Nursing Fundamentals Chapter 23.
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."
A nurse is preparing an operation theater for a surgical procedure. Which of the following points regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?
A commercially packaged surgical item is not considered sterile if past expiry date.
Which practice is a correct application of infection control practices?
A nurse performs handwashing each time she removes a pair of gloves.
Surgical asepsis is defined as
Absence of all microorganisms
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 preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room
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
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?
Contact
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene?
Decontaminate hands using an alcohol-based hand rub.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract
Which of the following masks should the nurse don when caring for a client with tuberculosis?
Filtered respirator
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?
Fungi
Two nurses are working together on the medical unit. One nurse goes to the other nurse and informs her that she just cut herself with a scalpel that was left on a procedure tray. Without knowing anything about the patient's or the other nurse's history, the nurse knows that her colleague is most at risk for which infectious disease?
Hepatitis B
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 adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step?
Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm).
To eliminate needlesticks as potential hazards to nurses, the nurse should:
Immediately deposit uncapped needles into puncture-proof plastic container.
The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?
In a bag marked "biohazards"
The nurse working with the hospital's infection control team is attempting to decrease the transmission of health care-associated pathogens. Which of the following will be most effective?
Incentivizing health care workers to utilize hand hygiene
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
A nurse changing the linens of a patient bed is exposed to urine and performs hand hygiene. Which of the following is a guideline for performing this skill properly following this patient encounter?
Keep hands lower than elbows to allow water to flow toward fingertips.
When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days previous. What should the nurse do?
Obtain a new bottle of sterile saline
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
The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which of the following actions by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
Which of the following is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled.
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated?
The nurse is caring for a client with a C. difficile infection.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the appropriate use of hand hygiene?
The nurse keeps fingernails less than ¼ inch long.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on the QSEN competency of safety?
The nurse places the client in a private room with monitored negative air pressure.
The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?
The nurse washes at least 1 inch above the area of contamination if present.
A nurse is caring for a 55-year-old post-operative 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
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 handrub is appropriate in which of the following situations?
When hands are visibly soiled
Which client would require a negative flow room?
an 81-year-old man with active tuberculosis and a productive cough
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
A nursing student comes to the university health center reporting a sore throat, malaise, and loss of appetite. The nurse assesses the student and determines she has large, white-yellow exudates in the back of the throat and a fever. The student is presenting with:
an infectious disease
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
Which nursing action is a component of medical asepsis?
handwashing after removing gloves
An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:
recapping a needle.
A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room?
thorough handwashing
Disinfectants are used:
to clean rooms between clients.
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift
When is hand hygiene with an alcohol-based rub appropriate, as opposed to using handwashing?
when hands are not visibly soiled
A nurse at health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What care should the nurse take 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 every 20 or 30 minutes. • Touch only the strings of the mask during removal.
Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.
• To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. • During some care activities for an individual client, nurses may need to change gloves more than once. • Nurses should remove PPE at the doorway or in an anteroom, except for the respirator.
After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply.
• Used syringe with attached needle • Used fingerstick lancet
A new graduate nurse is working in a long-term care facility. The nurse is frequently required to perform surgical asepsis procedures for her job. Which would not be appropriate? Select all that apply.
• artificial nails with intact, clear nail polish • artificial nails with dark purple nail polish
Which clients are at a heightened risk for infection? Select all that apply.
• client with an indwelling catheter • client with an IV catheter • client with gastric tube feeding
