Fundamentals Nursing Prep U Chapter 23 Asepsis and Infection Control

The nurse is preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply.

*Place a mask on the client. *Cover the client with a sheet during transport. *Communicate about precautions with the health care team. *Prepare the transport stretcher with a clean sheet.

An operating room nurse is putting on sterile gloves to assist with client surgery. Which actions are performed correctly in this procedure? Select all that apply.

*The nurse opens the outside wrapper by carefully peeling the top layer back. *The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. *The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove.

The nurse has collected data related to the recent ocurrence of several Health Care Associated Infections (HCAIs) in the acute care facility. What nursing interventions should be implemented to decrease Health Care Associated Infections (HCAIs)? Select all that apply.

*Wash hands before and after client care. *Encourage clients to receive vaccinations. *Cluster patients with similar conditions. *Select appropriate Personal Protective Equipment (PPE) for all isolation patients.

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

Apply a non-particulate (N-95) respirator when entering the room.

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)?

Fold soiled side to the inside and roll with inner surface exposed.

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

Gloves

A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to don her PPE. Which would be appropriate? Select all that apply.

Gloves Gown Mask with face shield

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

Handwashing before leaving the client's room.

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

Iatrogenic

When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. Which of the following is the appropriate action by the nurse?

Perform hand hygiene after removing the glove

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?

Perform surgical hand scrub using detergent.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

Sterile field is kept above waist level

The student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains:

Stress causes the body to release cortisol, which can increase the risk of infection.

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

When preparing a sterile field, the nurse notes that bottle of sterile saline was opened 48 hours ago and is half full. What should the nurse do?

discard the bottle

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

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin."

The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states which of the following?

"I do not need to wash my hands if I am using gloves."

Following insertion of a foley catheter, the nurse instructs the unlicensed assistant to remove the sterile gloves by inverting one glove into the other. The assistant states, "Why is that important?" Which response by the nurse is most appropriate?

"Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

"This antibiotic is the best choice since the causative organism is not known."

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."

Which of the following clients should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?

Client with a urinary catheter

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

A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter?

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

The nurse is asked to check the unit's supply of personal protective equipment (PPE) to see if additional equipment needs to be ordered from central supply. The nurse should assess the level of which of the following types of equipment? (Select ALL that apply.)

Non-sterile gloves Masks Gowns Protective eye wear

A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumoniae, which is particularly prone to cause infections, also referred to as what?

Pathogenic

The nurse is preparing a sterile field for a dressing change. How would the nurse add paper- wrapped sterile items to the sterile field?

Separate the sealed flaps and drop contents onto field.

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

Urinary tract

Which of the following are names of the transmission-based precautions defined by the Centers for Disease Control (CDC)? Select all that apply.

airborne precautions droplet precautions contact precautions

For which client would the use of standard precautions alone be appropriate?

an incontinent client in a nursing home who has diarrhea

The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin?

contact

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?

diligent handwashing practices

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

droplet

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

into a private room

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?

noncommunicable disease

A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is:

semen

A client has a systemic infection that resulted from an untreated urinary tract infection. The client has malaise and is confused. The client is

septic

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

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

within normal limits