Purple NCLEX Fundi: Infection Control Exam - Questions, Answers and Rationales The nurse is changing the central line dressing of a client receiving
... [Show More] parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1. Client's temperature 2. Expiration date on the bag 3. Time of last dressing change 4. Tightness of tubing connections Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change. A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? 1. Discard them in the unit trash. 2. Return them to the hospital pharmacy. 3. Send them to the laboratory for culture. 4. Save them for return to the manufacturer. When the client who is receiving PN develops a fever, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms. The other options are incorrect. Because culture for infectious organisms is necessary, the discontinued materials are not discarded or returned to the pharmacy or manufacturer. The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? 1. Calculate daily intake and output. 2. Monitor the temperature once daily. 3. Secure all connections in the PN system. 4. Monitor blood glucose levels every 12 hours. The nurse should plan to secure all connections in the tubing (tape is used per agency protocol). This helps prevent the restless client from pulling the connections apart accidentally. The nurse should also monitor intake and output, but this does not relate specifically to a risk for injury as presented in the question. Also, monitoring the temperature and blood glucose levels does not relate to a risk for injury as presented in the question. In addition, the client's temperature and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia, respectively. The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control? 1. The caregiver selects a previously opened gauze to cover the sternal wound. 2. The caregiver dons gloves before removal of the old dressing and then applies the new dressing. 3. The caregiver covers her mouth with her hand when she sneezes and then continues with the dressing change. 4. The caregiver washes hands before removal of the soiled dressing and again before applying the clean dressing. The single most effective technique to prevent the spread of germs and bacteria is hand washing. The initial step with all aseptic procedures is hand washing. Using previously opened gauze, not washing hands after sneezing, and not applying new gloves after removing the old dressing increase the risk of wound contamination as a result of poor aseptic technique. A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear? 1. Gloves only 2. Fluid shield mask 3. Gown, mask, and gloves 4. High-efficiency particulate air (HEPA) filter mask The hospitalized client with TB is placed on airborne isolation. A HEPA filter mask must be worn whenever the nurse enters the client's room, because these masks can remove almost 100% of the small TB particles. This mask must fit snugly around the nose and mouth. Option 1 is an incorrect option; although gloves may be needed, the nurse must wear a HEPA mask. Option 2 is incorrect. The mask must be a HEPA mask. Option 3 is an incorrect choice. The mask must be a HEPA mask, and there is no need for gown and gloves unless a wound, body fluid, or blood is involved. 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? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and face shield 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 assisting a female client to collect a midstream urine specimen. How should the nurse implement aseptic technique? 1. Cleansing the meatus with antiseptic pads using upward strokes 2. Letting go of the labia once this tissue is cleansed, to allow the client to urinate 3. Making sure that the fingers avoid touching the inside of the collection container 4. Instructing the client to urinate in the container after the labia have been cleansed The inside of the container is sterile, and sterility must be maintained. Fingers touching the inside of the container would cause the container to become unsterile. The meatus should be cleansed from front to back (toward the anus). Upward strokes would bring bacteria from the anal region toward the urinary meatus. The labia should remain open during the procedure. If they are allowed to close, this tissue will have to be cleansed again with the antiseptic pads. The client should void a small amount into the toilet before urinating into the specimen container to allow some of the organisms near the meatus to leave the area. A nurse is providing orientation to a newly graduated nurse. During a discussion of isolation procedures, which statement by the graduate nurse indicates a need for further review of isolation guidelines? 1. "A client with tuberculosis will be placed on airborne precautions." 2. "I will wear a mask when working with an isolated client who has a tracheostomy." 3. "I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room." 4. "I will remove the gown and gloves and wash my hands before leaving the client's room." Centers for Disease Control and Prevention (CDC) guidelines require that gowns used in isolation rooms be discarded after each use and not reused, even for the same client. The other options reflect correct isolation guidelines. A man has been admitted to the surgical unit after a hernia repair surgery. The medical record reports that the client is human immunodeficiency virus (HIV) positive. The nurse should implement which precautions for this client? 1. Contact precautions 2. Droplet precautions 3. Airborne precautions 4. Standard precautions Having an HIV-positive status does not warrant a special type of precaution; instead, the nurse will implement standard precautions. Contact, droplet, and airborne precautions are implemented with specific types of infections or diseases but are not necessary for HIV-positive clients unless some additional specific infection is present. A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath? 1. A gown and gloves 2. Gloves and goggles 3. A gown and goggles 4. Gloves and shoe protectors Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless it is anticipated that splashes of blood, bodily fluids, secretions, or excretions may occur. Shoe protectors are not necessary. A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the mother asks the nurse when the child can return to school, what should the appropriate response be? 1. "The child can return to school immediately." 2. "The child cannot return to school until seen by the health care provider in 1 week." 3. "The child should be kept home until the antibiotic eye drops have been administered for 24 hours." 4. "The child should be kept home until the antibiotic eye drops have been administered for 72 hours." Viral conjunctivitis is extremely contagious. The child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hours. A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription? 1. Transport the client through empty corridors only. 2. Place a mask on the client in preparation for transport. 3. Place a sterile gown on the client in preparation for transport. 4. Question the health care provider about whether a portable chest radiograph may be obtained. The client who is placed on contact precautions has a high microorganism count in some type of body secretion (such as feces or wound drainage). This client is placed in a private room whenever possible and is removed from the room only when absolutely necessary. Client transport should be done only for essential purposes. Notification of departmental personnel and disinfection of any environmental surfaces with which the client has contact are imperative. A nurse is preparing a plan of care for a client with a diagnosis of agranulocytosis who is being admitted to the hospital. The nurse determines that which is the priority when formulating the client's plan of care? 1. Fatigue 2. Constipation 3. [Show Less]