Fundamentals- Ch. 24
When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?
Cleanse and disinfect the sphygmomanometer.
The nurse is 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
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.
The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?
Discard the supplies and field and prepare a new sterile field.
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?
Disinfect it with alcohol swabs.
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.
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 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 C. 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 piece of personal protective equipment (PPE) should be removed first?
Gloves
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. Explanation: HIV can be carried from an infected person to another person through blood, semen, vaginal fluids and breast milk. HIV cannot be transmitted through the secretions of an infected person who is coughing, sneezing, or talking. HIV cannot be transmitted through body surface-to-body surface contact between an infected person and another person. When a person is positive for HIV, regardless of whether symptoms of the disease are present, HIV can be transmitted from an infected person to another person.
The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection?
Hand hygiene
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?
Hand hygiene is needed after contact with objects near the client.
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.
A nurse is inserting a male client's indwelling urinary catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he has brought the wrong-sized catheter to the bedside. What is the nurse's best action?
Illuminate the client's call light and have a colleague bring the correct catheter to the bedside. If you realize a supply is missing after setting up the sterile field, you should call for help. Leaving the sterile field unattended renders it contaminated.
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
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.
A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?
Keep hands lower than elbows to allow water to flow toward fingertips.
The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?
Open a new sterile dressing kit
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
Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next?
Perform hand hygiene
The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first?
Perform hand hygiene.
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.
Which interventions will be most effective in preventing the spread of infection in the health care setting?
Proper handwashing
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 is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?
Remove fresh fruit from the room. Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities. p.598
Which action is the best example of a nurse donning/removing protective equipment properly?
Removing respirator after leaving client's room
What is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled. If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas. p.624-628
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.
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?
Surgical asepsis
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
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 Explanation: The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in. (4 cm) from the outer edges.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
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. Explanation: Gloves should be removed prior to a gown. Hand hygiene is necessary before applying gloves and after touching a client's surroundings. The use of moisturizers is acceptable.
What is the most common client site for development of healthcare-associated infections (HAI)?
Urinary tract Explanation: The urinary tract is the most common site for healthcare-associated infections (HAI).
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 Applying the ointment with the gloved finger contaminates the prescription ointment. Sterile cotton-tipped applicators are used to apply ointments or solutions to the wound bed to avoid contaminating the wound. A 4 × 4 gauze pad should not be applied until the wound is cleansed properly with sterile supplies. Soiled dressing supplies should be placed in a biohazardous trash bag or container. p.604; 618
The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?
Use a sterile intravenous catheter.
The nurse is caring for a postoperative client in contact isolation. Which actions should the nurse employ to reduce the spread of disease? Select all that apply.
Wash hands after removing gloves before leaving the client's room. Place used syringes and uncapped needles in a puncture-resistant container after use.
In which situation is an alcohol-based rub not the appropriate option for hand hygiene?
When the nurse's hands are visibly soiled
Surgical asepsis is defined as:
absence of all microorganisms.
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
airborne
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?
an 80-year-old woman
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
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
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?
contact Wound infectious agents are transmitted through contact; therefore contact precautions are appropriate. p.615
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?
contact precautions Explanation: VRE is transmitted via contact. The nurse caring for a client with VRE should implement contact precautions which is wearing a gown and gloves while in the client's room. Droplet precautions include wearing a surgical mask while in the room. Special masks for airborne precautions are used for, but are not limited to: measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis. Standard precautions are used with all clients.
The school nurse is educating a group of teenagers about ways in which human immunodeficiency virus (HIV) can be transmitted. Which methods of infection transmission will the nurse educate the group about? Select all that apply.
contact with blood via sexual contact contact with wound openings via mucous membranes via syringes shared between the client and others
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
Which nursing action is a component of medical asepsis?
handwashing after removing gloves
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
To eliminate needlesticks as potential hazards to nurses, the nurse should:
immediately deposit uncapped needles into a puncture-proof plastic container.
The nurse is admitting a client who has been receiving prescribed antibiotics for pneumonia. The client reports experiencing loose, watery stools for the past 4 days. What would be the initial action for the nurse to take?
implementing contact isolation
A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?
indwelling catheter
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
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
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe food poisoning. p.595
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate
Any microorganism capable of disrupting normal physiologic body processes is a:
pathogen.
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?
perform hand hygiene before and after entering the client's room
A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?
reaches down to the bed to pick up a sterile drape
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?
surgical asepsis
The nurse observes a member of the care team removing a gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?
teach the colleague to let the gown fall away rather than pulling on the sleeves
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 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.
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
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift A new gown should be used by the nurse each time the nurse enters the room.
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 client care and interaction
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 special masks."
A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?
"Help me understand your thoughts about vaccinations."
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."
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 friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?
"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."
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." 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 pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:
"You may have infection in your birth canal that you are unaware of."
Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.
-Incubation period -Prodromal stage -Full stage of illness -Convalescent period
The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.
-Turn on the faucet and adjust force and temperature of the water. -Wet the hand and wrists. -Apply soap. -Wash the palms and backs of the hands for at least 20 seconds. -Pat the hands dry with a paper towel. -Turn the faucet off with a paper towel.
How long should a health care worker rub hands that are not visibly soiled for effective hand hygiene?
15 to 20 seconds Alcohol-based hand sanitizers are preferred over soap and water when hands are not visibly soiled. Sanitizers are easily accessible, take less time than soap and water, and contain emollients that help maintain skin health. Alcohol-based hand sanitizers are also more effective at killing many bacteria, compared to soap and water. On average, the nurse should rub the hands for 15 to 20 seconds, until the hands are dry. The nurse should rub the hands while washing with soap and water for 20 seconds. For surgical asepsis, the hand washing scrub lasts 2 to 6 minutes. p.607
Which practice is a correct application of infection control practices?
A nurse performs hand washing each time the nurse removes a pair of gloves.
After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter?
Alcohol-based hand rub
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
A 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.
The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.
Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.
