask when visitors or staff enter the room of a client with known or suspected disease. Gowning and gloving do not prevent airborne transmission. Visitors are permitted and there is no firm prohibition against touching the client. Use airborne precautions for clients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster).
A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry with the nurse practitioner because he would not give me any antibiotics." What would be the most accurate response by the nurse?
"Antibiotics have no effect on viruses."
A nurse is educating adolescents on how to prevent infections. What statement by one of the adolescents indicates that more education is needed?
"I don't wear a condom when I have sex, but I know my partners."
The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?
"Your infant's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."
What is the minimal amount of time that a nurse should scrub hands that are not visibly soiled for effective hand hygiene?
20 seconds
Which of the following most accurately defines an infection?
A disease resulting from pathogens in or on the body
A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate?
A reservoir
A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man?
Airborne route
What is the correct rationale for using body substance precautions?
All body substances are considered potentially infectious.
A nurse has seen several clients at a community health center. Which of the clients would be most at risk for developing an infection?
An older adult with several chronic illnesses
What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high?
Antimicrobial products
Which of the following statements about glove use and hand hygiene is true?
Artificial fingernails should not be worn by staff involved in direct client care.
What are the general nursing care guidelines that the nurse should follow when caring for clients in a health care facility?
Avoid jewelry with prongs or protruding stones.
Which of the following are characteristics of the stage of infection known as full stage of illness? Select all that apply.
B)Specific signs and symptoms are present. C)The organisms are growing and multiplying.
A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection?
Bacteria
A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply.
Basophils Neutrophils Eosinophils
A nurse has completed morning care for a client. There is no visible soiling on her hands. What type of technique is recommended by the CDC for hand hygiene?
Clean hands with an alcohol-based handrub.
Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?
Client receiving chemotherapy
Which statement is true of health care personnel and good hand hygiene?
Compliance is difficult to achieve.
A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?
Gather new sterile supplies and start over.
An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the following is an accurate guideline that should be discussed?
Hand hygiene must be performed after contact with inanimate objects near the client.
A nursing home recently has had a significant number of nosocomial infections. Which of the following measures might be instituted to decrease this trend?
Have written, infection-prevention practices for all employees
What is hepatitis B?
Hepatitis B is spread when blood, semen, or other body fluids from a person infected with the virus enters the body of someone who is not infected.
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
Hold sterile objects above waist level to prevent inadvertent contamination.
Which of the following is an example of the body's defense against infection?
Immune response
A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?
Intact skin and mucous membranes protect against microbial invasion.
A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection?
Nosocomial
Of all possible nursing interventions to break the chain of infection, which is the most effective?
Practicing hand hygiene
A college-aged student has influenza. At what stage of the infection is the student most infectious?
Prodromal stage
The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process?
Prodromal stage
A nurse is caring for a client with a serious bacterial infection. The client is dehydrated. Knowledge of the physical effects of the infection would support which of the following nursing diagnoses?
Risk for Imbalanced Body Temperature
A nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs?
Soil
A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation precautions should the nurse follow?
Standard precautions
The latest CDC guidelines designate standard precautions for all substances except which of the following?
Sweat
Which should be documented by the nurse?
The fact that sterile technique was used for a given procedure
The following procedures have been ordered and implemented for a hospitalized client. Which procedure carries the greatest risk for a nosocomial infection?
Urinary catheterization
What is the most common client site for development of healthcare-associated infections (HAI)?
Urinary tract
A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure?
Use sterile gloves to handle the entire drape surface.
A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted?
Vectors
A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when cleaning open wounds to protect himself from infection?
Wear a pair of sterile latex gloves.
Which of the following questions asked by the nurse when taking a client's health history would collect data about infection control?
When did you complete your immunizations?
A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field?
With sterile forceps or hands wearing sterile gloves
A community health nurse is providing care for several older adults. Which factor increases these clients' susceptibility to infections?
atrophy of the thymus gland because The thymus begins to shrink in late adolescence and continues to diminish into middle age, leading to a decline in cell-mediated and humoral immunity
A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called "the kissing disease." The nurse explains that the organisms causing this disease were transmitted by:
direct contact.
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
The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?
inserting an arm within each sleeve while touching the outer surface of the gown
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?
intravenous antibiotic administration
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections
A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?
place the specimens into plastic biohazard bags
When explaining the inflammatory response to nursing students, the instructor describes a series of events. Place the events in the order in which the instructor would describe them.
tissue injury dilation of blood vessels plasma flow out of capillaries white blood cell migration to the area phagocytosis
