Prep U ch 24 quiz 2

The nurse is preparing to enter a client's room who is on airborne precautions. Which technique should the nurse use when wearing a nonparticulate respirator (N-95) mask? Select all that apply.

-Tie the upper strings of mask snugly against back head. -Replace the mask after 20-30 minutes. -The mask covers the nose and mouth. The nonparticulate respirator (N-95) mask should be worn by covering the mouth and nose with the strings tied snugly against the back of head and lower strings against the back of the neck. The mask should be replaced every 20-30 minutes or when visibly damp or soiled. The mask should be removed by the strings, never touching the front of the mask. The mask should be discarded in a waterproof container.

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 should cleanse and disinfect the sphygmomanometer. A sphygmomanometer is another name for a blood pressure cuff. As this equipment is used on the outside of the arm versus entering a sterile body part, there is no need to have the equipment sterilized. It would be inappropriate for the nurse to use the visibly soiled blood pressure cuff or to throw it in the trash.

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 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.

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 Escherichia coli resides in the intestinal tract, is normal flora, and does not cause harm or infection in the client. Shigellosis is an infectious disease caused by a group of bacteria called Shigella, closely related to E. coli. Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria.

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. 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.

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) Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together: -C. 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.

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse?

Stop and obtain appropriate PPE The nurse should stop the task and obtain the appropriate protective wear. Protective equipment should be left outside of the room so that it can be donned prior to entering. Completing the task without the appropriate equipment can contaminate the nurse, which can lead to cross-contamination on the unit. Asking a colleague to finish the task is inappropriate.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerable to infection, so the 80-year-old woman is the client most at risk for infection. A neonate is defined as a child less than 4 weeks of age. An adolescent is a child aged 9 to 12 years. A toddler is a child who is 12 to 36 months or 1 to 3 years of age.

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

bacteria Bacteria may be transmitted through air, food, water, soil, vectors, or sexual activity

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact Fluids from a draining abscess can transmit infection through contact; therefore contact precautions are appropriate.

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. 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 an illness that is contracted after eating food.

The nurse is assisting a colleague with wound care. The colleague has established the sterile field and is pouring out normal saline into a sterile container, as seen in the picture above. What is the nurse's best action while observing the colleague perform the task?

observe the colleague and take no further action The colleague is demonstrating appropriate sterile technique. Consequently, there is no need to obtain a new dressing tray. The container cannot overlap the nonsterile edges of the field, but it does not necessarily need to be centered. The bottle should be held 4 to 6 in (10 to 15 cm) above the container, as pictured.

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

Which mask should the nurse don when caring for a client with tuberculosis?

Filtered respirator 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 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 Unless the supporting host becomes weakened, normal flora remains controlled. If the host's defenses are weakened, as in cases of HIV/AIDS, even benign microorganisms can cause opportunistic infections. This phenomenon is not due to mutations, spore production or the direct effects of a nutritional deficit.

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

The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath.

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. When a client is diagnosed with tuberculosis it is important for the nurse to remember that the client should be placed in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The nurse must wear the appropriate respirator when caring for the client, but visitors must wear masks. Simply being 3 feet away will not keep the visitor from being exposed to the client. The nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis.

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?

contact precautions Contact precautions should always be used when coming into contact with contaminated body fluids. Gown and gloves should be worn and protective eyewear if splashing may occur. Droplet precautions are used when there is a risk of transmitting pathogens within a 3-foot (1-meter) radius of the client when sneezing, coughing, etc. Neutropenic precautions are for the protection of the client due to immunosuppression. Airborne precautions should be instituted when exposure to microorganisms are transmitted by airborne route may occur.

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used as barriers to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients. Asking the client to state his or her name and date of birth is important to make sure the specimen is collected with the correct laboratory label. To protect the UAP from direct contact with the urine, a face mask is indicated.

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 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) -ventilator-associated events (VAEs). A peripherally inserted catheter is an invasive line. Nasogastric tubes and endotracheal tubes are not associated with HAIs.