Airborne
The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement?
a.) "I should use disposable plates, forks, and knives."
b.) "I should cough into tissues and throw them away carefully."
c.) "It's important to cover my mouth if I laugh, sneeze, or cough."
d.) "It's very important to wash my hands after I touch my mask, tissues, or body fluids."
a.) "I should use disposable plates, forks, and knives."
Rationale:
Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. The client should cover the mouth with a tissue when laughing, coughing, or sneezing and should dispose of tissues carefully. The client also may need to wear a mask as advised by the health care provider. It is important to perform proper hand washing after contact with body substances, tissues, or face masks.
The nurse is caring for a client with meningococcal pneumonia and implements which transmission-based precautions for this client?
a.) Private room or cohort client
b.) Personal respiratory protection device
c.) Private room with negative airflow pressure
d.) Mask worn by staff when the client needs to leave the room
a.) Private room or cohort client
Rationale:
Meningococcal pneumonia is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.
Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?
a.) Gloves and gown
b.) Gloves and goggles
c.) Gloves, gown, and shoe protectors
d.) Gloves, gown, goggles, and face shield
d.) Gloves, gown, goggles, and face shield
Rationale:
Splashes of body secretions can occur when providing colostomy care. Goggles and a face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
The nurse is concerned that a break occurred in a sterile field. Which action caused this break?
a.) Keeping the sterile field in eyesight
b.) Transferring a sterile object to a sterile field with a clean gloved hand
c.) Keeping objects on the field 1 inch from the edge
d.) Grasping the edge of the outermost flap and opening it away from oneself
b.) Transferring a sterile object to a sterile field with a clean gloved hand
Rationale:
To keep a sterile field sterile, objects added to the sterile field must be sterile and should be transferred with sterile hands
The nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which observations, if made by the instructor, indicate the need for further teaching?
a.) The student dons the dominant hand first then the non-dominant hand.
b.) The student dons the sterile gloves without washing the hands.
c.) The student uses the inner wrapper of the gloves as a sterile field.
d.) The student touches a glove on the overbed table, removes both gloves, and dons another sterile pair.
b.) The student dons the sterile gloves without washing the hands.
Rationale:
Hands must always be washed (even though sterile gloves are used) to keep germs from spreading. The order of placing gloves on is up to the user, so long as sterile technique is not broken. The inside wrapper provides an excellent area for use because it is sterile. If the gloves touch anything unsterile, they must be considered contaminated, and a new package of gloves must be obtained and used.
Which type of personal protective equipment are staff required to wear when caring for a client with airborne precautions?
a.) Face-shield mask
b.) Venturi mask
c.) Non-Surgical mask
d.) Fitted respiratory protective devices
d.) Fitted respiratory protective devices
Rationale: Specially fitted respiratory protective devices (N95 respirator mask) are required when caring for patients on airborne precautions.
The nurse has received a report from the emergency department that a client with bacterial meningitis will be coming to the unit. How would the nurse prepare the unit for this client?
a.) Prepare the contact isolation sign
b.) Fitted mask, gown, gloves, eyewear
c.) Isolation room with negative pressure
d.) Isolation room
d.) Isolation room
Rationale:
Meningitis requires droplet precautions with isolation room.
Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection?
a.) Taking off the gloves first before removing the gown
b.) Removing the gown without rolling it from inside out
c.) Washing the hands after the entire procedure has been completed
d.) Removing the gloves and then removing the gown using the neck ties
b.) Removing the gown without rolling it from inside out
Rationale:
The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other areas. Gloves are considered the dirtiest piece of equipment and therefore must be removed first. Hands must be washed after removal of the protective garb to remove any unwanted germs still present. Ungloved hands should be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves.
The client’s lab report reveals an elevated White Blood Cell (WBC) count and increased neutrophils. What do these findings indicate?
a.) A client probably has microorganisms that have not yet caused an infection
b.) A client does not have an infection.
c.) A client has an infection.
d.) A client is at high risk for infection.
c.) A client has an infection.
Rationale:
Laboratory values such as increased WBCs and increased Neutrophils indicate the presence of an infection.
The nurse teaches the mother of a child diagnosed with bacterial conjunctivitis about measures to prevent transmission of the infection. Which statement by the mother indicates a need for further teaching?
a.) "Hands need to be washed frequently."
b.) "A clean washcloth can be used to wipe my child's eyes."
c.) "It is all right to share towels and washcloths as long as they are bleached after use."
d.) "The eye drops must be given as prescribed, and hands need to be washed before and after instillation."
c.) "It is all right to share towels and washcloths as long as they are bleached after use."
Rationale:
Bacterial conjunctivitis is highly contagious, and infection-control measures should be taught. These measures include frequent hand washing and not sharing towels and washcloths, regardless of the bleaching process. Options 2 and 4 are also correct treatment measures.
The nurse is caring for a client who has cultured positive for Clostridium Difficile (C-Diff). Which action will the nurse take next?
a.) Instruct assistive personnel to use soap and water rather than sanitizer when washing hands.
b.) Wear an N95 respirator when entering the patient room.
c.) Place the client on droplet precautions.
d.) Teach the client cough etiquette.
a.) Instruct assistive personnel to use soap and water rather than sanitizer when washing hands.
Rationale:
C-Diff in an infection part of the contact precautions category. Wash hands with non-antimicrobial soap and water if contact with spores
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take while performing hand hygiene?
a.) Adjust the water temperature to feel hot.
b.) Apply 7 to 9 mL of liquid soap to the hands.
c.) Dries all surfaces of hands with fingers pointing up.
d.) Rub hands and arms to dry.
c.) Dries all surfaces of hands with fingers pointing up.
Rationale:
The nurse should dry all surfaces of hands with finger pointing up, using a dry disposable towel.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client’s pulse. Which of the following actions should the nurse take?
a.) Wear a gown and mask.
b.) Wear sterile gloves and a gown.
c.) Wear clean gloves and a clean gown.
d.) Wear protective eyewear.
c.) Wear clean gloves and a clean gown.
Rationale:
The nurse should wear clean gloves to prevent the transmission of MRSA
The nurse is preparing a presentation on standard precautions. Identify which statement should the nurse include in the presentation?
a.) Cut the needle off a syringe after using it to give a client an injection.
b.) Dispose of blood-contaminated materials in a biohazard container.
c.) Gloves should not be worn for client care unless body fluids are seen.
d.) Wear a mask when in direct contact with all clients.
b.) Dispose of blood-contaminated materials in a biohazard container.
Rationale:
Standard precautions is the first and most important tier according to the CDC guidelines for Isolation and Isolation precautions. Standard precautions were designed to be used for the care of all patients, in all settings, regardless of risk or presumed infection status.
The nurse has received a report from the emergency department that a client with tuberculosis will be coming to the unit. Which items will the nurse need to care for this client? (Select all that apply.)
a.) Private room
b.) Negative-pressure airflow in the room
c.) Surgical mask, gown, gloves, eyewear
d.) N95 respirator, gloves
e.) Communication signs for droplet precautions
f.) Communication signs for airborne precautions
a.) Private room
b.) Negative-pressure airflow in the room
d.) N95 respirator, gloves
f.) Communication signs for airborne precautions
A client is diagnosed with Scabies. Which type of personal protective equipment is most appropriate for this client?
a.) Private room; gloves; and an N95 respirator
b.) Private room; gloves; and regular surgical mask
c.) Private room; gloves; and gown
d.) Private room; negative-pressure airflow; and gown
c.) Private room; gloves; and gown
Rationale:
Scabies is contact. Client PPE should be gloves and gown.
The nurse is concerned that a client is at a risk for nosocomial infection. Which clients she would be more concerned about? (Select all that apply).
a.) Client recovering from surgery.
b.) Client ambulates twice a day with assistance.
c.) A client receiving pain medication.
d.) A client has an indwelling urinary catheter.
e.) A client receiving intravenous fluids.
a.) Client recovering from surgery.
d.) A client has an indwelling urinary catheter.
e.) A client receiving intravenous fluids.
Rationale:
Nosocomial infections are those that originate in the hospital.
The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Determine which signs and symptoms will the nurse assess to determine if the child is experiencing a localized infection response?
a.) Malaise, anorexia, enlarged lymph nodes, and increased white blood cells
b.) Chest pain, shortness of breath, and nausea and vomiting
c.) Dizziness and disorientation to time, date, and place
d.) Edema, pus, warmth, redness, tenderness, and loss of function
d.) Edema, pus, warmth, redness, tenderness, and loss of function
Rationale:
If an infection is localized, a patient usually experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site.