Infection Control
The nurse is caring for several patients. Which action is the most effective way to break the chain of infection?
A. Wearing gloves
B. Wearing a gown
C. Performing hand hygiene
D. Wearing a surgical mask
C. Perform hand hygiene
A patient's temperature is elevated. The nurse also notes an increased pulse and respiratory rate. Which condition should the nurse suspect?
A. Infection
B. Hypothermia
C. Dehydration only
D. Decreased metabolism
A. Suspect infection
Which intervention is appropriate when providing eye care?
A. Clean from outer canthus to inner canthus
B. Use soap to clean the eye
C. Clean from inner canthus to outer canthus
D. Use the same portion of the washcloth for every stroke
C. Clean from inner canthus to outer canthus
The nurse enters a patient's room and finds the patient attempting to get out of bed without assistance. Which action should the nurse take first?
A. Document the incident
B. Ensure the patient's immediate safety
C. Call the patient's family
D. Complete the patient's hygiene care
B. Ensure the patient's immediate safety
A patient with a pressure injury is receiving wound care. The nurse notes that the wound has increased in size despite regular dressing changes. Which factor should the nurse address first?
A. The type of dressing
B. The patient's favorite hygiene products
C. The source of pressure
D. The time of day the dressing is changed
C. The source of pressure
A patient with C. difficile requires hand hygiene after care. Which action should the nurse take?
A. Use an alcohol-based hand rub
B. Wash hands with soap and water
C. Wipe hands with an antiseptic wipe
D. Put on a new pair of gloves
B. Wash hands with soap and water
The nurse obtains a patient's vital signs and notices an unexpected abnormal value. What should the nurse do first?
A. Document the finding
B. Notify the provider
C. Reassess the patient and verify the finding
D. Administer medication
C. Reassess the patient and verify the finding
A patient wears dentures. Which instruction should the nurse provide?
A. Store dentures in hot water
B. Clean dentures daily
C. Leave dentures out permanently
D. Store dentures dry when removed
B. Clean dentures daily
The nurse is caring for four patients. Which patient should the nurse assess first?
A. Patient requesting assistance with bathing
B. Patient who needs a linen change
C. Patient with a new change in vital signs and possible infection
D. Patient requesting oral care
C. Patient with a new change in vital signs and possible infection
The nurse is caring for a patient suspected of having an infection. Which assessment findings would support this concern? SATA
A. Fever
B. Increased pulse
C. Increased respiratory rate
D. Lethargy
E. Lymphadenopathy
F. Increased appetite
A. Fever
B. Increased pulse
C. Increased respiratory rate
D. Lethargy
E. Lymphadenopathy
The nurse is explaining the chain of infection to a nursing student. Which example represents a fomite?
A. Mosquito
B. Tick
C. Doorknob
D. Infected patient
C. Doorknob
Which finding is considered a possible systemic manifestation of infection?
A. Increased appetite
B. Fever
C. Decreased respiratory rate
D. Increased energy
B. Fever
Which action is appropriate when providing ear hygiene?
A. Insert a cotton-tipped swab deep into the ear canal
B. Clean the external ear with a washcloth-covered finger
C. Irrigate the ear routinely
D. Remove all cerumen from the ear canal
B. Clean the external ear with a washcloth-covered finger
A nurse is caring for a patient with impaired mobility who is at risk for skin breakdown. Which intervention has the highest priority?
A. Apply lotion
B. Reposition the patient regularly
C. Give the patient a back massage
D. Change the patient's gown
B. Reposition the patient regularly
A nurse is teaching a student about infection prevention. The student says, "Wearing gloves means I don't have to perform hand hygiene." What is the nurse's best response?
A. "That is correct if the gloves remain intact."
B. "Gloves replace hand hygiene when caring for infected patients."
C. "Gloves do not replace proper hand hygiene."
D. "Hand hygiene is only needed after removing gloves."
C. "Gloves do not replace proper hand hygiene."
SATA: Which findings can increase a patient's susceptibility to infection?
A. Intact skin
B. Malnutrition
C. Advanced age
D. Invasive medical devices
E. Adequate immunization
F. Increased stress
B. Malnutrition
C. Advanced age
D. Invasive devices
F. Stress
A patient has a suspected infection. Which laboratory finding would support this suspicion?
A. Decreased WBC count
B. Elevated WBC count
C. Decreased ESR
D. Decreased neutrophils
B. Elevated WBC count
The nurse is caring for a patient receiving anticoagulant therapy who needs assistance with shaving. Which equipment is safest?
A. Straight razor
B. Disposable blade razor
C. Electric razor
D. Surgical scalpel
C. Electric razor
SATA: The nurse is developing a plan of care for a patient with impaired hygiene. Which outcomes are appropriate?
A. Patient verbalizes feeling comfortable and clean
B. Patient participates in necessary hygiene activities
C. Patient maintains intact skin and mucous membranes
D. Patient becomes completely independent regardless of limitations
E. Patient demonstrates appropriate skin-care measures
A. Patient verbalizes feeling comfortable and clean
B. Patient participates in necessary hygiene activities
C. Patient maintains intact skin and mucous membranes
E. Patient demonstrates appropriate skin-care measures
The nurse is preparing to provide care for four patients. Which action should the nurse perform FIRST?
A. Assist a stable patient with bathing after the patient requests privacy
B. Perform hand hygiene before entering the room of a patient requiring contact precautions
C. Replace the dentures of a patient who has finished eating
D. Provide eye care to an unconscious patient who has an intact blink reflex
B. Perform hand hygiene before entering the room of a patient requiring contact precautions.
The nurse is preparing to insert an indwelling urinary catheter. Which type of technique should the nurse use?
A. Medical asepsis
B. Clean technique
C. Surgical asepsis
D. Standard hygiene technique
C. Use surgical asepsis
The nurse is assessing an older adult for infection. Which finding is particularly important because older adults may have altered or less obvious manifestations of infection?
A. Changes in mental or functional status
B. Increased appetite
C. Increased skin elasticity
D. Increased cough reflex
A. Changes in mental or functional status
SATA: Which actions are appropriate when providing hygiene care?
A. Encourage the patient to perform as much self-care as possible
B. Respect the patient's personal preferences
C. Provide privacy
D. Complete all hygiene tasks for the patient regardless of ability
E. Modify hygiene practices according to the patient's needs
F. Ignore cultural preferences if they differ from hospital routines
A. Encourage the patient to participate in self-care
B. Respect personal preferences
C. Provide privacy
E. Modify care according to the patient's needs
The nurse is caring for a patient with a wound. During assessment, the nurse notes increasing drainage, necrotic tissue, and surrounding redness. What is the nurse's priority action?
A. Cover the wound and reassess next week
B. Document the findings and continue routine care
C. Recognize these findings as potential complications and report them appropriately
D. Apply heat directly to the wound
C. Recognize these findings as potential complications and report them appropriately
The nurse receives report on four patients. Which patient should the nurse assess FIRST?
A. A patient who needs assistance with bathing and asks the nurse to come back in 30 minutes
B. A patient with limited mobility who is due to be repositioned
C. A patient who has a new change in mental status and an elevated temperature
D. A patient who needs help cleaning and storing their dentures
C. A patient who has a new change in mental status and an elevated temperature.