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Which nursing action is a component of medical asepsis? handwashing after removing gloves insertion of an indwelling urinary catheter insertion of an intravenous catheter drawing blood from a central line |
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 or intravenous catheters). |
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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 dons a pair of gloves prior to any client contact. A nurse uses an alcohol-based handrub each time that the nurse’s hands are visibly soiled. A nurse ensures that the nurse rinses the hands thoroughly after the application of an alcohol-based handrub. |
A nurse performs hand washing each time the nurse removes a pair of gloves. Hand washing should be performed after the removal 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 handrubs are not followed by a rinse. |
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To eliminate needlesticks as potential hazards to nurses, the nurse should: Place the uncapped needle on a tray and carry it to the medicine room for disposal. Immediately deposit uncapped needles into puncture-proof plastic container. Stick the uncapped needle into a Styrofoam block and deposit in a plastic container. Slide the needle into the cap and deposit it in a puncture-proof plastic container. |
Immediately deposit uncapped needles into puncture-proof plastic container. All uncapped needles should be placed in puncture-proof plastic units immediately after use. |
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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. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse’s ability. Don a second pair of sterile gloves over the first pair. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. |
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. It is appropriate to adjust the gloves by touching sterile surface to sterile surface. |
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The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client? airborne droplet contact respiratory |
droplet Droplet precautions are appropriate because microorganisms exit the body during coughing, sneezing, and procedures such as suctioning. Airborne precautions are not used because droplets do not remain suspended in air. |
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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 (4 cm) from the outer edges. The sterile field is set up at waist level. Direct visualization of the sterile field is maintained. The top flap of the package is opened away from the new nurse’s body. |
The new nurse touches 1.5 in (4 cm) from the outer edges. The outer 1 in (2.5 cm) of the sterile package is safe to touch. It is necessary to call for help if supplies are needed before leaving the sterile field unattended; never turn away from a prepared field. The top flap of the sterile packaging should always be opened away from the body. |
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The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse? Discard the supplies and field and prepare a new sterile field. Educate the client on sterile fields and continue preparing for the procedure. Give the client the water pitcher and continue preparation. Remove the supplies from the field and replace with new supplies. |
Discard the supplies and field and prepare a new sterile field. If sterile procedure is disrupted in any way, the nurse must discard all items (including the field) and begin preparing a new sterile field. Reaching over a sterile field would disrupt the sterility of the area. The other options do not address the contamination of the sterile field. |
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Standard precautions apply to blood; all body fluids, secretions, and excretions; intact and nonintact skin and mucous membranes. True False |
True Standard precautions are used in the care of all hospitalized clients regardless of their diagnosis or possible infection status. These precautions apply to blood, all body fluids, secretions, and excretions except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes. Additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures. |
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An older adult patient has been diagnosed with a nosocomial respiratory infection and has been transferred to the intensive care unit. The nurse should understand what fact about the patient’s illness? The patient most likely became ill because of a compromised immune system. The patient’s illness has most likely been long-standing and chronic. The patient acquired the illness after he or she was admitted to the hospital. The patient acquired an opportunistic infection after receiving antibiotics. |
The patient acquired the illness after he or she was admitted to the hospital. Infections that are acquired by patients while they are institutionalized or hospitalized are called nosocomial infections. This is not necessarily the result of antibiotic use or a compromised immune system. If the infection were chronic, it would not be categorized as nosocomial. |
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A nursing student is preparing to perform wound care for a hospital patient. When establishing a sterile field, the nurse should consider what areas to be nonsterile? All of the field, except an 8-inch (20 cm) square near the centre of the field A 1-inch (2.5 cm) margin around the edge of the field The portion of the field that is closest to the patient The portion of the field that is closest to the student |
A 1-inch (2.5 cm) margin around the edge of the field A 1-inch margin around the edge of the sterile field is considered to be nonsterile. The portion of the field near the patient or the nurse is not considered to be nonsterile. |
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A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as which of the following? Iatrogenic Endogenous Exogenous Antibiotic resistant |
Iatrogenic An infection is referred to as iatrogenic when it results from a treatment or diagnostic procedure. There is not enough information to determine if the infection was exogenous (causative organism is acquired from other people) or endogenous (causative organism comes from microbial life harbored in the person). An antibiotic-resistant organism is an organism against which most common antibiotics are ineffective. |
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A home health nurse is completing a health history for a client. What is one question that is important to ask to identify a latex allergy for this client? "Have you ever had an allergic reaction to shellfish or iodine?" "Tell me what you use to wash your hands after toileting." "When you were a child, did you have frequent infections?" "Have you had any unusual symptoms after blowing up balloons?" |
"Have you had any unusual symptoms after blowing up balloons?" Awareness of a latex allergy is important for safe home care. Nurses need to ask whether clients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning. |
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A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? Remove the garments that are most contaminated. Make contact between two contaminated surfaces. Make contact between two clean surfaces. Handwashing before leaving the client’s room. |
Handwashing before leaving the client’s room. 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. |
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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? When a sterile item touches something that is not sterile, it may not be contaminated. Any partially uncovered sterile package need not be considered contaminated. A commercially packaged surgical item is not considered sterile if past expiration date. Sterility may not be preserved even when one sterile item touches another sterile item. |
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. |
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Disinfectants are used: to prepare instruments for surgery. to sterilize surgical drapes. to clean rooms between clients. for preoperative bowel preparations. |
to clean rooms between clients. A chemical used on lifeless objects is called a disinfectant. |
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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. Notify the CT department in advance so other clients and staff can be removed from the area. Question the need for the examination because the client must remain in Airborne Precautions. Request that the examination be done at the bedside. |
Place a surgical mask on the client and transport to the CT department at the specified time. Transport clients in Airborne Precautions out of the room only when necessary and place a surgical mask on the client, if possible. |
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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? After completing a wound dressing Before direct contact with clients After direct contact with clients When hands are visibly soiled |
When hands are visibly soiled Alcohol-based handrubs 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. |
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The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client? standard airborne droplet contact |
airborne Tuberculosis is transmitted via the air. Therefore, airborne precautions are required. Standard, droplet, and contact precautions will not be selected by the nurse for a client who has tuberculosis. |
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The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? an older adult client with a history of heart failure a school-age child who is current with immunizations an adolescent who has a right radial fracture a middle-aged adult who takes prescribed medication to control blood pressure |
an older adult client with a history of heart failure Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have pre-existing illnesses, appear to be more vulnerable to infection. School-age children are exposed to potential infections, but immunizations protect the child. An adolescent with a fracture or middle-aged adult taking medication to control BP could develop an infection, but not the highest risk. |
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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 post-surgical procedure the client admitted with a rash who reports recent exposure to measles the client admitted with diarrhea who tested positive for Escherichia coli (E.coli) the client placed in contact isolation who was admitted with a draining abdominal wound |
the client who is 48-hours post-surgical procedure Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between patients, the nurse should see clients clean to dirty. The nurse should see the client who has no signs of infection first. The nurse should see the client who is post-operative first before seeing the other clients who have symptoms of infections. |
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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. Consider the outside of the sterile package to be sterile. Consider the outer 3-in (8-cm) edge of a sterile field to be contaminated. Open sterile packages so that the first edge of the wrapper is directed toward the nurse. |
Hold sterile objects above waist level to prevent inadvertent contamination. Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 in (2.5 cm) of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse. |
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What is an accurate guideline for removing soiled gloves after client care? Use the nondominant hand to grasp the opposite glove, near the cuffed end on the outside exposed area. Remove the glove on the nondominant hand by pulling it straight off, keeping the contaminated area on the outside. After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. After removing the first glove, slide the fingers of the ungloved hand between the remaining glove and the wrist and pull the glove straight off, with the contaminated area on the outside. |
After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. When removing gloves, the dominant hand is used to grasp the opposite glove near the cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated area on the inside. The removed glove is held in the remaining gloved hand. Then, the fingers of the ungloved hand are slid between the remaining glove and the wrist, and the glove is pulled off and inverted. |
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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? Discard the sphygmomanometer in the trash Cleanse and disinfect the sphygmomanometer Send the sphygmomanometer for sterilization Use the sphygmomanometer |
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. |
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A pediatric client’s caregiver states, "I will never give my child vaccinations." What is the priority nursing response? "Vaccinations prevent disease." "Help me understand your thoughts about vaccinations." "Has your child received any previous vaccinations?" "Transmission of certain diseases is halted with vaccination." |
"Help me understand your thoughts about vaccinations." Seeking to understand the caregiver’s perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. The nurse could then collect assessment data regarding past vaccines and provide appropriate teaching. |
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The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? Allow many family members to visit at once. Deliver flowers and balloons to the room. Remove fresh fruit from the room. No special precautions are required. |
Remove fresh fruit from the room. Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities. |
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Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair removing the staples from a VRE-positive, postoperative client’s incision without prior handwashing sending a VRE-positive client to the radiology department for a chest X-ray without a face mask delivering a meal tray to a VRE-positive client without first donning gloves and a gown |
Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair Direct client contact between a VRE-positive client and another client without handwashing carries a significant risk of infection, especially when contact includes body fluids. Handwashing is necessary before a procedure such as staple removal, but foregoing this infection control measure is less likely to spread VRE unless the nurse failed to handwash after the procedure. VRE does not normally require droplet or airborne precautions. Delivering an item to a client without gloves or a gown is less of a risk than failing to wash the hands after such contact. |
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Which client presents the most significant risk factors for the development of Clostridium difficile infection? an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior a 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft A client with renal failure who receives hemodialysis three times weekly |
an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis. |
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Surgical asepsis is defined as: absence of all virulent microorganisms. absence of all microorganisms. slowed growth of microorganisms. use of hand washing, gowning, and gloving. |
absence of all microorganisms. Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms. |
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What is an accurate guideline for the use of PPE? Put on PPE after entering the client’s room. Substitute personal glasses for protective eyewear, if desired. Replace gloves if they are visibly soiled. When wearing gloves, work from "dirty" areas to "clean" ones. |
Replace gloves if they are visibly soiled. If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client’s room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas. |
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A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? Surgical asepsis technique Medical asepsis technique Droplet precautions Strict reverse isolation |
Surgical asepsis technique Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client’s bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others. |
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An operating room nurse is putting on sterile gloves to assist with client surgery. Which actions are performed correctly in this procedure? Select all that apply. The nurse places the sterile gloves on a clean dry surface at or below waist level. The nurse opens the outside wrapper by carefully peeling the top layer back. The nurse places the inner package on the work surface with the side labeled "cuff end" furthest from body. The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove. The nurse touches only the inner surface of the package and the gloves. |
•The nurse opens the outside wrapper by carefully peeling the top layer back. •The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. •The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove. There are several actions that the operating room nurse would perform when putting on sterile gloves. First, the nurse would open the outside wrapper by carefully peeling the top layer back. The nurse would carefully open the inner package by folding open the top flap, then the bottom and sides. The nurse would lift and hold the glove up and off the inner package with fingers down and carefully insert the hand "palm up" into the glove. The nurse would touch only the inner surface of the package and the gloves. The nurse would work at a surface level at or above the waist. The nurse would place the inner package labeled "cuff end" nearest to the body. The nurse touches only the outer surface of the inner package. |
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A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today 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? Wear gloves when touching the client. Wear a mask and gown in the client’s room. Avoid direct contact with the client. Perform hand hygiene before and after entering the client’s room. |
Perform hand hygiene before and after entering the client’s room. Hand hygiene is the most important way to prevent transmission of infection. |
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A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor? washes hands for 20 seconds with soap and water picks up the glove at the folded edge with the thumb and forefinger stretches the glove over the hand without touching the unsterile area reaches down to the bed to pick up a sterile drape |
reaches down to the bed to pick up a sterile drape The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully. |
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The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? Wear a protective gown and gloves with any direct contact. Apply a non-particulate (N-95) respirator when entering the room. Have the client wear a mask during care. Wear a mask with face shield during invasive procedures. |
Apply a non-particulate (N-95) respirator when entering the room. TB is an airborne infection and the nurse should wear a non-particulate mask (N-95) respirator. Gown and gloves would be indicted for infections that are transmitted via direct contact. A mask for face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care. |
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A nurse observed a colleague enter a patient’s room to respond to a call bell. The nurse believes that the colleague did not perform hand hygiene prior to giving care. What is the nurse’s most appropriate action? Ask the patient if she observed the nurse performing hand hygiene. Report this observation to the unit manager of clinical nurse leader. Ask the colleague if he performed hand hygiene before giving care. Complete an incident report documenting the nurse’s suspicions. |
Ask the colleague if he performed hand hygiene before giving care. Nurses have a responsibility to address lapses in infection control practices that they observe in health-care settings. In most cases, this should be addressed by discussing the matter with the person involved. It would be inappropriate to involve the patient. |
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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 Revising the facility’s infection control protocols Encouraging visitors to adhere to isolation precautions Limiting visitors to family members over the age of 18 |
Incentivizing health care workers to utilize hand hygiene Most health care-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. |
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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 uses soap and cold water to wash hands. The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands. The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. The nurse rinses thoroughly with water flowing away from the fingertips. |
The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. The nurse must wash at last 1 in (2.5 cm) above the area of contamination to properly performed hand hygiene. The nurse should use warm to hot water to wash hands. The amount of liquid soap varies depending on the concentration of the soap. The nurse rinses with water flowing toward the fingertips. |
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The nurse observes an unlicensed assistive personal (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 asks the client to state name and date of birth applies a mask with face shield performs hand hygiene before donning gloves |
removes gloves and walks out of the room Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used a barrier 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. The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. The other options are appropriate actions. |
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A nurse has finished providing morning care for a patient and is now planning to perform hand hygiene. Alcohol-based hand rub would be inappropriate in which of the following circumstances? The patient is being treated for an active infection. The nurse’s care involved direct contact with the patient’s skin surfaces. The nurse has dry, sensitive skin. The nurse’s hands are visibly soiled. |
The nurse’s hands are visibly soiled. Alcohol is not recommended when hands are dirty or visibly contaminated with materials such as blood. It may safely be used after contact with infected patients. Most alcohol products contain emollients that can prevent a drying action on the skin. |
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The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action? to protect the integrity of the nurse’s immune system to prevent the nurse from developing disease to eliminate disease-producing organisms from the nurse’s skin to sterilize the nurse’s hands to prevent infection |
to eliminate disease-producing organisms from the nurse’s skin The purpose of hand hygiene is to protect clients from infection by removing microorganisms from the skin. This action directly addresses client safety but is not directly related to effectiveness of care. Hand hygiene protects the nurse from infection but the primary purpose is to protect clients. Hand hygiene greatly reduces the number of microorganisms on the skin but does not result in sterile skin surfaces. |
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A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter? Use an alcohol-based hand rub to decontaminate hands. Remove all jewelry, including wedding bands before hand washing. Keep hands lower than elbows to allow water to flow toward fingertips. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. |
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. |
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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 the door open. The nurse uses droplet precautions when providing care for the client. The nurse keeps visitors 3 feet away from the infected person. The nurse places the client in a private room with monitored negative air pressure. |
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. |
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A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood? 1500 1200 2000 Wait until day 5 of treatment. |
1500 Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest. |
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Unbeknown to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur. |
•Incubation period •Prodromal stage •Full stage of illness •Convalescent period |
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Which action should the nurse perform first after an exposure to a client’s body fluids? |
Wash the exposed area with soap and water |
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The client is an employee on the medical unit at the local children’s hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? Contact Vehicle Droplet Airborne |
Contact Contact may be either direct or indirect. |
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A nursing student is alarmed to learn that the patient whom she has been assigned to provide care is positive for HIV. What infection control strategy should the student apply when caring for this patient? Perform hand hygiene using soap and water rather than alcohol-based hand rub. Wear a surgical mask if the patient has had a recent cough. Apply two pairs of gloves when performing tasks that involve contact with the patient’s skin. Apply routine precautions in the same manner as when caring for other patients. |
Apply routine precautions in the same manner as when caring for other patients. Infection with HIV or any other illness does not necessitate a deviation from the principles of routine precautions unless there is a specific reason that the patient is more susceptible to infection (e.g., immunosuppression). Although routine practices must be considered for all patients, patient susceptibility to infection will determine what, if any, additional measures may apply. However, there is no need to choose soap and water over alcohol rub. Masks and double-gloving are not normally required. |
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A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is: semen. blood. wound drainage. sputum. |
semen. Vehicle transmission involves the transfer of microorganisms by way of vehicles, or contaminated items that transmit pathogens. For example, food can carry Salmonella. In this case, semen can carry human immunodeficiency virus. |
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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? Airborne Contact Vector Vehicle |
Contact Direct contact involves body surface-to-body surface contact, causing the physical transfer of organisms between an infected or colonized host and a susceptible host. |
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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? Surgical asepsis Increased T cells Decreased antibiotics Increased vitamin C |
Surgical asepsis Clients are at risk for healthcare-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. |
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The nurse is preparing to perform hand washing. Arrange the steps in the correct order. 1 |
-Turn on the faucet and adjust force and temperature of the water. -Wet the hand and wrist areas. -Apply soap product. -Wash the palms and back of the hands for at least 15 seconds. -Pat hands dry with a paper towel. -Turn the faucet off with a paper towel. |
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A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter? Use an alcohol-based hand rub to decontaminate hands. Remove all jewelry, including wedding bands before hand washing. Keep hands lower than elbows to allow water to flow toward fingertips. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. |
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. |
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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. Consider the outside of the sterile package to be sterile. Consider the outer 3-in (8-cm) edge of a sterile field to be contaminated. Open sterile packages so that the first edge of the wrapper is directed toward the nurse. |
Hold sterile objects above waist level to prevent inadvertent contamination. Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 in (2.5 cm) of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse. |
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What is a recommended guideline for maintaining a sterile field? When a portion of the sterile field becomes contaminated, the nurse should remove the contaminated objects and continue with the procedure. If a supply is missing, the nurse may leave the sterile field briefly to obtain it. If the client touches the sterile field, the nurse should discard the supplies and prepare a new sterile field. If the client touches the nurse’s gloves during the procedure, the nurse may still proceed with the procedure. |
If the client touches the sterile field, the nurse should discard the supplies and prepare a new sterile field. If the client touches the sterile field, 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. Call for help if a supply is needed and do not leave the sterile field unobserved. |
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For which client would the use of standard precautions alone be appropriate? a client with diphtheria who needs p.m. care a client with TB who needs medications administered an incontinent client in a nursing home who has diarrhea a child with chickenpox who is treated in the emergency room |
an incontinent client in a nursing home who has diarrhea Standard precautions apply to blood and all body fluids, secretions, and excretions, except sweat. transmission-based precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as is the case in answers A, B, and D. |
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What is an accurate guideline for the use of PPE? Put on PPE after entering the client’s room. Substitute personal glasses for protective eyewear, if desired. Replace gloves if they are visibly soiled. When wearing gloves, work from "dirty" areas to "clean" ones. |
Replace gloves if they are visibly soiled. If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client’s room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas. |
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The nurse planning to insert an indwelling urinary catheter into a client should utilize which of the following techniques? Surgical asepsis Medical asepsis Universal precautions Contact precautions |
Surgical asepsis Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as inserting 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. |
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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 Revising the facility’s infection control protocols Encouraging visitors to adhere to isolation precautions Limiting visitors to family members over the age of 18 |
Incentivizing health care workers to utilize hand hygiene Most health care-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. |
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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 PICC line Salem sump nasogastric tube Endotracheal tube |
Urinary catheter Urinary catheters account for the highest percentage (26%) of hospital-associated infections. |
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A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today 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? Wear gloves when touching the client. Wear a mask and gown in the client’s room. Avoid direct contact with the client. Perform hand hygiene before and after entering the client’s room. |
Perform hand hygiene before and after entering the client’s room. Hand hygiene is the most important way to prevent transmission of infection. |
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Which client would require a negative flow room? a 21-year-old man with latent tuberculosis who is postoperative following repair of a femoral fracture a 4-year-old boy with meningitis an 81-year-old man with active tuberculosis and a productive cough a 3-year-old with influenza A and a productive cough |
an 81-year-old man with active tuberculosis and a productive cough Active tuberculosis always requires a negative flow room. |
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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. nails that are cut to ½ inch beyond the nail bed artificial nails with dark purple nail polish artificial nails with intact, clear nail polish nails that are chewed down to the nail bed |
artificial nails with dark purple nail polish artificial nails with intact, clear nail polish Artificial nails are never appropriate. Chewing of nails is not prohibited, but if the skin surrounding the nail is not intact, gloves should be worn. |
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A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor? washes hands for 20 seconds with soap and water picks up the glove at the folded edge with the thumb and forefinger stretches the glove over the hand without touching the unsterile area reaches down to the bed to pick up a sterile drape |
reaches down to the bed to pick up a sterile drape The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully. |
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A client who has been diagnosed with a cold is upset that antibiotic therapy was not prescribed. Which nursing response is most appropriate? "The common cold is a virus and will not respond to antibiotics." "We can ask the PCP for an antiviral medication." "Sometimes antibiotics work for colds and sometimes they do not." "Antibiotics have too many side effects anyway." |
"The common cold is a virus and will not respond to antibiotics." The best response from the nurse is to educate the client about the common cold and how it is treated. An antiviral medication is not effective for the common cold. Antibiotics do not work to cure colds as a virus causes them. While antibiotics do cause side effects they are not appropriate for use in this client. |
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The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps, in the correct order, that the nurse should take when donning sterile gloves. All options must be used. |
-Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. -With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. -Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. -Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas. The correct order of putting on sterile gloves, the nurse should first open the package, taking care not to touch the inner surface of the package or gloves. The nurse then should pick up the glove at the folded cuff with the thumb and forefinger and insert fingers while pulling the glove over the hand. Then, place the finger of the gloved hand inside the cuff of the remaining glove, taking care not to touch outside of the folded cuff. Once both gloves are on, adjust gloves touching only sterile areas. |
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The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? Wear a protective gown and gloves with any direct contact. Apply a non-particulate (N-95) respirator when entering the room. Have the client wear a mask during care. Wear a mask with face shield during invasive procedures. |
Apply a non-particulate (N-95) respirator when entering the room. TB is an airborne infection and the nurse should wear a non-particulate mask (N-95) respirator. Gown and gloves would be indicted for infections that are transmitted via direct contact. A mask for face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care. |
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The nurse observes an unlicensed assistive personal (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 asks the client to state name and date of birth applies a mask with face shield performs hand hygiene before donning gloves |
removes gloves and walks out of the room Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used a barrier 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. The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. The other options are appropriate actions. |
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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 dons a pair of gloves prior to any client contact. A nurse uses an alcohol-based handrub each time that the nurse’s hands are visibly soiled. A nurse ensures that the nurse rinses the hands thoroughly after the application of an alcohol-based handru |
A nurse performs hand washing each time the nurse removes a pair of gloves. Hand washing should be performed after the removal 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 handrubs are not followed by a rinse. |
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