What are the smallest infectious agents capable of causing an infection?
Your patient has developed a low-grade fever and states that she has felt very tired lately. You interpret these findings as indicating which stage of infection?
Full stage of illness
Efforts by healthcare facilities to reduce the incidence of HAIs include an awareness of which of the following?
The CDC requires all states to report HAI rates from each hospital.
The gastrointestinal tract is a common site for HAIs.
Joint Commission considers death or serious injury from HAIs a sentinel event
The causal agent for most HAIs is viral.
A patient develops a urinary tract infection after an indwelling urinary catheter has been inserted. This would most accurately be termed as which type of infection?
A viral infection
A chronic infection
An iatrogenic infection
An opportunistic infection
The nurse has opened the sterile supplies and donned two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must do which of the following?
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 disinfectant
Consider the outer 1 inch of the sterile field as contaminated
The CDC standard precaution recommendations apply to which of the following?
Only patients with diagnosed infections
Only blood and body fluids with visible blood
All body fluids including sweat
All patients receiving care in hospitals
In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?
When caring for a patient with latex allergy, the nurse creates a latex-safe environment by doing which of the following?
Carefully cleaning the wall-mounted blood pressure device before using it
Donning latex gloves outside the room to limit powder dispersal
Using a latex-free pharmacy protocol
Placing the patient in a semiprivate room
Which organization(s) initially developed the guidelines for minimum protection standards for infection prevention and control?
Individual healthcare facilities
The state governing body
Which of the following lists the recommended sequence for removing soiled personal protective equipment when the nurse prepares to leave the patient’s room?
Gown, goggles, mask, gloves, and exit the room
Gloves, wash hands, remove gown, mask, and goggles
Gloves, goggles, gown, mask, and wash hands
Goggles, mask, gloves, gown, and wash hands
For a nurse under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?
At least a 15-second scrub with plain soap and water
At least a 23-minute scrub with an antimicrobial soap
Use of an alcohol-based antiseptic handrub
That a mask be worn when scrubbing
Which hospitalized patient is most at risk for developing a healthcare-associated infection?
Mr. Y, a 60-year-old patient who smokes two packs of cigarettes daily
Mrs. J, a 40-year-old patient who has a white blood cell count of 6,000/mm3
Mr. L, a 65-year-old patient who has an indwelling urinary catheter in place
Mrs. M, a 60-year-old patient who is a vegetarian and slightly underweight
A patient develops food poisoning from contaminated potato salad. What is the means of transmission for the infecting organism?
A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. Which of the following is a priority nursing diagnosis?
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
The nurse teaches a patient at home to use clean technique when changing a wound dressing. This is which of the following?
The nurse's preference
Safe for the home setting
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient’s nursing care plan?
Document the findings and continue to monitor the patient.
Administer antipyretics, as ordered.
Increase the frequency of assessment to every hour and notify the patient’s physician.
Increase the frequency of wound care and contact the physician for an antibiotic order.
Which term would the nurse use to document wound drainage that is thick, odorous, and green?
A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, “I am so ugly now.” Based on this statement, what nursing diagnosis would be most appropriate?
Impaired skin integrity
Disturbed body image
Disturbed thought process
A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?
Using sterile dressing supplies
Suggesting dietary supplements
Applying antibiotic ointment
Performing careful hand hygiene
During a dressing change, inspection of the wound reveals what appears to be reddish-pink tissue in the wound. The nurse interprets this as most likely indicating:
A sign of infection
The nurse is performing a sterile irrigation of an open abdominal wound. Which intervention should be done first?
Direct a stream of solution into the wound.
Position the patient so the irrigation solution will flow from clean to dirty.
Assess the wound and surrounding tissue.
Put on sterile gloves.
The nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply.
The patient takes time to think about her responses to questions.
The patient’s age of 86 years.
Patient reports inability to control urine.
A scheduled hip arthroplasty
Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61.1 mg/dL).
Patient reports increased pain in right hip when repositioning in bed or chair.
The nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates the patient understands the explanation?
“I can expect to have more discomfort in the area where the cold is applied.”
“I should expect more drainage from the incision after the ice has been in place.”
“I should see less swelling and redness with the cold treatment.”
“My incision may bleed more when the ice is first applied.”
The nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?
The therapy is used to collect excess blood loss and prevent the formation of a scab.
The therapy will prevent infection, ensuring the wound heals with less scar tissue.
The therapy provides a moist environment and stimulates blood flow to the wound.
The therapy irrigates the wound to keep it free from debris and excess wound fluid.
After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, as what stage would this ulcer be classified?
An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of what factor?
A chronic disease
The nurse assesses a stage III pressure ulcer manifested as:
Redness that persists when pressure is relieved
An open lesion with full thickness tissue loss and visible subcutaneous fat
A necrotic area extending through the fascia to bone
A reddened area with an abrasion and pain
Which action would be a priority in preventing a patient from developing a pressure ulcer?
Using waterproof material on the bed
Massaging any reddened area frequently
Using an air-inflated ring to relieve pressure on areas
Using a mild cleansing agent when cleansing the skin
A nurse is assessing a patient in the resolution stage of an infection. The nurse would anticipate
Vague, non specific signs and symptoms of early stages of infection.
Full presense of signs and symptoms anticipated with an infection.
No symptoms. This would be the interval between invasion of pathogens and the appearance of symptoms.
A period of recovery. Signs and symptoms disappear and the person returns to a healthy state.
A patient is 7 days post operative. Which stage of the wound healing process is the patient most likely experiencing currently?
Reconstruction or Proliferative Phase.
Remodeling or Maturation Phase
As a nurse knowledgeable about the chain of infection, you are concerned with reducing reservoirs which are necessary for an infection to develop. A way to reduce reservoirs would include to
Wear gloves and other personal protective wear when caring for the patient.
Wash hands, use antiseptics and disinfectants.
Empty the foley catheter bag regularly and keep the bag below bladder level.
Instruct the patient to cover his nose and mouth when sneezing.
Which nursing action prevents an organism from exiting a reservoir in the chain of infection?
Use of disposible supplies.
Prompt, frequent administration of antibiotics.
A nurse is caring for a patient with a healing wound. The nurse is aware that multiple factors either promote or impede wound healing. Factors that can promote wound healing would include
A wound healing by secondary intention.
A clean surgical wound healing free of infection.
A past history of diabetes mellitus.
A past history of immunosuppressive therapy to promote healing.
A student nurse is teaching a new mother about immunizations. The student nurse knows teaching was effective when the new mother states that immunity acquired from either having the infection or being immunized and developing immunity is known as __________.
As a nurse, you are aware that the CDC has identified two tiers of precautions to prevent the spread of infection. The second tier, transmission-based precautions includes all of the following except
Wearing gloves when emptying a urinal.
Wearing a mask when working within 3 feet of the patient.
Wearing a gown if in contact with infectious agent.
Wearing a specially fitted mask when entering the patient's room.
A infection control nurse is concerned about the incidence of nosocomial infection in a particular facility. Which of the following would be least likely to place the patient at risk for developing a nosocomial infection?
Admission for outpatient surgery.
Several invasive treatments while closely monitoring vital signs.
Insertion of a foley catheter after surgery.
Treatment with broad spectrum antibiotics to ward off nosocomial infection
The nurse has selected a health problem of risk for infection related to trauma (surgical incision). The behavior outcome that has been written for the patient is for the incision to remain free from signs and symptoms of infection over the next 5 days. The nurse would be alert for clinical cues that the goal might not be met if the patient's assessment reveals which of the following?
Wound edges approximated.
Redness beyond the edges of the wound.
Coolness felt around the wound, no drainage.