Taylors Fundamentals - Ch. 24

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that: A. An older adult can have an infection without a fever B. An infection was present and has dissipated C. The clients symptoms are typical of an older adult client D. Without an elevated temperature, infection is not present

A - Older adults may not show a fever or may produce only a low-grade fever when an infection is present.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection? A. Create an area for sterile field and opening packages B. Place water-soluble lubricant on catheter tip prior to insertion C. Wash the perineal area with soap and water D. Ensure opening port of the catheter is closed

A - Pathogens require a portal of entry to cause infection. Insertion of an indwelling urinary catheter is a sterile technique; any contamination could cause a portal of entry. Using water-soluble lubricant on catheter tip prior to insertion is correct but will not prevent an infection nor will closing the opening port. Likewise, washing the perineal area with soap and water will reduce microorganisms but will not prevent infection alone.

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate? A. "Stress leads to increased secretion of cortisol, which suppresses your immune response." B. "Stress leads to a deterioration in the skin's barrier line of defense." C. "Stress causes the body's normal immune response to turn on itself." D. "Stress causes body fluids to accumulate, which leads to bacterial growth."

A - Physical or emotional stress causes the body to release cortisol, which can increase the risk of infection by suppressing the immune response. Stress has no effect on body fluid collection. Inadequate nutrition depresses almost every normal body defense against infection. The use of invasive devices or any break in the skin or mucous membranes leads to a disruption in the skin's barrier function against infection.

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? A. Droplet B. None C. Airborne D. Contact

A - Streptococcal pneumonia is transmitted through droplets; therefore droplet contact precautions are appropriate. The other options are inappropriate.

Which interventions will be most effective in preventing the spread of infection in the health care setting? A. Proper handwashing B. Sterilizing all client supplies C. Frequent room air exchanges D. Donning gloves for all client care

A - The most effective means of preventing the spread of infection in the health care setting is through proper handwashing. Sterilizing all client supplies is not possible nor would it omit bacterial transmission on the hands of health care workers. Frequent room air exchanges are important if a client has an illness, such as influenza or tuberculosis. Donning gloves for all client care helps to protect the nurse and client from contaminants but is not the most effective means of preventing the spread of illness.

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? A. removes gloves and walks out of the room B. applies a mask with face shield C. asks the client to state name and date of birth D. performs hand hygiene before donning gloves

A - 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.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply. A. The nurse has just completed documentation and is entering another clients room. B. The nurse is going from one room to another to introduce themselves at the start of the shift. C. The nurse is exiting a room after completed indwelling catheter care. D. The nurse has entered the client's room to adjust settings on the IV pump. E. The nurse has assisted a client with changing and caring for a new colostomy.

A, B, D - Alcohol-based handrub is preferred in situations when hands are not visibly soiled; before and after touching a client; before handling an invasive device for client care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; and after removing sterile or nonsterile gloves. Use of an alcohol-based handrub does not replace the need for gloves or for handwashing, however. After performing catheter care and assisting with changing a colostomy, gloves are worn and handwashing should take place.

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? A. The new nurse touches 1.5 in (4 cm) from the outer edges. B. The sterile field is set up at waist level. C. The top flap of the package is opened away from the new nurse's body. D. Direct visualization of the sterile field is maintained.

A. Only the outer 1 in (2.5 cm) of the sterile package is safe to touch. In this case, the nurse touches 1.5 in (4 cm), which is inside the sterile field. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body.

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds? A. one that remains directly outside the client's room B. one that remains in the client's room C. one that is the nurse's personal stethoscope D. one that the client has personally purchased for use

B - A dedicated stethoscope and blood pressure cuff should remain in the client's room. The other answers are incorrect.

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 hand rub is appropriate in which situation? A. After direct contact with clients B. When hands are visibly soiled C. Before direct contact with clients D. After completing a wound dressing

B - Alcohol-based hand rubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, except when the health care worker's hands are visibly soiled.

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? A. increased T cells B. surgical asepsis C. increased vitamin C D. decreased antibiotics

B - Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission? A. "Wearing the gloves and gown prevents sharing additional microorganisms with the client." B. "These barriers help prevent the transmission of infection to you or other people." C. "If you don't come into contact with anything with your body, you may wear gloves only, as long as you wash your hands after removing the gloves." D. "I understand; wearing these items is not pleasant but it really isn't optional."

B - Contact precautions block transmission of pathogens by direct or indirect contact Wearing a gown and gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing or even to others the visitors may come in contact with. While wearing gloves and gown may prevent sharing additional microorganisms with the client, that is not the reason for contact precautions. Agreeing that wearing the gown and gloves is not pleasant doesn't educate the family member.

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? A. Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container. B. Discard the bottle and get a new one because the saline has expired. C. Since the bottle has been open, previously used, and unexpired, "lip" it by pouring a small amount into a waste container or waste cup. D. Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening.

B - 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.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? A. Universal precautions B. Surgical asepsis C. Medical asepsis D. Contact precautions

B - Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter. Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate? A. The client will verbalize measures appropriate to minimize infection transmission. B. The client will state how to safely take the prescribed antibiotic. C. The client demonstrates the proper technique for hand hygiene. D. The client will identify signs and symptoms of worsening infection.

B - The client's knowledge deficit is related to antibiotic therapy. Therefore, the most appropriate outcome would be that the client states how to take the prescribed antibiotic. Identifying signs and symptoms of infection would relate to a nursing diagnosis of Deficient Knowledge related to infection. Verbalizing measures to minimize risk and demonstrating proper hand hygiene would be appropriate for a nursing diagnosis of Knowledge Deficit related to infection control or transmission, or possibly a nursing diagnosis of Risk for Infection.

Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care? A. slight bleeding noted while old dressing is removed B. skin is dry and intact C. redness size over sacral area is with minimal increase D. blanching over elbow area noted

B - The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare.

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond? A. "You will have to limit who comes to visit since they may be exposing you." B. "As we age, our immune system does not function as well." C. "It is possible that you are not washing your hands well enough." D. "There are a lot of infectious processes around and there is nothing that can be done."

B - The nurse should explain that during the aging process, the immune system decreases in function and the older adult client is at greater risk for becoming infected. Other risk factors for the older adult client include poor nutrition and fluid intake. Although washing hands is an important part of the prevention of infection, there are other methods such as airborne and droplet transmission that may be unavoidable. When it comes to visitation, the only limitation that should be set is that those who are ill or possibly infected should refrain from visiting the client. Informing the client that nothing can be done is not accurate, as there are preventative measures that may be taken to avoid exposure.

The nurse works at an agency that requires its employees to wear a face mask as long as the employee is in the building. The nurse performs the following activities while working. Which action is an error by the nurse? A. does not touch the mask with the hands while the nurse is wearing the mask B. omitting hand hygiene following removal of the nurse's mask C. touching the strings of the mask when applying or removing the mask D. positions the mask so that it covers both the nurse's nose and the mouth

B - The nurse should perform hand hygiene when removing the face mask. The purpose of hand hygiene at this time is to remove any microorganisms from the nurse's hands that could have been transferred from the mask to the hands during removal of the mask. The other actions are appropriate. Positioning the mask to cover the nose and mouth reduces entry and exit routes for transmission of microorganisms. Not touching the mask while wearing it also prevents transfer of microorganisms to the hands. Touching only the strings of the mask when removing it helps to prevent transferring microorganisms to the nurse's hands.

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: A. 4 days. B. 3 days. C. 5 days. D. 2 days.

B - Usually when a client is being screened for a parasitic infection, stool specimens are collected daily for 3 days. Parasites lay eggs in the GI tract that can be detected on examination. Moving organisms can easily be detected in fresh specimens.

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? A. droplet B. contact C. airborne D. none

C - Pulmonary tuberculosis is transmitted via airborne mechanisms; therefore airborne contact precautions are appropriate.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? A. with a client with a myocardial infarction B. with a client with pneumonia C. into a private room D. with another client with a draining wound

C - 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.

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? A. PICC line B. endotracheal tube C. urinary catheter D. Salem sump nasogastric tube

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

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. A. respiratory precautions B. microbial precautions C. airborne precautions D. contact precautions E. droplet precautions F. body fluid precautions

C, D, E - The CDC has three general precautions: contact, droplet, and airborne. Use contact precautions for clients with known or suspected infections that represent an increased risk for contact transmission. Use droplet precautions for clients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a client who is coughing, sneezing, or talking. Use airborne precautions for clients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster). Respiratory, microbial, and body fluid precautions are embedded in the three precautions.

Which is not appropriate regarding the use of gowns as PPE? A. use of paper or cloth gowns B. donning a gown when splashing C. use of a new gown each time the nurse enters the room D. use of one gown per person per shift

D - A new gown should be used by the nurse each time the nurse enters the client's room.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? A. a 12-year-old girl B. an 18-month-old infant C. a 2-year-old toddler D. an 80-year-old woman

D - 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 has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of: A. Aerobic activity B. Means of transmission C. Spore production D. Survival adaptation

D - An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae. Bacterial resistance is not demonstrated by aerobic activity. Spore production is another form of adaptation. Means of transmission is a component of the chain of infection, not an example of bacterial resistance.

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? A. neutropenic precautions B. droplet precautions C. airborne precautions D. contact precautions

D - 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 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.

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter? A. Use an alcohol-based hand rub to decontaminate the hands. B. Remove all jewelry, including wedding bands, before hand washing. C. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. D. Keep hands lower than elbows to allow water to flow toward fingertips.

D - 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.

A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the priority nursing action the nurse must perform before leaving the client's room? A. removing personal protective equipment that is most contaminated first B. spraying of disinfectant C. placing one bag of contaminated items within another D. thorough handwashing

D - Since the client has an infectious disease, the most important nursing action is to perform thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care item. Spraying a disinfectant before leaving the client's room, or placing one bag of contaminated items in another, is not the most important nursing action in this case. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Nurses remove the personal protective equipment that is most contaminated first to preserve the clean uniform underneath. There is no information to indicate this client is in isolation, so PPEs may not be required. Also it is not always necessary to wea PPEs to obtain vital signs.

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? A. Wear a protective gown and gloves with any direct contact. B. Have the client wear a mask during care. C. Wear a mask with face shield during invasive procedures. D. Apply a nonparticulate (N-95) respirator when entering the room.

D - TB is an airborne infection, and the nurse should wear a nonparticulate mask (N-95) respirator. Gown and gloves would be indicated for infections that are transmitted via direct contact. A mask with a face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care.