PrepU Chapter 23: Asepsis and Infection Control
The nurse is caring for a postpartum mother who delivered her second child yesterday. The mother states her older child has just been diagnosed with chickenpox. She is concerned her newborn will develop the disease. What is the best response by the nurse?
"Have you had chickenpox?"
The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?
"When your sputum culture is negative."
To eliminate needlesticks as potential hazards to nurses, the nurse should:
Immediately deposit uncapped needles into puncture-proof plastic container
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
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?
bradypnea is a response to IICP.
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?
decontaminate hands using an alcohol-based hand rub
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 a client who developed pneumonia while hospitalized. How will the nurse document this condition?
health care-associated infection (HCAI)
Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure?
if the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair
Any microorganism capable of disrupting normal physiologic body processes is a:
pathogen
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 action by the nurse is appropriate?
place a surgical mask on the client and transport to the CT department at the specified time
A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client?
rectum
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
What is an accurate guideline for the use of PPE?
replace gloves if they are visibly soiled
The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?
staff education on utilizing hand hygiene
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
surgical asepsis technique
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. from the outer edges
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?
the nurse keeps fingernails less than 1/4 in. long
Standard precautions apply to blood; all body fluids, secretions, and excretions; intact and nonintact skin and mucous membranes.
true
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
The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection?
urine culture is positive for vancomycin-resistant enterococci (VRE)
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 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?
write it down
The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?
"Help me understand your perspective about vaccinating."
The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the the education provided was effective? Select all that apply.
"I may transmit the virus to my child during pregnancy and childbirth." "If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus if I share needles with another person."
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?
5,850 mL
What is the pulse pressure of a client whose blood pressure is 132/82 mm Hg?
50
Which practice is a correct application of infection control practices?
a nurse performs hand washing each time the nurse removes a pair of gloves
A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
auscultate the lung sounds and count respirations
The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin?
contact
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 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
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 assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
listen for heart sounds
A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?
no stethoscope is required
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
there is an auscultatory gap
Personal protective equipment (PPE) is used in health care facilities to protect the staff from potentially infected clients.
true
