Prep U Quiz 3 ch 24 Asepsis and Infection Control

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.

Localized heat Purulent or malodorous drainage Pain with redness and swelling Signs of infection of the client's foot ulcer that the nurse includes in discharge teaching include redness, swelling, and pain; localized heat; and purulent or malodorous drainage. If the inside edges of the ulcer appear to be drawing together and/or if scabs are forming over the ulcer, the ulcer is likely to be healing.

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply.

Nonsterile gloves Hand hygiene When taking vital signs on a client after surgery, the nurse should practice hand hygiene. There is no need to use a gown or mask unless the client is diagnosed or suspected to have a transmittable infection. Since it is an aseptic versus sterile procedure, the nurse should use nonsterile gloves.

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.

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficileinfection. What should the nurse be sure to include with these precautions?

be sure that there are gloves of various sizes and gowns for use All health care workers and visitors should don a gown and gloves prior to entering the client's room. These bacteria are not transmitted by droplet. An N95 respirator mask is not required for this client.

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 Hand hygiene is the most important way to prevent transmission of infection.

The nurse has applied personal protective equipment (PPE) before caring for an immunocompromised client. When removing PPE, what action should the nurse perform?

when removing gloves, the nurse should do so by pulling on the cuff with two fingers, being careful not to touch the outside of the contaminated glove. The nurse should not touch the outside of the contaminated gown.

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

"I have set up this sterile field for your procedure, so please do not touch anything around the tray." If the client touches the sterile field, the nurse will need to discard the supplies and prepare a new sterile field. When any portion of the sterile field becomes contaminated, all portions of the sterile field must be discarded. The nurse should call for help if a supply is needed. The nurse should not leave the sterile field unobserved.

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." Viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.

5, 7, 2, 1, 3, 4, 6 The expected outcome to achieve when putting on and removing sterile gloves is that the gloves are applied and removed without contamination. The nurse performs this procedure using the steps in the order listed.

The nurse will assess a client who has a draining abscess. The nurse should perform what action to safely enter the room?

A draining abscess poses an infection control risk that is sufficiently addressed with contact precautions. Because there is no obvious risk of airborne or droplet transmission, masks, goggles, and face shields are not warranted.

Which practice is a correct application of infection control practices?

A nurse performs hand washing each time the nurse removes a pair of gloves. Hand washing should be performed each time the nurse removes of a pair of gloves. Gloves are not required for each and every client contact, and visibly soiled hands require a wash with soap and water. Alcohol-based hand rubs are not followed by rinsing of the hands.

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?

"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with." Contact precautions, which are not optional, block transmission of pathogens by direct or indirect contact. Explaining that the loved-one understands is not teaching information. Educating the visitor about drug-resistant infections is important but does not explain how to prevent transmission of the infection. Telling the visitor that he or she will get the infection if the visitor does not wear gloves is incorrect, the visitor is at a greater risk of getting and spreading the infection. Wearing gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing.

A nurse is preparing an operating room theatre for a surgical procedure. Which point 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 expiration date. When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

Which nursing action is a component of medical asepsis?

handwashing after removing gloves Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood).

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 client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

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 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.

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 To prevent the transmission of TB, the National Institute for Occupational Safety and Health recommends the use of a particulate air filter respirator that fits snugly to the face for all client care and interaction. A face mask does not block small TB particles effectively. Protective eyewear is only needed if contact with bodily fluids is expected. The client would be placed in a negative pressure room to prevent the potential spread of TB.

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 mostappropriate?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." By explaining that alcohol-based hand rubs are effective in preventing the spread of microbes, the nurse directly addresses the client's concern. While washing with soap and water may not be necessary, it doesn't address the client's concern. Alcohol-based hand rub is an appropriate method for hand hygiene even when you plan to touch the client.

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 Hand washing technique is the single most important procedure in reducing the spread of microorganisms from either the client to the surroundings or the surroundings to the client. A client does not need to learn a sterile technique for the abdominal incision. Most client procedures are related to clean handing and do not need gloves to be added to a dressing change. The nurse should review signs of infection and healing of the abdominal incision.

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 When setting up a sterile field, the correct technique is to keep the sterile field above the waist level. A nurse would open the sterile package away from him- or herself first. The sterile gloves are applied after the sterile container is opened. The sterile field is maintained with a 1-in. (2.5-cm) border.