The nurse is setting up a sterile field.

Which action by the nurse best exhibits surgical

asepsis? 
1. Disinfecting an item before adding it to a sterile field
2. Allowing sterile gloved hands to fall below the waist
3. Suctioning the oral cavity of an unconscious client
4. Touching only the inside surface of the first glove while pulling it onto the hand
Touching only the inside surface of the first glove while pulling it onto the hand
Rationale 1: Disinfecting an item is an example of medical asepsis, not surgical
asepsis. 
Rationale 2: If sterile gloved hands fall below the waist, they are considered to be
unsterile. 
Rationale 3: Suctioning the oral cavity of a client is considered contaminating.
Rationale 4: Touching only the inside surface of the first glove while pulling it onto the
hand is the correct technique when applying sterile gloves. This prevents contamination
of the outside of the glove, which must remain sterile.

The nurse is using medical asepsis when providing client care. Which action did the
nurse demonstrate? 
1. Administering parenteral medications
2. Changing a dressing
3. Performing a urinary catheterization
4. Using personal protective equipment
Using personal protective equipment
Rationale 1: Administering parenteral medications requires surgical asepsis. 
Rationale 2: Changing a dressing requires surgical asepsis.
Rationale 3: Performing a urinary catheterization requires surgical asepsis.
Rationale 4: Using personal protective equipment demonstrates medical asepsis.
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The nurse is reviewing the care needs for a group of assigned clients. Which client
should the nurse recognize as being most at risk for a nosocomial infection?
1. A client in the emergency department with abdominal pain 
2. A 19-year-old woman in her first trimester of pregnancy
3. A 72-year-old male client with COPD
4. An 86-year-old female client on steroid therapy
An 86-year-old female client on steroid therapy
Rationale 1: A client in the emergency department with abdominal pain has just arrived
in the facility, and not enough time has elapsed for this client to be considered to have a
nosocomial infection. If this client has an infection, it would be community acquired.
Rationale 2: The 19-year-old female who is pregnant is at a low risk.
Rationale 3: The 72-year-old male with COPD is at a lower risk for infection than the
82-year-old because the older client has a weakened immune system because of taking
steroids.
Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice
10th 706
Rationale 4: The client most at risk for a nosocomial infection is the client who is 86
years old and on steroid therapy. The very old and very young are most susceptible to
infections. The 86-year-old client is also on steroid therapy, which compromises the
immune system.
The nurse is preparing discharge teaching for a client recovering from surgery. What
instruction is the most important for the nurse to give this client who has a surgical
wound?
1. Adjust the diet so it contains more fruits and vegetables.
2. Apply lubricating lotion to the edges of the wound.
3. Notify the physician of any edema, heat, or tenderness at the wound site.
4. Thoroughly irrigate the wound with hydrogen peroxide.
Notify the physician of any edema, heat, or tenderness at the wound site.
Rationale 1: Increasing intake of fruits and vegetables would increase vitamin C, which
helps with wound healing, but more protein would be the best choice.
Rationale 2: Applying lubricating lotion to the edges of a wound would impede the
healing process.
Rationale 3: A client being discharged with an open surgical wound has to be instructed
on the detection of infection because the skin is the first line of defense. Signs such as
edema, heat, and tenderness would indicate a local infection.
Rationale 4: Irrigating with hydrogen peroxide would break down good granulating
tissue, so this would not increase healing.
A patient is diagnosed with a systemic infection. What will the nurse most likely assess
in this client? 
1. Edema, rubor, heat, and pain
2. Fever, malaise, anorexia, nausea, and vomiting
3. Palpitations, irritability, and heat intolerance
4. Tingling, numbness, and cramping of the extremities
Fever, malaise, anorexia, nausea, and vomiting
Rationale 1: Edema, rubor, heat, and pain are symptoms of a local infection.
Rationale 2: Fever, malaise, anorexia, nausea, and vomiting are symptoms of a
systemic infection. Rationale 3: Palpitations, irritability, and heat intolerance are
symptoms of a thyroid condition. 
Rationale 4: Tingling, numbness, and cramping of the extremities are symptoms of
hypocalcemia.
An older client with gallbladder disease has had a cholecystectomy. Which factor should
the nurse realize would influence the development of an infection in this client?
1. Active bowel sounds
2. Dry intact skin
3. Intact mucous membranes
4. Susceptibility of the client
Susceptibility of the client
Rationale 1: Active bowel sounds would indicate the body is able to defend itself
against an infection.
Rationale 2: Dry intact skin is a factor that would help the body defend against an
infection.
Rationale 3: Intact mucous membranes is a factor that would help the body defend
against infection.
Rationale 4: How susceptible the client is for an infection is one of the factors that
influences microorganism growth. This client is 80 years old and has a surgical incision,
so the first line of defense, the skin, is not intact.
The nurse is reviewing collected data from a client. Which information should the nurse
identify as a physiological barrier to defend the clients body from microorganisms?
1. Heavy smoking
2. Moisturizing the skin
3. Breakdown of skin
4. Voiding quantity sufficient
Voiding quantity sufficient
Rationale 1: Heavy smoking does not defend the body from microorganisms; it
destroys the cilia in the nose that help to filter organisms.
Rationale 2: Moisturizing the skin can allow microorganisms to enter the body.
Rationale 3: Breakdown of the skin can allow microorganisms to enter the body.
Rationale 4: Voiding quantity sufficient is a barrier that helps the body defend itself
against microorganisms. The act of voiding flushes those organisms that might try to
enter the body through the urinary meatus.
The nurse determines that a client has active immunity to a microorganism. What did
the nurse assess that caused the client to develop this type of immunity?
1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox
3. Receiving a rabies shot after being bitten by a rabid dog
4. Receiving an injection of gamma globulin
Having chickenpox
Rationale 1: Receiving an injection for tetanus is an example of acquired passive
immunity.
Rationale 2: When the client has the disease, the body stimulates the process of
acquired active immunity.
Rationale 3: Receiving an injection for rabies is an example of artificially acquired
passive immunity.
Rationale 4: Receiving an injection of gamma globulin is an example of artificially
acquired passive immunity.
A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to
this client?
1. A tetanus toxoid injection
2. An immunization for rabies
3. An injection of immunoglobulin
4. Mothers breast milk with antibodies in it
An immunization for rabies
Rationale 1: A tetanus toxoid injection is not specific for rabies.
Rationale 2: Receiving an immunization for rabies is an example of artificially acquired
passive immunity. Rationale 3: An injection of immunoglobulin is not specific for rabies.
Rationale 4: Mothers breast milk is another example of passive immunity, but not for
rabies.
The nurse is planning care for a client. Which intervention would be appropriate to
reduce the risk of infection?
1. Assess vital signs only once daily.
2. Raise the temperature in the clients room.
3. Wash hands.
4. Wear a mask for all client care.
Wash hands
Rationale 1: Assessing vital signs is important but should occur more frequently than
once daily.
Rationale 2: Raising the temperature in a clients room would contribute to the growth of
microorganisms.
Rationale 3: Washing hands is always the first and best way to stop the spread of
microorganisms, which cause infections.
Rationale 4: Wearing a mask for all clients is not practical and is unnecessary unless a
microorganism is airborne and the client is in isolation.
The nurse wants to protect a client from developing an infection. Which action should
the nurse take to break a link in the chain of infection?
1. Cover the mouth and nose when sneezing.
2. Place contaminated linens in a paper bag.
3. Use personal protective equipment (PPE) sparingly.
4. Wear gloves at all times.
Cover the mouth and nose when sneezing.
Rationale 1: Covering the mouth and nose when sneezing prevents airborne droplets
from escaping into the air for others to contract in the chain of infection.
Rationale 2: Placing linens in a paper bag would allow germs to come out through the
bag, and the linen would act as a fomite, thus allowing the chain to continue.
Rationale 3: PPE, according to OSHA standards, has to be used whenever the
situation dictates, not sparingly. Rationale 4: Gloves have to be worn but are to be
changed between clients and hands washed.
The nurse is caring for a client with hepatitis A. Which technique should the nurse use
to promote proper hand- washing technique with this client?
1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use.
3. Hold the hands upward under the faucet.
4. Use approximately a teaspoon of soap.
Use approximately a teaspoon of soap.
Rationale 1: When the water is turned on, it should be adjusted so it does not splatter
even if the flow is not
very forceful.
Rationale 2: Cleaning the faucet after use would defeat the whole purpose of washing
the hands. If the sink needs cleaning, clean it before washing the hands.
Rationale 3: Holding the hands upward under the faucet is incorrect. They should be
held downward so the soap, germs, and water are washed downward from the hands
and down the sink.
Rationale 4: Approximately 1 teaspoon of soap should be used when performing proper
hand-washing technique.
The nurse is removing personal protective equipment. Which nursing action
demonstrates the appropriate technique for removing a mask?
1. Bend the strip at the top of the mask. 
2. Loop the ties over the ears.
3. Tie the strings in a bow.
4. Touch the mask by the strings only.
Touch the mask by the strings only.
Rationale 1: Bending the strip at the top of the mask is done when applying a mask.
Rationale 2: Looping the ties over the ears is done when applying a mask.
Rationale 3: Tying the strings in a bow under the chin is done when applying a mask.
Rationale 4: Touching the mask by the strings is the appropriate intervention because
the mask is considered contaminated.
The nurse is preparing to remove soiled gloves. What action should the nurse take first?
1. Drop the gloves into the appropriate waste receptacle.
2. Ease the fingers into the gloves.
3. Grasp the outside of the nondominant glove.
4. Hook the bare thumb inside the other glove.
Grasp the outside of the nondominant glove.
Rationale 1: Dropping the gloves in the appropriate waste receptacle occurs after the
gloves are removed.
Rationale 2: Easing the fingers into the glove is done when applying gloves.
Rationale 3: In order to remove gloves after use, one must grasp the outside of the
nondominant glove.
Rationale 4: Hooking the bare thumb inside the other glove is done after the gloves are
removed.
The nurse is concerned that a break occurred in a sterile field. Which action occurred
that caused this break?
1. Grasping the edge of the outermost flap and opening it away from oneself
2. Keeping objects on the field 1 inch from the edge
3. Keeping the sterile field in eyesight
4. Transferring a sterile object to a sterile field with a clean gloved hand
Transferring a sterile object to a sterile field with a clean gloved hand
Rationale 1: Grasping the edge of the outermost flap and opening it away from oneself
will maintain the sterility of a field.
Rationale 2: Keeping objects on the field 1 inch from the edge will maintain the sterility
of a field. 
Rationale 3: Keeping the sterile field in eyesight will maintain the sterility of a field.
Rationale 4: Transferring a sterile object onto a sterile field with a gloved hand would
render the field unsterile only if the gloves are not sterile.
A client needs to be placed in contact isolation. What items should the nurse ensure are
included in this clients room?
1. Cabinet stocked with gloves and gowns
2. Cards and records
3. Paper towels, sink, and blood pressure cuff
4. Sign on the door
Paper towels, sink, and blood pressure cuff
Rationale 1: A cabinet stocked with gloves and gowns would be on the outside of the
room. 
Rationale 2: Cards and records should never be taken into an isolation room.
Rationale 3: Paper towels and a sink for hand washing should be in the clients room so
they can be used before the staff leaves the room. A blood pressure cuff needs to stay
in the clients room to prevent cross contamination.
Rationale 4: The sign explaining the kind of isolation should be on the outside of the
door to alert the staff of what is needed to enter.
The RN has just been stuck with a syringe while dropping it into a sharps container that
was too full in a clients room. What action should the nurse take first for this puncture
wound?
1. Complete an injury report.
2. Encourage bleeding.
3. Initiate first aid.
4. Wash the area with soap and water.
Encourage bleeding.
Rationale 1: This is not the first step. It can be done later.
Rationale 2: Encouraging bleeding is the first step.
Rationale 3: Initiating first aid is not the first step.
Rationale 4: Washing the area with soap and water is not the first step.
The nurse is preparing to leave a clients isolation room. Which action should the nurse
take first when removing a grossly soiled gown?
1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand.
2. Release the neck ties of the gown and allow the gown to fall forward.
3. Untie the strings at the neck first.
4. Untie the strings at the waist first.
Untie the strings at the waist first.
Rationale 1: Gloves are not left on while taking off a soiled gown.
Rationale 2: The neck ties are untied after the ties at the waist are untied.
Rationale 3: To leave an isolation room where a gown has been worn, one must untie
the gown at the waist first, not at the neck.
Rationale 4: To leave an isolation room where a gown has been worn, one must untie
the gown at the waist first, not at the neck. After the neck ties are untied, the gown is
allowed to fall forward.
The nurse is preparing a presentation on standard precautions. Which statement should
the nurse include in the presentation?
1. Cut the needle off a syringe after using it to give a client an injection. 
2. Dispose of blood-contaminated materials in a biohazard container.
3. Gloves should not be worn for client care unless body fluids are seen. 
4. Wear a mask when in direct contact with all clients.
Dispose of blood-contaminated materials in a biohazard container.
Rationale 1: Needles should never be cut, bent, or altered in any way, as this would
place the health care
provider at risk of being stuck.
Rationale 2: Disposal of blood-contaminated materials in a biohazard container is a
standard precaution.
Rationale 3: Gloves should be worn when providing client care whether body
secretions are seen or not.
Rationale 4: Masks need not be worn when giving routine direct client care unless the
clients condition so warrants.
A client diagnosed with tuberculosis is being admitted to a care area. Which nursing
action prevents the transmission of the disease?
1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at
the beginning of each shift.
3. Wash the hands only after leaving the room.
4. Wear a mask when exiting the room.
Have the client wear a mask when coming from admission. 
Rationale 1: When a client has an airborne disease and must go elsewhere in the
hospital, the client must wear
a mask.
Rationale 2: Supplies to prevent transmission of disease should be stocked at the end
of the shift so that adequate supplies will be available for the next health care provider.
Rationale 3: Hands should be washed before and after client care.
Rationale 4: The mask should be removed just as the staff leaves the clients room, not
when coming out of the
room.
The nurse is concerned that a client is at risk for a nosocomial infection. What did the
nurse assess to make this clinical decision?
Select all that apply.
1. Client is receiving intravenous fluids.
2. Client has an indwelling urinary catheter.
3. Client is recovering from surgery.
4. Client is receiving pain medication.
5. Client is ambulating twice a day with assistance.
1. Client is receiving intravenous fluids.
2. Client has an indwelling urinary catheter.
3. Client is recovering from surgery.
Rationale 1: Bacteremia can occur from an intravascular line.
Rationale 2: The client could develop an infection from an invasive procedure or device
such as an indwelling urinary catheter.
Rationale 3: After surgery, the clients health status is compromised, lowering the clients
defenses to fight infection.
Rationale 4: Receiving pain medication does not increase the clients risk for developing
a nosocomial infection.
Rationale 5: Ambulation does not increase the clients risk for developing a nosocomial
infection.
A client diagnosed with an infectious disease asks the nurse how the infection got inside
her body. Which responses would be appropriate for the nurse to make?
Select all that apply.
1. It depends on the number of organisms present to cause a disease.
2. It depends on how aggressive the organisms are to cause a disease.
3. It depends upon how the organisms get inside the body to cause a disease.
4. It depends upon where the person is at the time the disease is present.
5. It depends upon where the person works.
1. It depends on the number of organisms present to cause a disease.
2. It depends on how aggressive the organisms are to cause a disease.
3. It depends upon how the organisms get inside the body to cause a disease.
4. It depends upon where the person is at the time the disease is present.
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The nurse determines that a client has adequate physiological barriers to defend the
body against infection. What did the nurse assess in this client?
Select all that apply.
1. Intact and dry skin
2. Intact oral mucous membranes
3. Bowel sounds present in all four quadrants 
4. Nasal congestion
5. Urinary retention
1. Intact and dry skin
2. Intact oral mucous membranes
3. Bowel sounds present in all four quadrants 
Rationale 1: Intact skin is the bodys first line of defense against microorganisms.
Rationale 2: Intact mucous membranes are the bodys first line of defense against
microorganisms.
Rationale 3: Peristalsis tends to move microbes out of the body.
Rationale 4: Nasal congestion would mean that the nasal passages would be
ineffective in filtering microorganisms from inspired air.
Rationale 5: Urinary retention would cause the urine to remain in the body, possibly
leading to an infection.
A client is diagnosed with a communicable disease, and must be placed in isolation.
The nurse should identify which diagnosis as a priority for this client?
1. Social Isolation
2. Anxiety
3. Acute Pain
4. Imbalanced Nutrition: Less Than Body Requirements
Social Isolation
Rationale 1: Social Isolation would be appropriate for the client who needs to be
separated from others during a contagious episode.
Rationale 2: Anxiety would be appropriate if the client were demonstrating
apprehension regarding a change in life activities because of the communicable
disease.
Rationale 3: Acute Pain would be appropriate if the client were experiencing
discomfort.
Rationale 4: Imbalanced Nutrition: Less Than Body Requirements would be
appropriate if the client were too
ill to eat adequately.
A client tells the nurse that the newly diagnosed communicable disease is negatively
impacting employment and causing a stressful situation at home. What diagnosis
should the nurse select as a priority for this client?
1. Anxiety
2. Acute Pain
3. Social Isolation
4. Low Self-Esteem
Anxiety
Rationale 1: Anxiety is appropriate because the client is discussing the impact of the
communicable disease on work and home life.
Rationale 2: Acute Pain is not appropriate, as the client is not experiencing discomfort.
Rationale 3: Social Isolation is not appropriate, as the client has not been placed in
transmission precaution at
this time.
Rationale 4: Low Self-Esteem is incorrect because the client is not expressing negative
comments about himself.
A client is being discharged after a surgical procedure. On what should the nurse
instruct the client to reduce the risk of infection?
Select all that apply.
1. Hand-washing technique
2. The importance of adequate nutrition
3. Covering the mouth and nose when coughing or sneezing 
4. Increasing contact with others
5. Restricting rest period
1. Hand-washing technique
2. The importance of adequate nutrition
3. Covering the mouth and nose when coughing or sneezing 
Rationale 1: The nurse should instruct the client on the correct hand-washing technique
to reduce the risk of infection.
Rationale 2: The nurse should instruct the client on the importance of adequate
nutrition to reduce the risk of infection.
Rationale 3: The nurse should instruct the client to cover the mouth and nose when
coughing or sneezing to reduce the risk of infection.
Rationale 4: The nurse should instruct the client to minimize exposure to others when
recovering from surgery to reduce the risk of infection.
Rationale 5: The nurse should instruct the client to get adequate rest and sleep when
recovering from surgery to reduce the risk of infection.
A client in isolation ambulates with assistance to the bathroom. After toileting, what
should the unlicensed assistive personnel do?
1. Assist the client with hand washing. 
2. Assist the client back to bed.
3. Change the clients bed.
4. Leave the clients room.
Assist the client with hand washing.
Rationale 1: The client should utilize good hand washing after going to the bathroom.
The unlicensed assistive
personnel should assist the client with hand washing.
Rationale 2: After handwashing, the unlicensed assistive personnel should assist the
client back to bed.
Rationale 3: The clients bed can be changed at any time.
Rationale 4: The unlicensed assistive personnel should not leave the clients room until
the client has washed her hands and has been assisted back to bed.
While irrigating a clients abdominal wound, the irrigate splashes into the nurses nose
and eyes. What should the nurse do?
1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline. 
2. Begin HIV high-risk exposure prophylaxis within 24 hours.
3. Wash the areas with soap and water.
4. Have blood drawn for hepatitis B antibodies.
Flush the nose and eyes for 5 to 10 minutes with water or normal saline. 
Rationale 1: After an exposure to the mucous membranes, the area should be flushed
for 5 to 10 minutes with
saline or water.
Rationale 2: The client was not identified as being HIV-positive.
Rationale 3: Washing the area with soap and water would be appropriate for a puncture
or laceration.
Rationale 4: Being tested for hepatitis B would be appropriate after a puncture or
laceration but not for a splash to the mucous membranes.
The nurse is reviewing the agents available to disinfect the hands after providing client
care. Which agents should the nurse consider using?

Select all that apply.

1. Triclosan
2. Chlorine (bleach)
3. Isopropyl alcohol
4. Hydrogen peroxide
5. Chlorhexidine gluconate
1. Triclosan
3. Isopropyl alcohol
5. Chlorhexidine gluconate
Rationale 1: Triclosan is an agent that can be used on the hands as a disinfectant.
Rationale 2: Chlorine bleach is used to clean blood spills.
Rationale 3: Isopropyl alcohol is an agent that can be used on the hands as a
disinfectant.
Rationale 4: Hydrogen peroxide is used to clean surfaces.
Rationale 5: Chlorhexidine gluconate is an agent that can be used on the hands as a
disinfectant.
The nurse needs to apply personal protective equipment before entering a clients room.
In which order should the nurse perform the following actions?

Place the steps in the order in which they should be performed.

1. Apply gloves.
2. Apply eyewear.
3. Apply the gown.
4. Apply the face mask.
5. Perform hand hygiene.
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