A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines?
The nurse carries the patient's soiled bed linens close to the body to prevent spreading microorganisms into the air
The nurse places soiled bed linens and hospital gowns on the floor when making the bed
The nurse moves the patient table away from the nurse's body when wiping it off after a meal
The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items
A school nurse is performing an assessment of a student who states: I'm too tired to keep my head up in class. The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection?
Incubation period
Prodromal stage
Full stage of illness
Convalescent period
A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands?
The nurse is providing a bed bath for a patient
The nurse has visibly soiled hands after changing the bedding of a patient
The nurse removes gloves when patient care is completed
The nurse is inserting a urinary catheter for a female patient
The nurse is assisting with a surgical placement of a cardiac stent
The nurse removes old magazines from a patient's table
A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly?
The nurse removes all jewelry including a platinum wedding band
The nurse washes hands to one inch above the wrists
The nurse uses approximately two teaspoons of liquid soap
The nurse keeps hands higher than elbows when placing under faucet
The nurse uses friction motion when washing for at least 15 seconds
The nurse rinses throroughly with water flowing toward fingertips
The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must
Keep splashes on the sterile field to a minimum
Cover the nose and mouth with gloved hands if a sneeze is imminent
Use forceps soaked in a disinfectant.
Consider the outer 1 inch of the sterile field as contaminated
The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?
Only patients with diagnosed infections
Only patients with visible blood, body fluids or sweat
Only patients with nonintact sking
All patients receiving care in hospitals
In addition to standard precautions, the nurse would initiate droplet precautions for which patients?
A patient diagnosed with rubella
A patient diagnosed with diptheria
A patient diagnosed varicella
A patient diagnosed with tuberculosis
A patient diagnosed with MRSA
An infant diagnosed with adenovirus infection
A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation?
Ask another nurse to hold the hand of the patient and continue setting up the field
Remove the instrument that was touched by the patient and continue setting up the sterile field
Discard the supplies and prepare a new sterile field with another person holding the patient's hand
No action is necessary since the patient has touched his or her own sterile field
A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task?
Place the bottle cap on the table with the edges down
Hold the bottle inside the edge of the sterile field
Hold the bottle with the label side opposite the palm of the hand
Pour the solution from a height of 4-6 inches
A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?
Remove gown, goggles, mask, gloves, and exit the room
Remove gloves, perform hand hygiene, then remove gown, mask and goggles
Untie gown waistrings, remove gloves, goggles, gown, mask; perform hand hygiene
Remove goggles, mask, gloves, gown and perform hand hygiene
A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the priority action of the nurse following the exposure?
Report the incident to the appropriate person and file an incident report
Wash the exposed area with warm water and soap
Consent to postexposure prophylaxis at appropriate time
Set up counseling sessions regarding safe practice to protect self
The nurse assesses patients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection?
A 60 year old patient who smokes two packs of cigarettes daily
A 40 year old patient who has a white blood cell count of 6,000mm
A 65 year old patient who has an indwelling urinary catheter in place
A 60 year old patient who is a vegetarian and slightly underweight
A nurse is caring for an obese 62 year old patient with arthritis who has developed an open reddened are over his sacrum. What is a priority nursing diagnosis for this patient?
Imbalanced Nutrition: More Than Body Requirements related to immobility
Impaired Physical Mobility related to pain and discomfort
Chronic pain related to immobility
Risk for infection related to altered skin integrity
A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is considered:
The nurse's preference
Safe for the home setting
Unethical behavior
Grossly negligent
A nurse is using personal protective equipment when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care?
The nurse puts on PPE after entering the patient room
The nurse works from clean ares to dirty areas during bath
The nurse personalizes the care by substituting glasses for goggles
The nurse removes PPE prior to leaving eh patient room.
Routine and nasal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized by MRSA. The client is surprised at this finding, since he enjoys generally robust health. What should the client nurse teach him about this diagnostic finding?
This finding becomes part of your medical record, but it is not a threat to yourself or others
You may not develop any systems, but you may be given a round of antibiotics to eliminate this bacteria
This means that this organism is present on your skin, but it doesn't necessarily mean that you will become sick
It's very fortunate that this was detected early, since this had the potential to make you very sick
Which of the following are basic principles of surgical asepsis?
Avoid talking, coughing, sneezing, or reaching over a sterile field
Hold sterile objects at hip level or above
Never turn your back on a sterile field
Only a sterile object can touch another sterile object
Forceps soaked in disinfectant can be used to place items on sterile fields
Consider the outer one inch of a sterile field to be contaminated
Which of the following is an accurate guideline for the use of PPE?
Put on PPE after entering the client's room
When wearing gloves work from dirty areas to clean ones
Substitute personal glasses for protective eyewear if desired
Replace gloves if they are visibly soiled
A client on the surgical unit has developed an infection at the site of a laparoscopy. This type of infection is best termed as which of the following?
Endogenous
Antibiotic resistant
Latrogenic
Exogenous
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 of the following actions by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time
Question the need of the examination because the client must remain in Airborne Precautions
Request that the examination be done at the bedside
Notify the CT department in advance so other clients and staff can be removed from the area
A nurse is caring for a client with urinary incontinence and acute diarrhea. What is the highest priority diagnosis for this client?
Impaired walking
Risk of loneliness
Risk of infection
Social isolation
When is hand hygiene with an alcohol based rub appropriate, as opposed to using handwashing?
When hands have been in contact with blood or bodily fluids
When hands have been in contact with blood or bodily fluids, but there is no visible soiling
When hands are not visibly soiled
Before eating and after using the restroom
Which of the following pieces of PPE should be removed first?
goggles
gloves
gown
respirator
A nurse is performing a venipuncture on a client and notices that there is a hole on one of the sterile gloves. What would be the appropriate action to take to maintain a sterile field?
Stop the procedure, remove damaged gloves, perform handwashing, and open new sterile gloves
Finish the procedure and perform hand washing immediately afterward
Finish the procedure, remove damaged gloves, and open new sterile gloves
Stop the procedure, remove damaged gloves, and open new sterile gloves
A nurse is caring for a child who is hospitalize for diptheria. Which one of the following guidelines would be appropriate when caring for this patient?
use a private room with the door closed
use respiratory protection when entering the room of client with known or suspected diptheria
place client in private room that has monitored negative air pressure
wear PPE when entering the room for all interactions that may involve contact with the client
An infection control nurse is discussing needle stick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from which of the following?
Recapping a needle
Full needle boxes
Faulty needle and syringes
Needles left in the client's lines
An acute medical unit of a hospital currently has a number of clients who have tested positive for MRSA. Which of the following measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?
Diligent hand washing practices
Reduce length of stay for MRSA-positive clients
Constant use of gloves when on the unit
Prophylactic antibiotic therapy for MRSA-negative clients
Which of the following is an accurate guideline for removing soiled gloves after client care?
Use the non-dominant hand to grasp the opposite glove, near the cuffed end, on the outside exposed area
Remove the glove on the non-dominant hand by pulling it straight off, keeping the contaminated area on the outside
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 non-dominant hand, hold the removed glove in the remaining gloved hand
Unbeknown to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stage of infection in the sequence in which they will occur.
1. ❌ 2. ❌ 3. ❌ 4. ❌
Upon review of a client's microbiology culture results, the nurse recognizes which organisms as indicative of normal flora?
Eschiricia coli in the intestinal tract
Shigella in the urinary tract
Shigella in the intestinal tract
Eschiricia coli in the urinary tract
For which of the following clients, would the use of Standard Precautions alone be appropriate?
A client with TB who needs medications administered
A child with chickenpox who is treated in the ER
A client with diptherea who needs pm care
An incontinent client who lives in a nursing home who has diarrhea
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. Which of the following is an accurate guideline for using this technique?
Consider the outer 3 inch edge of a sterile field to be contaminated
Open sterile packages so the first edge of the wrapper is directed toward you
Consider the outside of the sterile package to be sterile
Hold sterile objects above waist level to prevent accidental contamination
When caring for clients at the health care facility, the nurse knows that clients are susceptible to infections. Which of the following clients are at a greater risk for infection?
Client with an IV catheter
Client with an indwelling catheter
Client with hypertension
Client with gastric tube feeding
Client with fever and chills
A nurse is taking care of a client with TB who has developed resistance to the ordered antibiotic. Which type of client is most likely at increase risk for infection?
Older adult
Pregnant
Adult
Child
Transit and residential bacterial flora can reside on the hands, so strict handwashing techniques are important. Where are resident bacteria most likely to reside?
Attached to dirt or grease
In creases of the skin
On exposed areas of the hand
Under the fingernails
