Ch. 24 Asepsis & Infection Control

Question 1

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?

A) The nurse carries the patients’ soiled bed linens close to the body to prevent spreading microorganisms into the air
B) The nurse places soiled bed linens and hospital gowns on the floor when making the bed
C) The nurse moves the patient table away from the nurse’s body when wiping it off after a meal
D) The nurse cleans the most soiled items in the patient’s bathroom first and follows with the cleaner items

Answer 1

b.
During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and they are more specific during the full stage of illness before disappearing by the convalescent period.

Question 2

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? Select all that apply.

A) Providing a bed bath for a patient
B) Visibly soiled hands after changing the bedding of a patient
C) Removing gloves when patient care is completed
D) Inserting a urinary catheter for a female patient
E) Assisting with a surgical placement of a cardiac stent
F) Removing old magazines from a patient’s table

Answer 2

a, c, d, f.
It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. Keep in mind that handrubs are not appropriate for use with C. difficile infection.

Question 3

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? Select all that apply.

A) Removes all jewelry including a platinum wedding band
B) Washes hands to 1 in above the wrists
C) Uses approximately one teaspoon of liquid soap
D) Keeps hands higher than elbows when placing under faucet
E) Uses friction motion when washing for at least 20 seconds
F) Rinses thoroughly with water flowing toward fingertips

Answer 3

b, c, e, f.
Proper hand hygiene includes removing jewelry (with the exception of a plain wedding band), wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 20 seconds, washing to 1 in above the wrists with a friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward fingertips.

Question 4

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. Which action by the nurse is appropriate?

A) Keep splashes on the sterile field to a minimum
B) Cover the nose and mouth with gloved hands if a sneeze is imminent
C) Use forceps soaked in a disinfectant
D) Consider the outer 1 in of the sterile field as contaminated

Answer 4

d.
Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile.

Question 5

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?

A) Only patients with diagnosed infections
B) Only patients with visible blood, body fluids, or sweat
C) Only patients with nonintact skin
D) All patients receiving care in hospitals

Answer 5

d.
Standard precautions apply to all patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes.

Question 6

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply.

A) A patient diagnosed with rubella
B) A patient diagnosed with diphtheria
C) A patient diagnosed with varicella
D) A patient diagnosed with tuberculosis
E) A patient diagnosed with MRSA
F) An infant diagnosed with adenovirus infection

Answer 6

a, b, f.
Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Airborne precautions are used for patients who have infections spread through the air with small particles; for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

Question 7

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?

A) Ask another nurse to hold the hand of the patient and continue setting up the field
B) Remove the instrument that was touched by the patient and continue setting up the sterile field
C) Discard the supplies and prepare a new sterile field with another person holding the patient’s hand
D) No action is necessary since the patient has touched his or her own sterile field

Answer 7

c.
If the patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient’s hand and reinforcing what is happening.

Question 8

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?

A) Place the bottle cap on the table with the edges down
B) Hold the bottle inside the edge of the sterile field
C) Hold the bottle with the label side opposite the palm of the hand
D) Pour the solution from a height of 4 to 6 in (10 to 15 cm)

Answer 8

d.
To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm).

Question 9

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?

A) Remove gown, goggles, mask, gloves, and exit the room
B) Remove gloves, perform hand hygiene, then remove gown, mask, and goggles
C) Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene
D) Remove goggles, mask, gloves, and gown, and perform hand hygiene

Answer 9

c.
If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room.

Question 10

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 first action of the nurse following the exposure?

A) Report the incident to the appropriate person and file an incident report
B) Wash the exposed area with warm water and soap
C) Consent to PEP at appropriate time
D) Set up counseling sessions regarding safe practice to protect self

Answer 10

b.
When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe practice to protect self and others.

Question 11

The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

A) A 60-year-old patient who smokes two packs of cigarettes daily
B) A 40-year-old patient who has a white blood cell count of 6,000/mm3
C) A 65-year-old patient who has an indwelling urinary catheter in place
D) A 60-year-old patient who is a vegetarian and slightly underweight

Answer 11

c.
Indwelling urinary catheters have been implicated in most HAIs. Cigarette smoking, a normal white blood cell count, and a vegetarian diet have not been implicated as risk factors for HAIs.

Question 12

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient?

A) Imbalanced nutrition
B) Impaired physical mobility
C) Chronic pain
D) Infection

Answer 12

d.
The priority risk factor in this situation is the possibility of an infection developing in the open skin area. The other risk factors may be potential problems for this patient and may also require nursing interventions after the first diagnosis is addressed.

Question 13

A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan?

A) It is the personal preference of the nurse whether or not to use clean technique
B) The use of clean technique is safe for the home setting
C) Surgical asepsis is the only safe method to use in a home setting
D) It is grossly negligent to recommend clean technique for changing a wound dressing

Answer 13

b.
In the home setting, where the patient’s environment is more controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the appropriate procedure for the home and is not a personal preference or a negligent action.

Question 14

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care?

A) The nurse puts on PPE after entering the patient room
B) The nurse works from “clean” areas to “dirty” areas during bath
C) The nurse personalizes the care by substituting glasses for goggles
D) The nurse removes PPE after the bath to talk with the patient in the room

Answer 14

b.
When using PPE, the nurse should work from “clean” areas to “dirty” ones, put on PPE before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or anteroom just before exiting.

Question 15

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

A) a school-age child who is current with immunizations
B) an older adult client with a history of heart failure

Answer 15

B) an older adult client with a history of heart failure

Neonates and older adults are higher risk

Question 16

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?

A) the client placed in contact isolation who was admitted with a draining abdominal wound
B) the client who is 48-hours postsurgical procedure

Answer 16

B) the client who is 48-hours postsurgical procedure

Question 17

A client is being admitted to the hospital for elevated temperature for the past 24 hours. He had his right knee replaced 4 days ago in the same facility. Which assessment is a priority for now?

A) Homans sign
B) Auscultate lung sounds.

Answer 17

B) Auscultate lung sounds.

Question 18

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?

A) infectious disease
B) noncommunicable disease

Answer 18

B) noncommunicable disease

Question 19

When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field?

A. Keep the sterile field at least 6 ft
away from the client’s bedside.
B. Instruct the client to refrain from coughing and sneezing during the dressing change.
C. Place a mask on the client to limit the spread of micro‑organisms into the surgical wound.
D. Keep a box of facial tissues nearby for the client to use during the dressing change.

Answer 19

C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the dressing change.

Question 20

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

A. The flap closest to the body
B. The right side flap
C. The left side flap
D. The flap farthest from the body

Answer 20

D. CORRECT: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client’s safety. Unless the nurse pulls the top flap (the one farthest from her body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it.

Question 21

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.)

A. A bottle containing a sterile solution
B. The edge of the sterile drape at the base of the field
C. The inner wrapping of an item on the sterile field
D. An irrigation syringe on the sterile field
E. One gloved hand with the other gloved hand

Answer 21

C. CORRECT: The inner wrappings of any objects dropped onto the sterile field are sterile. Touch them with sterile gloves.
D. CORRECT: Any objects dropped onto the sterile field during the setup are sterile. Touch the syringe with sterile gloves.
E. CORRECT: One sterile gloved hand may touch the other sterile gloved hand because both are sterile

Question 22

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.)

A. Apply 3 to 5 mL of liquid soap to dry hands.
B. Wash the hands with soap and water for at least 15 seconds.
C. Rinse the hands with hot water.
D. Use a clean paper towel to turn off hand faucets.
E. Allow the hands to air dry after washing.

Answer 22

B. CORRECT: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes.
D. CORRECT: If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands.

Question 23

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.)

A. The provider drops a sterile instrument onto the near side of the sterile field.
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
C. The procedure is delayed 1 hr because the provider receives an emergency call.
D. The nurse turns to speak to someone who enters through the door behind the nurse.
E. The client’s hand brushes against the outer edge of the sterile field.

Answer 23

B. CORRECT: Fluid permeation of the sterile drape or barrier contaminates the field.
C. CORRECT: Prolonged exposure to air contaminates a sterile field.
D. CORRECT: Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field.

Question 24

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.)

A. Planning and evaluating control
and prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common‑source outbreaks

Answer 24

A. CORRECT: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies.
B. CORRECT: Reporting of communicable and infectious diseases assists with determining public health policies.
C. CORRECT: Reporting of communicable and
infectious diseases assists with ensuring
proper medical treatment is available.
E. CORRECT: Reporting of communicable and
infectious diseases assists with monitoring
for common‑source outbreaks.

Question 25

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?

A. Allergic reaction
B. Ringworm
C. Systemic lupus erythematosus
D. Tuberculosis

Answer 25

A. A pink body rash is a manifestation of an allergic reaction.
B. Red circles with white centers is a manifestation of ringworm.
C. A red edematous rash bilaterally on the cheeks is a manifestation of systemic lupus erythematosus.
D. CORRECT: A cough for 3 weeks and beginning to cough up blood are manifestations of tuberculosis.

Question 26

A nurse is caring for a client who reports a
severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A. Prodromal
B. Incubation
C. Convalescence
D. Illness

Answer 26

D. CORRECT: The illness stage is when the client experiences manifestations specific to the infection.

Question 27

A charge nurse is reviewing with a newly
hired nurse the difference in manifestations
of a localized versus a systemic infection.
Which of the following are manifestations of a systemic infection? (Select all that apply.)

A. Fever
B. Malaise
C. Edema
D. Pain or tenderness
E. Increase in pulse and respiratory rate

Answer 27

A. CORRECT: A fever indicates that the infection is affecting the whole body, and therefore systemic.
B. CORRECT: Malaise indicates that the infection is affecting the whole body.
E. CORRECT: An increase in pulse and respiratory rate indicates that the infection is affecting the whole body.

Question 28

A nurse is contributing to the plan of care for
a client who is being admitted to the facility
with a suspected diagnosis of pertussis.
Which of the following interventions should
the nurse include? (Select all that apply.)

A. Place the client in a room that has negative air pressure of at least six exchanges per hour.
B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable.
D. Use sterile gloves when handling soiled linens.
E. Wear a gown when performing care that might result in contamination from secretions.

Answer 28

B. CORRECT: Wear a mask when within 3 ft of the client.
C. CORRECT: Place a surgical mask on the client during transport to another area of the facility.
E. CORRECT: Wear a gown if the nurse’s clothing or skin might be contaminated with body secretions or excretions.

Question 29

Which of the following is the most significant and commonly found infection-causing agent in health care institutions?

A. Bacteria
B. Fungi
C. Viruses
D. Mold

Answer 29

A)
Bacteria are the most significant infection-causing agents in the health care system. Bacteria can be categorized by shape, by their reaction to the Gram stain, or according to their need for oxygen. Fungi (molds and yeasts) can cause infection and are present in the air, soil, and water. Viruses cause infections including the common cold and do not respond to antibiotics.

Question 30

Which infection or disease may be spread by touching a contaminated inanimate article?

A. Rabies
B. Giardia
C. E. coli
D. Influenza

Answer 30

D)
Influenza may be spread if a person touches a contaminated article and then touches one’s eyes or nose. The reservoir for rabies is animals; for Giardia, water; and for E. coli, water or food.

Question 31

During which stage of infection is the patient most contagious?

A. Incubation period
B. Prodromal stage
C. Full stage of illness
D. Convalescent period

Answer 31

B)
The patient is most infectious during the prodromal stage when early signs and symptoms of the disease are present but are often vague and nonspecific. During this stage, the patient often does not realize he or she is contagious and spreads the infection.

Question 32

T/F: Soaps and detergents (nonantimicrobial agents) are considered adequate for routine mechanical cleansing of the hands and removal of most transient microorganisms.

Answer 32

True
Soaps and detergents (nonantimicrobial agents) are considered adequate for routine mechanical cleansing of the hands and removal of most transient microorganisms.

Question 33

T/F: Standard precautions should be used when caring for a noninfectious, postoperative patient who is vomiting blood.

Answer 33

True
Standard precautions should be used when caring for a noninfectious, postoperative patient who is vomiting blood.

Question 34

What are the 6 parts of the chain of infection?

Answer 34

Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Host