Asepsis Flashcards
The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following?
1. Eliminate the reservoir.
2. Block the portal of exit from the reservoir.
3. Block the portal of entry into the host.
4. Decrease the susceptibility of the host.
- Answer: 2. Rationale: Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other individuals. Since the carrier individual is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir (option 1). Blocking the entry into a host (option 3) or decreasing the susceptibility of the host (option 4) will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 31-9.
Which is the most effective nursing action for preventing and controlling the spread of infection?
1. Thorough hand hygiene
2. Wearing gloves and masks when providing direct client care
3. Implementing appropriate isolation precautions
4. Administering broad-spectrum prophylactic antibiotics
- Answer: 1. Rationale: Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand hygiene is the most effective way to prevent movement of potentially infective materials. PPE (gloves and masks) is indicated for situations requiring standard precautions (option 2). Isolation precautions are used for clients with known communicable diseases (option 3). Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-8.
In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform?
1. Wear a mask during dressing changes.
2. Provide disposable meal trays and silverware.
3. Follow standard precautions in all interactions with the client.
4. Use surgical aseptic technique for all direct contact with the client.
- Answer: 3. Rationale: Standard precautions include all aspects of contact precautions with the exception of placing the client in a private room. A mask is indicated when working over a sterile wound rather than an infected one (option 1). Disposable food trays are not necessary for clients with infected wounds unlikely to contaminate the client’s hands (option 2). Sterile technique (surgical asepsis) is not indicated for all contact with the client (option 4). The nurse would utilize clean technique when dressing the wound to prevent introduction of additional microbes. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-10.
When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?
1. Goggles
2. Gown
3. Surgical mask
4. Clean gloves
- Answer: 1. Rationale: Unless overly contaminated by material that has splashed in the nurse’s face and cannot be effectively rinsed off, goggles may be worn repeatedly (option 1). Since gowns are at high risk for contamination, they should be used only once and then discarded or washed (option 2). Surgical masks (option 3) and gloves (option 4) are never washed or reused. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-11b.
While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm (1/4 in.). What is the best action for the nurse to take?
1. Remove the glove and start over with a new pair.
2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand.
3. Ask a colleague to assist by unrolling the cuff.
4. Leave the cuff rolled under.
- Answer: 4. Rationale: It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of the fingers and hand that will be used to perform the sterile procedure. The rolled-under portion is now contaminated and should not be unrolled by the nurse or colleague since it would then touch the remaining sterile portion of the glove (option 3). Cognitive Level:Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-11d.
The nurse evaluates the chart of a 65-year-old client with no apparent risk factors and concludes that which immunizations are current? Select all that apply.
1. Last tetanus booster was at age 50
2. Receives a flu shot every year
3. Has not received the hepatitis B vaccine
4. Has not received the hepatitis A vaccine
5. Has not received the herpes zoster vaccine
- Answer: 2, 3, and 4. Rationale: Flu shots are recommended for all adults over age 50. Only adults at risk need to receive hepatitis B and A vaccine (note that this is different than for children). Options 1 and 5 are incorrect because all adults should receive a tetanus booster every 10 years (or sooner if injured) and adults over age 60 should receive the herpes zoster vaccination. Cognitive Level: Remembering. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcomes: 31-8; 31-6.
A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be _____________.
- Answer: Because a malnourished client with a wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Diagnosing. Learning Outcome: 31-7.
After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred?
1. “We will use antimicrobial soap and hot water to wash our hands at least three times per day.”
2. “We must wash or peel all raw fruits and vegetables before eating.”
3. “A wound or sore is not infected unless we see it draining pus.”
4. “We should not share toothbrushes but it is OK to share towels and washcloths.”
- Answer: 2. Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness, swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not share washcloths or towels (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcomes: 31-8; 31-5.
- Which of the numbered areas is considered sterile on a person in the operating room? You may assume that all articles were sterile when applied.
- Answer: 1. Rationale: Sterile objects are considered unsterile if placed lower than the waist. Only area 1 in this situation would be considered sterile. Above the neck, higher than 2 inches above the elbow, below the waist/table, and the back are all considered unsterile. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcomes: 31-1; 31-11c.
The nurse determines that a field remains sterile if which of the following conditions exist?
1. Tips of wet forceps are held upward when held in ungloved hands.
2. The field was set up 1 hour before the procedure.
3. Sterile items are 2 inches from the edge of the field.
4. The nurse reaches over the field rather than around the edges.
- Answer: 3. Rationale: All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas. When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field (option 1). Fields should be established immediately before use to prevent accidental contamination when not observed closely (option 2). Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 31-11c.
