g.
Keep the pathway from the bed to the bathroom
A5. CARE OF CLIENTS TO PROMOTE
AND MAINTAIN SAFETY AND THOSE
WITH RISK FOR INFECTION
1. The nurse's first action after discovering an electrical fire in
a patient's room is to:
a. Activate the fire alarm.
b. Confine the fire by closing all doors and windows.
c. Remove all patients in immediate danger.
d. Extinguish the fire by using the nearest fire
extinguisher.
2. A parent calls the pediatrician's office frantic about the
bottle of cleaner that her 2-year-old son drank. Which of
the following is the most important instruction the nurse
gives to this parent?
a. Give the child milk.
b. Give the child syrup of ipecac.
c. Call the poison control center.
d. Take the child to the emergency department.
3. The nursing assessment on a 78-year-old woman reveals
shuffling gait, decreased balance, and instability. On the
basis of the patient's data, which one of the following
nursing diagnoses indicates an understanding of the
assessment findings?
a. Activity intolerance
b. Impaired bed mobility
c. Acute pain
d. Risk for falls
4. A couple is with their adolescent daughter for a school
physical and state they are worried about all the safety
risks affecting this age. What is the greatest risk for injury
for an adolescent?
a. Home accidents
b. Physiological changes of aging
c. Poisoning and child abduction
d. Automobile accidents, suicide, and substance abuse
5. The nurse found a 68-year-old female patient wandering in
the hall. The patient says she is looking for the bathroom.
Which interventions are appropriate to ensure the safety of
the patient? (Select all that apply.)
a. Insert a urinary catheter.
b. Leave a night light on in the bathroom.
c. Ask the physician to order a restraint.
d. Keep the bed in low position with upper and lower
side rails up.
e. Assign a staff member to stay with the patient.
f. Provide scheduled toileting during the night shift.
clear.
6. The family of a patient who is confused and ambulatory
insists that all four side rails be up when the patient is
alone. What is the best action to take in this situation?
(Select all that apply.)
a. Contact the nursing supervisor.
b. Restrict the family's visiting privileges.
c. Ask the family to stay with the patient if possible.
d. Inform the family of the risks associated with side-rail
use.
e. Thank the family for being conscientious and put the
four rails up.
f. Discuss alternatives with the family that are
appropriate for this patient.
7. A physician writes an order to apply a wrist restraint to a
patient who has been pulling out a surgical wound drain.
Place the following steps for applying the restraint in the
correct order.
a. Explain what you plan to do.
b. Wrap a limb restraint around wrist or ankle with soft
part toward skin and secure.
c. Determine that restraint alternatives fail to ensure
patient's safety.
d. Identify the patient using proper identifier.
e. Pad the patient's wrist.
Answer: C, D, A, E, B
8. A child in the hospital starts to have a grand mal seizure
while playing in the playroom. What is your most important
nursing intervention during this situation?
a. Begin cardiopulmonary respiration.
b. Restrain the child to prevent injury.
c. Place a tongue blade over the tongue to prevent
aspiration.
d. Clear the area around the child to protect the child
from injury.
9. A 62-year-old woman is being discharged home with her
husband after surgery for a hip fracture from a fall at
home. When providing discharge teaching about home
safety to this patient and her husband, the nurse knows
that:
a. A safe environment promotes patient activity.
b. Assessment focuses on environmental factors only.
c. Teaching home safety is difficult to do in the hospital
setting.
d. Most accidents in the older adult are caused by
lifestyle factors.
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10. The nursing assessment of an 80-year-old patient who
demonstrates some confusion but no anxiety reveals that
the patient is a fall risk because she continues to get out of
bed without help despite frequent reminders. The initial
nursing intervention to prevent falls for this patient is to:
a. Place a bed alarm device on the bed.
b. Place the patient in a belt restraint.
c. Provide one-on-one observation of the patient.
d. Apply wrist restraints.
11. To ensure the safe use of oxygen in the home by a
patient, which of the following teaching points does the
nurse include? (Select all that apply.)
a. Smoking is prohibited around oxygen.
b. Demonstrate how to adjust the oxygen flow rate
based on patient symptoms.
c. Do not use electrical equipment around oxygen.
d. Special precautions may be required when traveling
with oxygen
12. How does the nurse support a culture of safety? (Select all
that apply.)
a. Completing incident reports when appropriate
b. Completing incident reports for a near miss
c. Communicating product concerns to an immediate
supervisor
d. Identifying the person responsible for an incident
13. At 3 am the emergency department nurse hears that a
tornado hit the east side of town. What action does the
nurse take first?
a. Prepare for an influx of patients
b. Contract the American Red Cross
c. Determine how to restore essential services
d. Evacuate patients per the disaster plan
14. A nurse is caring for a client who was just admitted to the
unit after falling at a nursing home. This client is oriented
to person, place, and time and can follow directions.
Which of the following actions by the nurse are
appropriate to decrease the risk of a fall? (Select all that
apply.)
a. Place a belt restraint on the client when he is sitting
on the bedside commode.
b. Keep the bed in low position with full side rails up.
c. Ensure that the client's call light is within reach.
d. Provide the client with nonskid footwear.
e. Complete a fall-risk assessment.
15. A nurse manager is reviewing care of a client who has had
a seizure with nurses on the unit. Which ofthe following
statements by a nurse requires further instruction?
a. "I will place the client on his side."
b. "I will go to the nurses' station for assistance."
c. "I will administer medications as prescribed."
d. "I will be prepared to insert an airway."
16. A nurse observes smoke coming from under the door of
the staff lounge. Which of the following is the priority
action by the nurse?
a. Extinguish the fire.
b. Pull the fire alarm.
c. Evacuate the clients.
d. Close all open doors on the unit.
17. A charge nurse is designating room assignments for
clients who will be admitted to the unit. Based on the
nurse's knowledge of fall prevention, which of the following
clients should be assigned to the room closest to the
nurses' station?
a. A 43-year-old client who is postoperative following a
laparoscopic cholecystectomy
b. A 61-year-old client being admitted for telemetry to
rule out a myocardial infarction
c. A 50-year-old client who is postoperative following
an open reduction internal fixation of
d. the ankle
e. A 79-year-old client who is postoperative following a
below-the-knee amputation
18. A nurse is caring for a newly admitted client who has a
documented history of falls. Which of thefollowing is the
priority action by the nurse?
a. Complete a fall-risk assessment.
b. Educate the client and family on fall risks.
c. Complete a physical assessment.
d. Survey the client's belongings.
19. A nurse is providing discharge instructions to a client who
has a prescription for the use of oxygen in his home.
Which of the following should the nurse teach the client
about using oxygen safely in his home? (Select all that
apply.)
a. Family members who smoke must be at least 10 ft
from the client when oxygen is in use.
b. Nail polish should not be used near a client who is
receiving oxygen.
c. A "No Smoking" sign should be placed on the front
door.
d. Cotton bedding and clothing should be replaced with
items made from wool.
e. A fire extinguisher should be readily available in the
home.
20. A nurse educator is conducting a parenting class for new
parents. Which of the following statements made by a
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 participant indicates a need for further clarification and
instruction?
a. "I will begin swimming lessons as soon as my baby
can close her mouth under water."
b. "Once my baby can sit up, he should be safe in the
bathtub."
c. "I will test the temperature of the water before
placing my baby in the bath."
d. "Once my infant starts to push up, I will remove the
mobile from over the bed."
21. A home health nurse is discussing the dangers of carbon
monoxide poisoning with a client. Which of the following
information should the nurse include in her counseling?
a. Carbon monoxide has a distinct odor.
b. Water heaters should be inspected every 5 years.
c. The lungs are damaged from carbon monoxide
inhalation.
d. Carbon monoxide binds with hemoglobin in the
body.
22. A nurse educator is presenting a module on basic first aid
for newly licensed home health nurses. The nurse
educator evaluates the teaching as effective when the
newly licensed nurse states the client who has heat stroke
will have which of the following?
a. Hypotension
b. Bradycardia
c. Clammy skin
d. Bradypnea
23. A home health nurse is discussing the dangers of food
poisoning with a client. Which of the following information
should the nurse including in her counseling? (Select all
that apply.)
a. Most food poisoning is caused by a virus.
b. Immunocompromised individuals are at risk for
complications from food poisoning
c. Clients who are especially at risk are instructed to
eat or drink only pasteurized milk,yogurt, cheese, or
other dairy products.
d. Healthy individuals usually recover from the illness in
a few weeks.
e. Handling raw and fresh food separately to avoid
cross contamination may prevent food poisoning.
Source: https://quizlet.com/50999054/chapter-27-patient-safety-flash-cards/
1. If an infectious disease can be transmitted directly from
one person to another, it is a:
a. Susceptible host.
b. Communicable disease.
c. Port of entry to a host.
d. Port of exit from the reservoir.
When an infectious disease can be transmitted directly from
one person to another, it is termed a communicable disease.
No vector is necessary for transmission.
2. Which is the most likely means of transmitting infection
between patients?
a. Exposure to another patient's cough
b. Sharing equipment among patients
c. Disposing of soiled linen in a shared linen bag
d. Contact with a health care worker’s hand
Hands become contaminated through contact with the patient
and the environment and serve as an effective vector of
transmission.
3. Identify the interval when a patient progresses from
nonspecific signs to manifesting signs and symptoms
specific to a type of infection.
a. Illness stage
b. Convalescence
c. Prodromal stage
d. Incubation period
The prodromal stage is the interval between entrance of a
pathogen into the body and appearance of first symptoms.
4. Which of the following is the most effective way to break
the chain of infection?
a. Hand hygiene
b. Wearing gloves
c. Placing patients in isolation
d. Providing private rooms for patients
Hands become contaminated through contact with the patient's
environment. Clean hands interrupt the transmission of
microorganisms.
5. A family member is providing care to a loved one who has
an infected leg wound. What would you instruct the family
member to do after providing care and handling
contaminated equipment or organic material?
a. Wear gloves before eating or handling food.
b. Place any soiled materials into a bag and double bag
it.
c. Have the family member check with the doctor about
need for immunization.
d. Perform hand hygiene after care and/or handling
contaminated equipment or material.
Clean hands interrupt the transmission of microorganisms from
family members.
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6. A patient is isolated for pulmonary tuberculosis. The nurse
notes that the patient seems to be angry, but he knows
that this is a normal response to isolation. Which is the
best intervention?
a. Provide a dark, quiet room to calm the patient.
b. Reduce the level of precautions to keep the patient
from becoming angry.
c. Explain the reasons for isolation procedures and
provide meaningful stimulation.
d. Limit family and other caregiver visits to reduce the
risk of spreading the infection.
Patients on isolation precautions may interpret the
needed restrictions as a sign of rejection by the health
care worker.
7. The nurse wears a gown when:
a. The patient's hygiene is poor.
b. The nurse is assisting with medication
administration.
c. The patient has acquired immunodeficiency
syndrome (AIDS) or hepatitis.
d. Blood or body fluids may get on the nurse's clothing
from a task that he or she plans to perform.
The gown serves as a barrier between the patient's blood
and/or body fluid and potential contact with the caregiver's
skin.
8. The nurse has redressed a patient's wound and now plans
to administer a medication to the patient. Which is the
correct infection control procedure?
a. Leave the gloves on to administer the medication.
b. Remove gloves and administer the medication.
c. Remove gloves and perform hand hygiene before
administering the medication.
d. Leave the medication on the bedside table to avoid
having to remove gloves before leaving the patient's
room.
Gloves need to be changed, and hand hygiene performed to
prevent transfer of microorganisms from one source (wound) to
another (nurse's hands).
9. When a nurse is performing surgical hand asepsis, the
nurse must keep hands:
a. Below elbows.
b. Above elbows.
c. At a 45-degree angle.
d. In a comfortable position.
Keeping hands above the elbows when performing a surgical
scrub prevents contaminated water from contact with hands.
10. What is the best method to sterilize a straight urinary
catheter and suction tube in the home setting?
a. Use an autoclave.
b. Use boiling water.
c. Use ethylene oxide gas.
d. Use chemicals for disinfection.
The best sterilizer in a home setting is boiling water.
11. A patient has an indwelling urinary catheter. Why does an
indwelling urinary catheter present a risk for urinary tract
infection?
a. It keeps an incontinent patient's skin dry.
b. It can get caught in the linens or equipment.
c. It obstructs the normal flushing action of urine flow.
d. It allows the patient to remain hydrated without
having to urinate.
The presence of a catheter in the urethra breaches the natural
defenses of the body. Reflux of microorganisms up the
catheter lumen from the drainage bag or backflow of urine in
the tubing increases the risk of infection.
12. Put the following steps for removal of protective barriers
after leaving an isolation room in order:
a. Untie top, then bottom mask strings and remove
from face.
b. Untie waist and neck strings of gown. Allow gown to
fall from shoulders and discard. Remove gown,
rolling it onto itself without touching the contaminated
side.
c. Remove gloves.
d. Remove eyewear or goggles.
e. Perform hand hygiene.
Answer: C, D, B, A, E
13. Your ungloved hands come in contact with the drainage
from your patient's wound. What is the correct method to
clean your hands?
a. Wash them with soap and water.
b. Use an alcohol-based hand cleaner.
c. Rinse them and use the alcohol-based hand cleaner.
d. Wipe them with a paper towel.
Physically removing wound drainage is most effectively
accomplished by washing with soap and water.
14. A patient's surgical wound has become swollen, red, and
tender. You note that the patient has a new fever and
leukocytosis. What is the best immediate intervention?
a. Notify the health care provider and use surgical
technique to change the dressing.
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 b. Reassure the patient and recheck the wound later.
c. Notify the health care provider and support the
patient's fluid and nutritional needs.
d. Alert the patient and caregivers to the presence of
an infection to ensure care after discharge.
Early intervention can reduce the risk of sepsis caused by the
progression of the infection. Fever depletes body fluid stores,
resulting in an increased risk of dehydration, and providing
proper nutrition promotes healing.
15. While preparing to do a sterile dressing change, a nurse
accidentally sneezes over the sterile field that is on the
over-the-bed table. Which of the following principles of
surgical asepsis, if any, has the nurse violated?
a. When a sterile field comes in contact with a wet
surface, the sterile field is contaminated by capillary
action.
b. Fluid flows in the direction of gravity.
c. A sterile field becomes contaminated by prolonged
exposure to air.
d. None of the principles were violated.
Avoid activities that create air currents, such as sneezing.
When you sneeze, microorganisms travel through the air by
droplets, contaminating the sterile field.
Source: https://quizlet.com/90971106/fundamentals-chapter-28-infection-
prevention-and-control-flash-cards/
1. The client has a 6-inch laceration on his right forearm. The
arm develops an infection. Which of the following is a sign
of an acute inflammatory process?
a. A blanching of the skin
b. A decrease in temperature at the site
c. A decrease in the number of white blood cells
d. A release of histamine that adds to the pain
response
A sign of an acute inflammatory process is pain. The swelling
of inflamed tissues increases pressure on nerve endings,
causing pain. Chemical substances such as histamine also
stimulate nerve endings, adding to the pain response. The skin
is not blanched; but rather, with the increase in local blood
flow; it is reddened. The symptom of localized warmth results
from a greater volume of blood at the inflammatory site. The
cellular response of acute inflammation involves WBCs arriving
at the site. There is an increase in WBCs, rather than a
decrease.
2. A female client has been undergoing diagnostic testing
since admission to the medical unit in the hospital. The
results of blood testing are sent back to the unit. Upon
reviewing the results, the nurse will report which of the
following findings to the physician, which is abnormal?
a. Erythrocyte sedimentation rate (ESR) 35 mm/hr
b. White blood cell (WBC) count 8000/mm3
c. Neutrophils 65%
d. Iron 75 g/100 mL
The normal erythrocyte sedimentation rate for women is 20
mm/hr. The client's ESR is 35 mm/hr, indicating the presence
of the inflammatory process. The normal WBC count is 5000-
10,000/mm3. The client is within normal limits at 8000/mm3.
The normal neutrophil count is 55-70%. The client is within
normal limits at 65%. The normal iron level is 60-90 g/100 mL.
The client is within normal limits at 75 g/100 mL.
3. The nurse is observing the new staff member work with
the client. Of the following activities, which one has the
greatest possibility of contributing to a nosocomial
infection and requires correction?
a. Washing hands before applying a dressing
b. Taping a plastic bag to the bed rail for tissue
disposal
c. Placing a Foley catheter bag on the bed when
transferring a client
d. Using alcohol to cleanse the skin before starting an
intravenous line
The staff member who places the Foley catheter bag on the
bed when transferring the client is placing the client at risk for a
nosocomial infection because urine in the catheter or drainage
tube may reenter the bladder (reflux). Washing hands before
applying a dressing is a correct action to help prevent a
nosocomial infection. Taping a plastic bag to the bed rail for
tissue disposal is a correct action to aid the client in proper
disposal of secretions. Using alcohol to cleanse the skin before
starting an intravenous line is a correct action to prevent a
nosocomial infection of the bloodstream.
4. Droplet precautions will be instituted for the client admitted
to the infectious disease unit with:
a. Streptococcal pharyngitis
b. Herpes simplex
c. Pertussis
d. Measles
Droplet precautions are instituted when droplets are larger than
5 micrometers, such as in the case of streptococcal
pharyngitis. Contact precautions are instituted for herpes
simplex. Airborne precautions are instituted with pulmonary
TB. Airborne precautions are instituted with measles.
5. In a small rural hospital they work with a wide variety of
clients. Of this afternoon client's admitted, the nurse
acknowledges the client with the highest susceptibility to
infection is the individual with:
a. Burns
b. Diabetes
c. Pulmonary emphysema
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 d. Peripheral vascular disease
Burn clients have a very high susceptibility to infection because
of the damage to skin surfaces. This would be the individual
with the highest risk for infection. Victims of chronic diseases
such as diabetes mellitus and multiple sclerosis are
susceptible to infection because of general debilitation and
nutritional impairment. Diseases that impair body system
defenses, such as emphysema and bronchitis (which impair
ciliary action and thicken mucus), increase susceptibility to
infection. Diseases that impair body system defenses, such as
peripheral vascular disease (which reduces blood flow to
injured tissues), increase susceptibility to infection.
6. A nurse must display understanding of the mental
implications of a client on isolation precautions when
planning care to control the risk of:
a. Denial
b. Aggression
c. Regression
d. Isolation
A sense of loneliness may develop because normal social
relationships become disrupted. The nurse should plan care to
control the risk of the client feeling isolated. Denial is not a risk
related to isolation. Aggression is not a risk for the client on
isolation precautions. Regression is not a risk related to
isolation.
7. Surgical aseptic techniques are employed by a nurse
when:
a. Inserting an intravenous catheter
b. Placing soiled linen in moisture-resistant bags
c. Disposing of syringes in puncture-proof containers
d. Washing hands before changing a dressing
Surgical asepsis should be used during procedures that
require intentional perforation of the client's skin, such as with
the insertion of IV catheters. The nurse is employing medical
aseptic technique when placing soiled linen in moisture-
resistant bags. The nurse is employing medical aseptic
technique when disposing of syringes in puncture-proof
containers. The nurse is employing medical aseptic technique
when washing hands before changing a dressing.
8. A nurse is changing the dressing and accidentally drops
the packing onto the client's abdomen. The client has a
large, deep abdominal incision that is packed with sterile
half-inch packing and covered with a dry 4 4 gauze. The
nurse should:
a. Add alcohol to the packing and insert it into the
incision
b. Throw the packing away, and prepare a new one
c. Pick up the packing with sterile forceps, and gently
place it into the incision
d. Rinse the packing with sterile water, and put the
packing into the incision with sterile gloves
A sterile object (the packing) remains sterile only when
touched by another sterile object. The client's abdomen is not
sterile; therefore, the nurse should throw the packing away and
prepare a new one. The nurse should not add alcohol to the
packing and insert it into the incision. The packing is
considered contaminated as it touched a nonsterile surface
and should be discarded. The nurse should not rinse the
packing with sterile water and put the packing into the incision
as it is considered contaminated. It touched a nonsterile
surface. The nurse should throw the packing away and prepare
a new one.
9. A client has a viral infection. Which of the following is
typical of the illness stage of the course of her infection?
a. There are no longer any acute symptoms.
b. An oral temperature reveals a febrile state.
c. The client was first exposed to the infection 2 days
ago but has no symptoms.
d. The client "feels sick" but is able to continue her
normal activities.
During the illness stage the client manifests signs and
symptoms specific to the type of infection. The client with a
viral infection would likely exhibit a fever. There are no longer
any acute symptoms during the convalescent period. An
example of a client in the incubation period is when the client
was first exposed to the infection 2 days ago, but has no
symptoms. The client who "feels sick" but is able to continue
normal activities is in the prodromal stage of a course of
infection.
10. The nurse recognizes that special care must be taken in
the handling of which of the following to prevent the
transmission of hepatitis A?
a. Blood
b. Feces
c. Saliva
d. Vaginal secretions
To prevent the transmission of hepatitis A, the nurse needs to
take special care when handling feces. Hepatitis B and C may
be found in blood. Hepatitis A is not found in saliva. Hepatitis A
is not found in vaginal secretions.
11. The parent of a preschool child asks the nurse how
chickenpox (varicella zoster) is transmitted. The nurse
identifies that the virus is:
a. Carried by a vector organism
b. Carried through the air in droplets after sneezing or
coughing
c. Transmitted through person-to-person contact
d. Acquired through contact with contaminated objects
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Varicella zoster virus (chickenpox) is transmitted by droplets
carried through the air after sneezing or coughing. Varicella
zoster virus (chickenpox) is not transmitted by a vector.
Person-to-person contact is not responsible for varicella zoster
virus (chickenpox) transmission. The transmission of varicella
zoster virus (chickenpox) does not occur by contact with
contaminated objects.
12. While working with clients in the postoperative period, the
nurse is very alert to the results of laboratory tests. Which
one of the following results is indicative of an infectious
process?
a. Iron 80 g/100 mL
b. Neutrophils 65%
c. White blood cells (WBC) 18,000/mm3
d. Erythrocyte sedimentation rate (ESR) 15 mm/hr
An elevated WBC count is indicative of an acute infection. The
normal WBC count is 5000 to 10,000/mm3. The normal
neutrophil count is 55%-70%. The client is within normal limits
at 65%. The normal iron level is 60-90 g/100 mL. The client is
within normal limits at 80 g/100 mL. The normal erythrocyte
sedimentation rate (ESR) is up to 15 mm/hr for men and up to
20 mm/hr for women. The client is within normal limits at 15
mm/hr.
13. Which of the following is an example of a nursing
intervention that is implemented to reduce a reservoir of
infection for a client?
a. Covering the mouth and nose when sneezing
b. Wearing disposable gloves
c. Isolating client's articles
d. Changing soiled dressings
To control or eliminate reservoir sites for infection, the nurse
eliminates or controls sources of body fluids, drainage, or
solutions that might harbor microorganisms. The nurse also
carefully discards articles that become contaminated with
infectious material such as in changing soiled dressings.
Covering the mouth and nose when sneezing is an intervention
to control a portal of exit. Wearing disposable gloves helps
protect the susceptible host. Isolating client's articles is an
intervention to control transmission.
14. In preventing and controlling the transmission of
infections, the single most important technique is:
a. Hand hygiene
b. The use of disposable gloves
c. The use of isolation precautions
d. Sterilization of equipment
The most important and most basic technique in preventing
and controlling transmission of infections is hand hygiene. Use
of disposable gloves may help reduce the transmission of
infections, but is not the single most important technique to
prevent and control the transmission of infections. The use of
isolation precautions is not the single most important technique
to prevent and control the transmission of infections.
Sterilization of equipment is not the single most important
technique to prevent and control the transmission of infections.
15. A client with active tuberculosis is admitted to the medical
center. The nurse recognizes that admission of this client
to the unit will require the implementation by the staff of:
a. Airborne precautions
b. Droplet precautions
c. Contact precautions
d. Reverse isolation
A client with active tuberculosis requires airborne precautions.
A client with active tuberculosis does not require droplet
precautions, as the droplet nuclei of tuberculosis are smaller
than 5 micrometers. Contact precautions are not necessary for
the client with active tuberculosis. Reverse isolation is not
required for the client with active tuberculosis.
16. The nurse recognizes the appropriate procedures for
sterile asepsis. Of the following, which action is consistent
with sterile asepsis?
a. Clean forceps may be used to move items on the
sterile field.
b. Sterile fields may be prepared well in advance of the
procedures.
c. The first small amount of sterile solution should be
poured and discarded.
d. Wrapped sterile packages should be opened starting
with the flap closest to the nurse.
Before pouring the solution into the container, the nurse pours
a small amount (1 to 2 mL) into a disposable cap or plastic-
lined waste receptacle. The discarded solution cleans the lip of
the bottle. This action is consistent with sterile asepsis. Sterile
forceps should be used to move items on a sterile field when
using sterile asepsis. Sterile fields should not be prepared well
in advance of a sterile procedure. A sterile object or field
becomes contaminated by prolonged exposure to air. Wrapped
sterile packages should be opened starting with the flap
farthest away from the nurse (i.e., the top flap).
17. Older adult clients may react differently to infectious
processes and a nurse suspects that her older adult client
may be experiencing hypostatic pneumonia. The nurse
must be alert to atypical signs and symptoms, such as:
a. Hypotension
b. Confusion
c. Erythema
d. Chills
An infection in older adults may not present with typical signs
and symptoms. Atypical symptoms such as confusion,
incontinence, or agitation may be the only symptoms of an
infectious illness. An unexplained increased heart rate,
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confusion, or generalized fatigue may be the only symptoms of
pneumonia in the older adult. Hypotension is not one of the
atypical symptoms of an older adult experiencing infection. It
may be a symptom of a systemic infection related to an
elevation in body temperature (regardless of age). Erythema is
a typical symptom of a localized infection. Chills are a typical
symptom of a systemic infection.
18. What is the correct order for a nursing assistant for putting
on the protective equipment when caring for a client in
isolation?
a. Wash her hands, apply the mask and eyewear, put
on the gown, and then apply gloves
b. Apply the mask and eyewear, put on the gown, wash
her hands, and then apply gloves
c. Wash her hands, put on the gown, apply the mask
and eyewear, and then apply the gloves
d. Put on the gown, apply the mask and eyewear, wash
her hands, and then apply gloves
The correct sequence for putting on protective equipment is to
perform hand hygiene, apply the mask and eyewear, apply
gown, and then apply gloves. Apply the mask and eyewear,
put on the gown, wash her hands, and then apply gloves; wash
her hands, put on the gown, apply the mask and eyewear, and
then apply the gloves; put on the gown, apply the mask and
eyewear, wash her hands, and then apply gloves are not the
correct sequences for putting on protective equipment.
19. A client has required a mid-abdominal surgical incision
which necessitates a sterile dressing. An appropriate
intervention for the nurse to implement in maintaining
sterile asepsis is to:
a. Put sterile gloves on before opening sterile packages
b. Discard packages that may have been in contact
with the area below waist level
c. Place the cap of the sterile solution well within the
sterile field
d. Place sterile items on the very edge of the sterile
drape
A sterile object held below a person's waist is considered
contaminated. To maintain sterile asepsis, packages that may
have been in contact with the area below waist level should be
discarded. Sterile gloves are not put on before opening sterile
packages as the outside of the packages is not sterile. The
nurse uses hand hygiene and opens sterile packages, being
careful to keep the inner contents sterile. After a cap or lid is
removed, it is held in the hand or placed sterile side (inside) up
on a clean surface. A bottle cap or lid should never rest on a
sterile surface, even though the inside of the cap is sterile. The
edges of a sterile field are considered to be contaminated.
Sterile items should be placed in the middle of the sterile field
to maintain sterile asepsis.
20. The nurse is preparing to assist with a sterile procedure in
the surgical suite. An appropriate technique that the nurse
includes in the surgical scrub is to:
a. Keep the hands below the elbows throughout the
scrub
b. Use a brush on the palms and dorsal surface of the
hands
c. Maintain the scrub for at least 2 to 5 minutes
d. Wash well around all jewelry
A surgical scrub should be maintained for at least 2 to 5
minutes. To avoid contamination during a surgical hand scrub,
the nurse holds the hands above the elbows. Several studies
suggest that neither a brush nor a sponge is necessary to
reduce bacterial counts on the hands, especially when an
alcohol-based product is used. For maximum elimination of
bacteria, all jewelry should be removed.
21. An appropriate isolation procedure for the nurse to
implement when working with a client who is found to have
methicillin-resistant Staphylococcus aureus (MRSA) is to:
a. Leave all linen in the client's room
b. Place specimen containers in plastic bags for
transport
c. Wipe the stethoscope off before removing it from the
room
d. Remove the mask and goggles first when leaving the
client's room
Specimen containers should be placed in plastic bags for
transport with a label on the outside of the bag. Linen should
be placed in an impervious linen bag and may be removed
from the client's room. Bags should be tied securely at the top
with a knot. For the person infected with MRSA, equipment
remains in the room. After discharge or with the discontinuation
of isolation, client care equipment is properly cleaned and
reprocessed, and single-use items are discarded. Gloves
should be removed first when leaving the client's room.
22. A client is found to have a bacterial infection of
Escherichia coli. The nurse, recognizing the effects of this
bacterium, anticipates that the client will demonstrate:
a. Diarrhea
b. Coughing
c. Cold sores around the mouth
d. Discharge from the eyes
Escherichia coli causes gastroenteritis and urinary tract
infections. The client with E. coli infection is likely to
demonstrate diarrhea. E. coli is found in the colon, not the
respiratory tract. Cold sores are seen with herpes simplex virus
(type 1), not with E. coli. Discharge from the eyes is not seen
with E. coli infection. It may be seen with Neisseria
gonorrhoeae.
23. Which of the following clients is at greatest risk for
acquiring an infection?
a. A 56-year-old with a urinary catheter 2 days after
prostatectomy
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 b. A 27-year-old diagnosed with human
immunodeficiency virus (HIV)
c. A 43-year-old who is 3 days post appendectomy and
is currently afebrile
d. A 16-year-old with a compound fractured femur as a
result of a bike accident
Clients are at risk for acquiring infections because of lower
resistance to infectious microorganisms, increased exposure to
numbers and types of disease-causing microorganisms, and
invasive procedures. The exposure to earth-bound
microorganisms makes the compound fracture client at the
greatest risk since that risk is uncontrollable.
24. A nurse is caring for a client who has colonized methicillin-
resistant Staphylococcus aureus (MRSA). Which of the
following statements reflects the best understanding of the
client's condition?
a. "This client has the bacteria present but it hasn't
become infected."
b. "This makes the client's MRSA very infectious and
so a danger to others."
c. "Just be sure to follow standard precautions and
there won't be a problem."
d. "The client needs to be watched closely for a
conversion to active MRSA."
If a microorganism is present or invades a host, grows, and/or
multiplies but does not cause infection, this is referred to as
colonization.
25. The greatest drawback to the routine use of antibacterial
hand soaps and gels is that they:
a. Are expensive
b. Irritate the skin
c. Kill resident flora
d. Encourage resistant bacteria
Antibacterial products kill resident flora and that can lead to the
development of infection. The remaining options may be true
but they are not the primary negative outcome of the regular
use of antibacterial hand cleansing products.
26. The nurse knows that Staphylococcus aureus found
normally on the skin of a client who has had surgery poses
a particular risk for that client developing:
a. A cold sore
b. Gastroenteritis
c. A wound infection
d. A urinary tract infection
Staphylococcus aureus found normally on/in skin, hair, anterior
nares, and the mouth can result in wound infections,
pneumonia, food poisoning, and cellulitis. Streptococcus (ß-
hemolytic group B) organisms may result in urinary tract
infections or gastroenteritis while herpes simplex is viral in
nature.
27. What is the most appropriate answer to the client's
question, "What's the difference between antibacterial and
antimicrobial hand soaps?"
a. "There is no real difference; use the less expensive."
b. "Antibacterial soaps are more effective at preventing
infections."
c. "Antimicrobial soap is better since it won't kill the
good bacteria on the skin."
d. "Any soap will do; it's the technique for proper hand
washing that is the key."
The use of antimicrobial hand hygiene products is
recommended because they remove transient organisms but
leave resident flora intact. There is a difference in the products
and it is true that the effectiveness of hand hygiene is
dependent on proper technique, but the client's question is
best answered by the information provided in option 3.
28. A presurgical client asks the nurse why it seems "so easy
to get an infection in the wound" after surgery. The nurse's
most appropriate response to this question is:
a. "The contaminated dressing acts as a breeding
ground for microorganisms that then infect the
wound."
b. "The body's immune system is weakened by the
surgery and can't fight off the infection as
effectively."
c. "While infections occur, there are many very
effective antibiotics available to help minimize the
risk of that happening."
d. "The surgical wound provides the microorganisms on
the surrounding skin a path to enter deep into the
body's tissues."
Resident skin microorganisms are not virulent. However, they
can cause serious infection when surgery or other invasive
procedures allow them to enter deep tissues. While the other
options are not incorrect, they do not answer the client's
question as effectively.
29. The nurse obtains a new, dry nebulizer when preparing to
give an elderly asthmatic client a nebulizer treatment
because the risk of infection is increased because:
a. The client's age increases the risk factor for potential
infection
b. The client's immune system is compromised as a
result of asthma
c. There is a potential presence of Pseudomonas
organisms in the reservoir
d. There is a chance for microorganisms to enter the
body via the respiratory system
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Pseudomonas organisms survive and multiply in nebulizer
reservoirs used in the care of clients with respiratory problems.
While the remaining options are correct, they are not the
primary reason for getting a new, dry nebulizer.
30. A client is told that he is a carrier of the hepatitis B virus.
When asked to explain this situation in more detail, the
nurse's best response is:
a. "You need to be careful not to pass the virus to other
people."
b. "You aren't sick, but you do have the virus within
your body."
c. "Be tested often so as to monitor whether the virus
becomes active."
d. "While you show no signs of the illness, you can
pass the virus to others."
Carriers are persons who show no symptoms of illness but
who have pathogens on or in their bodies that are transferred
to others. While the other options are not incorrect, they do not
address the client's questions as directly as does the answer.
31. The nurse can best minimize the risk for infection when
initiating an intravenous site by:
a. Proper vein site selection
b. Effective topical skin preparation
c. Appropriate site dressing
d. Gloving for the procedure
When a needle pierces a client's skin regardless of the
location, organisms enter the body if proper skin prepping was
not performed. The remaining options have an effect on
infection control but not to the degree that skin prepping does.
32. A client enters a neighborhood walk-in clinic reporting the
symptoms of "a head cold." When the health care provider
does not prescribe an antibiotic, the client asks the nurse
to explain "why not." The nurse's most appropriate
response is:
a. "Antibiotics aren't usually necessary for colds, and
they are really very expensive if you don't have
insurance."
b. "You know what they say; a cold will go away with
medication in 2 weeks; without medication in 14
days."
c. "Your health care provider believes in treating the
symptoms since there are so many different strains
of the common cold."
d. "Common colds don't usually require an antibiotic,
and taking one results in making it harder to treat
infections when they do occur."
Organisms with resistance to key antibiotics are becoming
more common in acute care settings. This is associated with
the frequent and sometimes inappropriate use of antibiotics.
While the remaining options are not incorrect, they may seem
insensitive or incomplete in answering the client's question.
33. The nurse is caring for a postoperative client with a
localized sinus infection. The most appropriate means by
which the nurse can minimize the risk of this client
developing a systemic infection is to:
a. Adhere strictly to standard precaution techniques
b. Dispense prescribed anti-infective medication as
ordered
c. Monitor the client regularly for exacerbation of the
sinus infection
d. Review lab work daily to determine the presence of
increased white cell count
If an infection is localized (e.g., a wound infection), use of
standard precautions and personal protective equipment (PPE)
will block the spread of infection to other sites, thus preventing
an infection that affects the entire body instead of just a single
organ or part (systemic). While the other options are not
incorrect, they are not as directed at minimizing the risk of
infection as is the answer.
34. The nurse and a client are discussing the client's tendency
to develop numerous "colds" during the winter months.
The client's health history reveals that he is a 1 pack a day
smoker. Which of the following nursing statements is most
appropriate regarding the possible relationship between
the client's cigarette smoking and the frequency of winter
colds?
a. "Smoking decreases your body's immune system,
and so you can't fight off the colds as effectively."
b. "If you stopped smoking you would have fewer colds
and just generally feel better all year around."
c. "The nicotine in the cigarettes has an effect on your
blood vessels, decreasing the circulation of
antibodies that would attack the cold viruses."
d. "Smoking damages the little hairs in your nose and
airways so they can't trap the airborne cold viruses
and keep them from entering your body."
Cilia lining the upper airway trap inhaled microbes and sweep
them outward in mucus to be expectorated or swallowed.
Smoking appears to paralyze these tiny hairs, and so they are
not able to function effectively. Consequently, microbes
including the cold viruses are able to enter into the respiratory
tract. The other options present unproven theories, generalized
statements, or less thorough explanations of the relationship
between smoking and respiratory illnesses.
35. Which of the following clients is at greatest risk for
acquiring a health care-associated (nosocomial) infection?
a. A 32-year-old hospitalized for 2 days for migraine
headaches
b. A client with type 1 diabetes who has been
experiencing hypoglycemia
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 c. A trauma victim taken directly from the ED to surgery
and then to the postsurgical unit
d. A pregnant 24-year-old diagnosed with both sinusitis
and otitis media and prescribed an oral antibiotic
The number of health care employees having direct contact
with a client, the type and number of invasive procedures, the
therapy received, and the length of hospitalization influence the
risk of infection. The other options do not have the potential for
infection as does the client who has been treated in various
locations within the health care facility.
36. A client is admitted for treatment of various poorly healing,
infected leg ulcers. The nurse recognizes that the client's
nutritional history is of primary importance since:
a. Nutrition is vital to the client's overall health status
b. The client's food intake will likely be decreased as a
result of the illness
c. Wound healing and infection prevention are
negatively impacted by poor nutrition
d. The client's habits regarding food intake are directly
related to this hospitalization
A reduction in protein, carbohydrates, and fats as a result of
illness, inadequate diet, or debility increases a client's
susceptibility to infection and delays wound healing. While the
other options are not incorrect, they are not as directly related
to the cause of the client's poorly healing, infected wounds.
37. A client admitted for an abdominal hysterectomy reports
that she has been under a lot of stress since the death of
her mother and wonders how that will affect her surgery
and recovery. Which of the following nursing statements
reflects the most therapeutic response to the client's
question?
a. "Being under stress isn't going to help your recovery;
you need to relax and focus on yourself and getting
well."
b. "Your mother's death must be very stressful for you
but she would want you to concentrate on getting
healthy."
c. "Stress does have a negative effect on the body's
ability to heal; is there anything I can do to help you
minimize the stress you feel?"
d. "Your health care provider can prescribe you some
medication to help you cope with the stress; would
you like me to mention it?"
Increased stress elevates cortisone levels, causing decreased
resistance to infection and the ability to heal. While the other
options may not be incorrect, they do not have the degree of
therapeutic value as does the answer since it explains the
effects of stress and also offers support.
38. A client admitted for an abdominal hysterectomy reports
that she has been under a lot of stress since the death of
her mother and wonders how that will affect her surgery
and recovery. Which of the following nursing interventions
reflects the most therapeutic understanding of the
relationship stress has on the body and its ability to
recover from surgery?
a. Suggest a demonstration of relaxation techniques
b. Arrange for the hospital chaplain to visit the client
c. Offer to call and get an order for an antianxiety
medication
d. Share a personal antidote concerning a similarly
stressful situation
Increased stress elevates cortisone levels, causing decreased
resistance to infection and the ability to heal. Reinforcement of
relaxation techniques would be the most therapeutic response
because it would provide the client with a long-term, self-
initiated coping mechanism. It would not be appropriate to
arrange for a clergy visit without first discussing it with the
client. Sharing a similar personal situation would have little
therapeutic value, and such a personal nurse-oriented
conversation should be avoided. While facilitating antianxiety
medication may not be incorrect, it is premature at this time.
39. The nurse is providing care for a client who
postoperatively has developed an infected incisional
wound and is depressed and anorexic. Which of the
following nursing interventions has priority?
a. Sterile wound care
b. Frequent small meals
c. Administration of antidepressant medication
d. Educating the client regarding wound care at home
The priority of administering therapies to promote wound
healing overrides the goal of educating the client to assume
self-care therapies at home. While the other options reflect
appropriate interventions for this client, none has priority over
wound care.
40. The nurse is educating a client diagnosed with type 2
diabetes, who is susceptible to foot wounds, on how to
minimize the risk for infection related to poor wound
healing by not being a susceptible host. The most
appropriate suggestion would be to:
a. Inspect feet and legs daily for skin breakdown
b. See a podiatrist regularly for appropriate foot care
c. Keep blood sugar levels within normal range to
maximize the ability to heal
d. Eat well-balanced meals in order to provide the
nutrients necessary for healing
Good infection control begins with prevention. Review with
clients and their families preventive measures to strengthen
their defenses. In the case of a diabetic client, keeping blood
sugar levels within normal limits maximizes the client's ability to
both heal and fight infection. While the other options are not
incorrect, they are more directed towards healing than
prevention.
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41. For infectious organisms to grow and multiply enough to
cause illness, they need an environment that has
appropriate amounts of: (Select all that apply.)
a. Food
b. Space
c. Water
d. Oxygen
e. Warmth
f. Darkness
To thrive, organisms require a proper environment, including
appropriate food, oxygen, water, temperature, pH, and light.
Space does not generally affect microorganism growth.
42. Which of the following are considered portals of exit in the
chain of infection? (Select all that apply.)
a. A bleeding cut
b. A hardy sneeze
c. A kiss on the lips
d. A urinary catheter
e. A scraped knuckle
f. A friendly handshake
After microorganisms find a site to grow and multiply, they
must find a portal of exit if they are to enter another host and
cause disease. Portals of exit include sites such as blood,
skin/mucous membranes, respiratory tract, genitourinary tract,
gastrointestinal tract, and transplacental (mother to fetus).
Unless the skin of the hands was broken (not intact), this
contact would not be considered a portal of exit.
43. Which of the following assessment data indicate the
presence of a local inflammatory process? (Select all that
apply.)
a. Client reports being cold
b. Left elbow warm to the touch
c. Elevated white blood cell (WBC) count
d. Pitting edema of +2 around the right ankle
e. Client reports knee pain of 5 on a scale of 1 to10
f. Client observed grimacing while raising shoulder to
brush hair
Signs of localized inflammation include swelling, redness, heat,
pain or tenderness, and loss of function in the affected body
part. When inflammation becomes systemic, other signs and
symptoms develop, including fever, leukocytosis, malaise,
anorexia, nausea, vomiting, lymph node enlargement, or organ
failure.
Source: https://quizlet.com/43971067/chapter-28-infection-prevention-and-
control-flash-cards/
1. What is the most effective way to control transmission of
infection?
a. Isolation precautions
b. Identifying the infectious agent.
c. Hand Hygiene Practices
d. Vaccinations
Hands contaminated with transient bacteria are a primary
source for transmission of infection.
2. A patient who has been isolated for Clostridium difficile
(C.diff) asks you to explain what he should know about
this organism. What is the most appropriate information to
include in patient teaching? SELECT ALL THAT APPLY.
a. The organism is usually transmitted through the fecal
oral route.
b. Hands should always be cleaned with soap and
water versus alcohol-based hand sanitizer.
c. Everyone coming into the room must be wearing a
gown and gloves.
d. While the patient is in contact precautions, he cannot
leave the room.
e. C diff dies quickly outside the body.
C. difficile enters a person's body via ingestion of the spores
that are spread via the fecal-oral route. Alcohol-based hand
sanitizers have proved ineffective with C. difficile because of
the spore that surrounds the organism, thus thorough
handwashing is recommended. The most common way C.
difficile is spread in a health care environment is through
workers' contaminated hands; therefore, barriers such as
gloves and gowns are an important part of preventing
transmission between patients.
3. Your assigned patient has a leg ulcer that has a dressing
on it. During your assessment you find that the dressing is
saturated with purulent drainage. Which action would be
best on your part?
a. Reinforce dressing with a clean, dry dressing and
call the health care provider.
b. Remove wet dressing and apply new dressing using
sterile procedure.
c. Put on gloves before removing the old dressing; then
obtain a wound culture.
d. Remove saturated dressing with gloves, remove
gloves, then perform hand hygiene and apply new
gloves before putting on a clean dressing.
Gloves need to be changed, and hand hygiene performed to
prevent transfer of microorganisms from one source to
another. Gloves may have microscopic holes that allow
microorganisms to have contact with the caregiver's skin.
Therefore, gloves are removed, and hand hygiene is
performed whenever the nurse moves from an activity
requiring gloves to another nursing action or leaves the
patient's room and whenever all patient tasks are completed.
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4. A patient is diagnosed with methicillin-resistant
Staphylococcus aureus (MRSA) pneumonia. Which type
of isolation precaution is most appropriate for this patient?
a. Reverse isolation
b. Droplet precautions
c. Standard precautions
d. Contact precautions
The patient has a multidrug resistant organism within his
respiratory tract that has become pathogenic. The route of
transmission for this type of condition is respiratory; thus,
whenever the patient coughs or sneezes, organisms are
sprayed into the air and then drop onto surfaces in the room. In
addition to gown and gloves, a mask must also be worn.
5. A family member is providing care to a loved one who has
an infected leg wound. What would you instruct the family
member to do after providing care and handling
contaminated equipment or organic material?
a. Wear gloves before eating or handling food.
b. Place any soiled materials into a bag and double bag
it.
c. Have the family member check with the health care
provider about need for immunization.
d. Perform hand hygiene after care and/or handling
contaminated equipment or material.
Clean hands interrupt the transmission of microorganisms from
family members.
6. When should a nurse wear a mask? (Select all that apply).
a. The patient's dental hygiene is poor.
b. The nurse is assisting with an aerosolizing
respiratory procedure such as suctioning.
c. The patient has acquired immunodeficiency
syndrome (AIDS) and a congested cough.
d. The patient is in droplet precautions.
e. The nurse is assisting a health care provider in the
insertion of a central line catheter.
Masks are used for three primary purposes in health care
settings: (1) placed on health care personnel to protect them
from contact with infectious material from patients (e.g.,
respiratory secretions); (2) placed on health care personnel
when engaged in procedures requiring sterile technique to
protect patients from exposure to infectious agents carried in a
health care worker's mouth or nose; and (3) placed on
coughing patients to limit potential dissemination of infectious
respiratory secretions from the patient to others.
7. Which type of personal protective equipment are staff
required to wear when caring for a pediatric patient who is
placed into airborne precautions for confirmed chicken
pox/herpes zoster? (Select all that apply.)
a. Disposable gown
b. N 95 respirator mask
c. Face shield or goggles
d. Surgical mask
e. Gloves
The organism is dispersed into the air and is light enough to
stay afloat for long periods of time. Wearing protective covering
and the filtration mask or hood prevents the staff from
breathing in the infected air particles.
8. The infection control nurse has asked the staff to work on
reducing the number of iatrogenic infections on the unit.
Which of the following actions on your part would
contribute to reducing health care-acquired infections?
(Select all that apply.)
a. Teaching correct hand washing to assigned patients
b. Using correct procedures in starting and caring for
an intravenous infusion
c. Providing perineal care to a patient with an
indwelling urinary catheter
d. Isolating a patient who has just been diagnosed as
having tuberculosis
e. Decreasing a patient's environmental stimuli to
decrease nausea
Iatrogenic infections are infections associated with a procedure
or therapy. The patient with tuberculosis was probably infected
outside of the health care environment, and preventing nausea
is not associated directly with infection prevention.
9. Which of the following actions by the nurse comply with
core principles of surgical asepsis? (Select all that apply.)
a. Set up sterile field before patient and other staff
come to the operating suite.
b. Keep the sterile field in view at all times.
c. Consider the outer 2.5 cm (1 inch) of the sterile field
as contaminated.
d. Only health care personnel within the sterile field
must wear personal protective equipment.
e. The sterile gown must be put on before the surgical
scrub is performed.
Keeping the sterile field in view at all times confirms that no
contamination has occurred. The outer 2.5-cm (1-inch) of the
sterile field is the most likely place for accidental
contamination. The sterile table should be set up after the
patient and staff are in the room to prevent a higher risk of
contamination of the sterile field by air current. All surgical
personnel will be wearing protective personal equipment in the
surgical suite, not just those within the sterile field. The sterile
gown and gloves are donned after the surgical scrub.
10. What does it mean when a patient is diagnosed with a
multidrug-resistant organism in his or her surgical wound?
(Select all that apply.)
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 a. There is more than one organism in the wound that
is causing the infection.
b. The antibiotics the patient has received are not
strong enough to kill the organism.
c. The patient will need more than one type of antibiotic
to kill the organism.
d. The organism has developed a resistance to one or
more broad-spectrum antibiotics, indicating that the
organism will be hard to treat effectively.
e. There are no longer any antibiotic options available
to treat the patient's infection.
Multidrug-resistant organisms are bacteria that have become
resistant to certain antibiotics, and these antibiotics can no
longer be used to control or kill the bacteria.
11. Which of these statements are true regarding disinfection
and cleaning? (Select all that apply.)
a. Proper cleaning requires mechanical removal of all
soil from an object or area.
b. General environmental cleaning is an example of
medical asepsis.
c. When cleaning a wound, wipe around the wound
edge first and then clean inward toward the center of
the wound.
d. Cleaning in a direction from the least to the most
contaminated area helps reduce infections.
e. Disinfecting and sterilizing medical devices and
equipment involve the same procedures.
Environmental surfaces (e.g., bedside table) potentially can
contribute to cross-transmission by contamination of health
care personnel from hand contact with contaminated surfaces,
medical equipment, or patients. Cleaning from the least to the
most contaminated area of a wound prevents recontamination
of the cleaned area.
12. Which of the following nursing actions would most
increase a patient's risk for developing a health care-
associated infection?
a. Use of surgical aseptic technique to suction an
airway
b. Urinary catheter drainage bag placed below the level
of the bladder
c. Clean technique for inserting a urinary catheter
d. Use of a sterile bottled solution more than once
within a 24-hour period
13. The home health nurse is teaching a patient and family
about hand hygiene in the home. The nurse is sure to
emphasize washing hands before
a. And after shaking hands.
b. And after treatments.
c. Opening the refrigerator.
d. And after using a computer.
Source: https://quizlet.com/150117709/clinical-practice-exam-1-chapter-29-
flash-cards/
1. You are conducting an education class at a local senior
center on safe-driving tips for seniors. Which of the
following should you include? (Select all that apply)
a. Drive shorter distances
b. Drive only during daylight hours
c. Use the side and rearview mirrors carefully
d. Keep a window rolled down while driving if has
trouble hearing
e. Look behind toward the blind spot
f. Stop driving at age 75
Educate patients regarding safe driving tips (e.g., driving
shorter distances or only in daylight, using side and rearview
mirrors carefully, and looking behind them toward their "blind
spot" before changing lanes). If hearing is a problem,
encourage the patient to keep a window rolled down while
driving or reduce the volume of the radio or CD player.
Counseling is often necessary to help older patients make the
decision of when to stop driving.
2. A nurse is evaluating a pt who is in soft wrist restraints.
Which of the following activities does the nurse perform?
(Select all that apply).
a. Check the patient’s peripheral pulse in the restrained
extremity
b. Evaluate the patient’s need for toileting
c. Offer the patient fluids if appropriate
d. Release both limbs at the same time to perform
range of motion (rom)
e. Inspect the skin under each restraint
The nurse should evaluate patient for signs of injury every 15
minutes (e.g., circulation, vital signs, ROM, physical and
psychological status, and readiness for discontinuation. The
nurse should evaluate patient's need for toileting, nutrition and
fluids, hygiene, and elimination and release restraint at least
every 2 hours but should do it one limb at a time.
3. You are admitting Mr. Jones, a 64 yr old pt who had a right
hemisphere stroke and recent fall. His wife stated that he
has a history of high BP, which is controlled by an
antihypertensive and a diuretic. Currently he exhibits left-
sided neglect and problems with spatial and perceptual
abilities and is impulsive. He has moderate left-sided
weakness that requires the assistance of two and the use
of a gait belt to transfer to a chair. He currently has an IV
line and a urinary catheter in place. Which factors increase
his fall risk at this time? (select all that apply)
a. Smokes a pack a day
b. Used a cane to walk at home
c. Takes antihypertensive and diuretics
d. History of recent fall
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 e. Neglect, spatial and perceptual abilities, impulsive
f. Requires assistance with activity, unsteady gait
g. IV line, urinary catheter
Smoking is not a risk factor for falls. Use of the cane at home is
not a current risk factor for falls. Risk is determined by his
current status.
4. What is your role as a nurse during a fire? (Select all that
apply).
a. Help to evacuate patients
b. Shut off medical gases
c. Use a fire extinguisher
d. Single carry patients out
e. Direct ambulatory patients
Direct all ambulatory patients to walk by themselves to a safe
area. If you have to carry a patient, do so correctly (e.g., two-
man carry). After a fire is reported and patients are out of
danger, nurses and other personnel take measures to contain
or extinguish it such as closing doors and windows, placing wet
towels along the base of doors, turning off sources of oxygen
and electrical equipment, and using a fire extinguisher.
5. A nurse is educating parents to look for clues in teenagers
for possible substance abuse. Which environmental and
psychosocial clues should the nurse include? (Select all
that apply).
a. Blood spots on clothing
b. Long-sleeved shirts in warm weather
c. Changes in relationships
d. Wearing dark glasses indoors
e. Increased computer use
Environmental clues include the presence of drug-oriented
magazines, beer and liquor bottles, drug paraphernalia and
blood spots on clothing, and the continual wearing of long-
sleeved shirts in hot weather and dark glasses indoors.
Psychosocial clues include failing grades, change in dress,
increased absenteeism from school, isolation, increased
aggressiveness, and changes in interpersonal relationships.
Source: https://quizlet.com/236574614/potter-perry-chapter-27-patient-safety-
and-quality-flash-cards/
1. The nurse and a new nurse in orientation are caring for a
patient with pneumonia. Which statement by the new
nurse will indicate a correct understanding of this
condition?
a. "An infectious disease like pneumonia may not pose
a risk to others."
b. "We need to isolate the patient in a private negative-
pressure room."
c. "Clinical signs and symptoms are not present in
pneumonia."
d. "The patient will not be able to return home."
Infections are infectious and/or communicable. Infectious
diseases may not pose a risk for transmission to others,
although they are serious for the patient. Pneumonia is not a
communicable disease—a disease that is transmitted directly
from one individual to the next, so there is no need for
isolation. A private negative-air pressure room is used for
tuberculosis, not pneumonia. Clinical signs and symptoms are
present in pneumonia. Frequently, patients with pneumonia do
return home unless there are extenuating circumstances.
2. The patient and the nurse are discussing Rickettsia
rickettsii—Rocky Mountain spotted fever. Which patient
statement to the nurse indicates understanding regarding
the mode of transmission for this disease?
a. "When camping, I will use sunscreen."
b. "When camping, I will drink bottled water."
c. "When camping, I will wear insect repellent."
d. "When camping, I will wash my hands with hand
gel."
Rocky Mountain spotted fever is caused by bacteria
transmitted by the bite of ticks. Wearing a repellent that is
designed for repelling ticks, mosquitoes, and other insects can
help in preventing transmission of this disease. Drinking plenty
of uncontaminated water, wearing sunscreen, and using
alcohol-based hand gels for cleaning hands are all important
activities to participate in while camping, but they do not
contribute to or prevent transmission of this disease.
3. The nurse is providing an educational session for a group
of preschool workers. The nurse reminds the group about
the most important thing to do to prevent the spread of
infection. Which information did the nurse share with the
preschool workers?
a. Encourage preschool children to eat a nutritious diet.
b. Suggest that parents provide a multivitamin to the
children.
c. Clean the toys every afternoon before putting them
away.
d. Wash their hands between each interaction with
children.
The single most important thing that individuals can do to
prevent the spread of infection is to wash their hands before
and after eating, going to the bathroom, changing a diaper, and
wiping a nose and between touching each individual child. It is
important for preschool children to have a nutritious diet; a
healthy individual can fight infection more effectively. A health
care provider, along with the parent, makes decisions about
dietary supplements. Cleaning the toys can decrease the
number of pathogens but is not the most important thing to do
in this scenario.
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4. The nurse is admitting a patient with an infectious disease
process. Which question will be most appropriate for a
nurse to ask about the patient's susceptibility to this
infectious process?
a. "Do you have a spouse?"
b. "Do you have a chronic disease?"
c. "Do you have any children living in the home?"
d. "Do you have any religious beliefs that will influence
your care?"
Multiple factors influence a patient's susceptibility to infection.
Patients with chronic diseases such as diabetes mellitus and
multiple sclerosis are also more susceptible to infection
because of general debilitation and nutritional impairment.
Other factors include age, nutritional status, trauma, and
smoking. The other questions are part of an admission
assessment process but are not pertinent to the infectious
disease process.
5. The patient experienced a surgical procedure, and
Betadine was utilized as the surgical prep. Two days
postoperatively, the nurse's assessment indicates that the
incision is red and has a small amount of purulent
drainage. The patient reports tenderness at the incision
site. The patient's temperature is 100.5° F, and the WBC
is 10,500/mm3. Which action should the nurse take first?
a. Plan to change the surgical dressing during the shift.
b. Utilize SBAR to notify the primary health care
provider.
c. Reevaluate the temperature and white blood cell
count in 4 hours.
d. Check to see what solution was used for skin
preparation in surgery.
The nursing assessment indicates signs and symptoms of
infection, requiring the primary health care provider to be
notified of the patient's needs. SBAR—Situation, Background,
Assessment, and Recommendation—can be utilized to
organize thoughts and data and to provide a thorough
explanation of the patient's current status. The reevaluation of
temperature is a good choice, but it will take longer than 4
hours to make a change in the white blood cells. Changing the
dressing may be a need during the shift but is not a first
priority. Checking to see about the skin preparation used 2
days ago may or may not be useful information at this time.
6. The nurse is providing an education session to an adult
community group about the effects of smoking on
infection. Which information is most important for the
nurse to include in the educational session?
a. Smoke from tobacco products clings to your clothing
and hair.
b. Smoking affects the cilia lining the upper airways in
the lungs.
c. Smoking can affect the color of the patient's
fingernails.
d. Smoking tobacco products can be very expensive.
A normal defense mechanism against infection in the
respiratory tract is the cilia lining the upper airways of the lungs
and normal mucus. When a patient inhales a microbe, the cilia
and mucus trap the microbe and sweep them up and out to be
expectorated or swallowed. Smoking may alter this defense
mechanism and increase the patient's potential for infection.
Smoking can be expensive, the smell does cling to hair and
clothing, and the tar within the smoke can alter the color of a
patient's nails. This information can be included in the
education but does not constitute the most important point.
7. A female adult patient presents to the clinic with reports of
a white discharge and itching in the vaginal area. A nurse
is taking a health history. Which question is the priority?
a. "When was the last time you visited your primary
health care provider?"
b. "Has this condition affected your eating habits in any
way?"
c. "What medications are you currently taking?"
d. "Are you able to sleep at night?"
Antibiotics and oral contraceptives can disrupt normal flora in
the vagina, causing an overgrowth of Candida albicans in that
area. It is important to ask the patient about current
medications to obtain information that may assist with
diagnosis. The body contains normal flora (microorganisms)
that live on the surface of skin, saliva, oral mucosa,
gastrointestinal tract, and genitourinary tract. The normal flora
of the vagina causes vaginal secretions to achieve a low pH,
inhibiting the growth of many microorganisms. Visiting the
primary health care provider is important for the patient's health
maintenance but is not the priority. Learning about the patient's
eating and sleeping habits will assist in the plan of care but is
not the priority.
8. The nurse is caring for a school-aged child who has
injured the right leg after a bicycle accident. Which signs
and symptoms will the nurse assess for to determine if the
child is experiencing a localized inflammatory response?
a. Malaise, anorexia, enlarged lymph nodes, and
increased white blood cells
b. Chest pain, shortness of breath, and nausea and
vomiting
c. Dizziness and disorientation to time, date, and place
d. Edema, redness, tenderness, and loss of function
The body's cellular response to an injury is seen as
inflammation. Signs of localized inflammation include swelling,
redness, heat, pain or tenderness, and loss of function in the
affected body part. Systemic signs of inflammation include
fever, malaise, and anorexia, as well as enlarged lymph nodes
and increased white blood cells. Chest pain, shortness of
breath, and nausea and vomiting are signs and symptoms of a
cardiac alteration. Dizziness and disorientation to time, date,
and place may indicate a neurologic alteration.
9. Which interventions utilized by the nurse will indicate the
ability to recognize a localized inflammatory response?
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 a. Vigorous range-of-motion exercises
b. Turn, cough, and deep breathe
c. Orient to date, time, and place
d. Rest, ice, and elevation
Signs of localized inflammation include swelling, redness, heat,
pain or tenderness, and loss of function in the affected body
part. One sign of the inflammatory response, particularly after
an injury, is swelling or edema. Resting the affected injured
area, using ice as ordered, wrapping the area to provide
support—particularly if it is an extremity—and elevating the
injured area will help to decrease swelling or edema. Turning,
coughing, and deep breathing are utilized for postoperative
patients and for immobilized patients to help prevent an
infectious process such as pneumonia. Orientation to date,
time, and place is an intervention utilized with many different
types of patients who may be confused. Vigorous range of
motion would irritate the inflammatory process. Range of
motion is utilized for individuals who need to improve
movement of their extremities, including immobilized patients.
10. The nurse is caring for a group of medical-surgical
patients. Which patient is most at risk for developing an
infection?
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
c. A patient who is recovering from a right total hip
surgery
d. A patient who has been admitted for stabilization of
heart problems
The patient who is recovering from a right total hip surgery has
a large incision from the surgery. This break in the skin
increases the likelihood of infection. Any break in the integrity
of the skin and mucous membranes allows pathogens to enter
and exit the body. The patient has had anesthesia, which
depresses the respiratory system and has the potential to
decrease the expansion of alveoli and to increase the chance
of infection in the respiratory system. A patient who is having
chest pain, experiencing dehydration, or being admitted with
heart problems does not have open incisions that break the
skin; therefore, his or her infection risk is lower.
11. The nurse is caring for a patient with leukemia and is
preparing to provide fluids through a vascular access (IV)
device. Which nursing intervention is a priority in this
procedure?
a. Review the procedure with the patient.
b. Position the patient comfortably.
c. Maintain surgical aseptic technique.
d. Gather available supplies.
You maintain surgical aseptic technique at the patient's
bedside (e.g., when inserting IV or urinary catheters, suctioning
the tracheobronchial airway, and sterile dressing changes)
because patients with disease processes of the immune
system are at particular risk for infection. These diseases
include leukemia, AIDS, lymphoma, and aplastic anemia.
These disease processes weaken the defenses against an
infectious organism. Reviewing the procedure with the patient,
positioning the patient, and gathering the supplies are all
important steps in the procedure but are not the priority in the
procedure since the patient already has a compromised
immune response.
12. The nurse is caring for an adult patient in the clinic who
has been evacuated and is a victim of flooding. The nurse
teaches the patient about rest, exercise, and eating
properly and how to utilize deep breathing and
visualization. What is the primary rationale for the nurse's
actions related to the teaching?
a. Topics taught are standard information taught during
health care visits.
b. The patient requested this information to teach the
extended family members.
c. Stress for long periods of time can lead to
exhaustion and decreased resistance to infection.
d. These techniques will help the patient manage the
pain and loss of personal belongings.
The body responds to emotional or physical stress by the
general adaptation syndrome. If stress extends for long periods
of time, this can lead to exhaustion, whereby energy stores are
depleted and the body has no defenses against invading
organisms. Techniques of deep breathing and visualization
may be helpful with pain, but they are not the primary reason.
The teachings listed are not all standard interventions taught at
every health care visit. There is no data to indicate the patient
requested this information for the family.
13. The nurse is caring for a patient who is susceptible to
infection. Which instruction will the nurse include in an
educational session to decrease the risk of infection?
a. Teaching the patient about fall prevention
b. Teaching the patient to take a temperature
c. Teaching the patient to select nutritious foods
d. Teaching the patient about the effects of alcohol
A patient's nutritional health directly influences susceptibility to
infection. A reduction in the intake of protein and other
nutrients such as carbohydrates and fats reduce body
defenses against infection and impairs wound healing. This is
the only teaching point that directly influences risk. Teaching
the patient how to take a temperature can help the patient
assess if there is a fever, but it is not related to decreasing the
individual's risk for infection. Teaching the patient about fall
prevention or about the effects of alcohol does not decrease
the risk of infection.
14. A diabetic patient presents to the clinic for a dressing
change. The wound is located on the right foot and has
purulent yellow drainage. Which action will the nurse take
to prevent the spread of infection?
a. Position the patient comfortably on the stretcher.
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 b. Explain the procedure for dressing change to the
patient.
c. Review the medication list that the patient brought
from home.
d. Don gloves and other appropriate personal
protective equipment.
Localized infections are most common in the skin or with
mucous membrane breakdown. Wear gloves and other
personal protective equipment as appropriate when examining
or providing treatment to localized infected areas to create a
protective barrier. Positioning the patient, explaining the
procedure, and reviewing the medication list are all tasks that
need to be completed, but they do not prevent the spread of
infection.
15. A patient presents with pneumonia. Which priority
intervention should be included in the plan of care for this
patient?
a. Observe the patient for decreased activity tolerance.
b. Assume the patient is in pain and treat accordingly.
c. Provide the patient ice chips as requested.
d. Maintain the room temperature at 65° F.
Systemic infection, like pneumonia, causes more generalized
symptoms than local infection. This type of infection can result
in fever, fatigue, nausea and vomiting, and malaise; be alert for
changes in the patient's level of activity and responsiveness.
Nurses do not assume but assess and communicate with the
patient about pain. While providing the patient with ice chips
may be appropriate, it is not a priority and there is no reason
for the patient to be limited to ice. Maintaining the room
temperature at 65° F is too cold.
16. The nurse is caring for a patient in an intensive care unit
who needs a bath. Which priorityaction will the nurse take
to decrease the potential for a health care-associated
infection?
a. Use local anesthetic on reddened areas.
b. Use nonallergenic tape on dressings.
c. Use a chlorhexidine wash.
d. Use filtered water.
The Centers for Disease Control and Prevention (CDC)
recommends the use of chlorhexidine (CHG) bathing for
patients in intensive care units, patients who are scheduled for
surgery, and all patients with invasive central line catheters as
part of MRSA reduction efforts. Using local anesthetics,
nonallergenic tape, and filtered water does not affect the cause
of a health care-associated infection by, for example,
decreasing microbial counts like a CHG bath.
17. The infection control nurse is reviewing data for the
medical-surgical unit. The nurse notices an increase in
postoperative infections from Aspergillus. Which type of
health care-associated infection will the nurse report?
a. Vector
b. Exogenous
c. Endogenous
d. Suprainfection
An exogenous infection comes from microorganisms found
outside the individual such as Salmonella, Clostridium tetani,
and Aspergillus. They do not exist as normal floras. A vector
transmits microorganisms and is usually a type of insect or
organism. Endogenous infection occurs when part of the
patient's flora becomes altered and an overgrowth results (e.g.,
staphylococci, enterococci, yeasts, and streptococci). This
often happens when a patient receives broad-spectrum
antibiotics that alter the normal floras. A suprainfection
develops when broad-spectrum antibiotics eliminate a wide
range of normal flora organisms, not just those causing
infection.
18. The patient has contracted a urinary tract infection (UTI)
while in the hospital. Which action will most likely increase
the risk of a patient contracting a UTI?
a. Reusing the patient's graduated receptacle to empty
the drainage bag.
b. Allowing the drainage bag port to touch the
graduated receptacle.
c. Emptying the urinary drainage bag at least once a
shift.
d. Irrigating the catheter infrequently.
Allowing the urinary drainage bag port to touch contaminated
items (graduated receptacle) may introduce bacteria into the
urinary system and contribute to a urinary tract infection. The
urinary drainage bag should be emptied at least once a shift.
Patients should have their own receptacle for measurement to
prevent cross-contamination. Repeated catheter irrigations
increase the chance so irrigating infrequently will be beneficial
in reducing the risk.
19. Which nursing action will most likely increase a patient's
risk for developing a health care-associated infection?
a. Uses surgical aseptic technique to suction an airway
b. Uses a clean technique for inserting a urinary
catheter
c. Uses a cleaning stroke from the urinary meatus
toward the rectum
d. Uses a sterile bottled solution more than once within
a 24-hour period
Using clean technique (medical asepsis) to insert a urinary
catheter would place the patient at risk for a health care-
associated infection. Urinary catheters need to be inserted
using sterile technique, which is also referred to as surgical
asepsis. Surgical aseptic technique (also called sterile
technique) should be used when suctioning an airway because
it is considered a sterile body cavity. Washing from clean to
dirty (urinary meatus toward rectum) is correct for decreasing
infection risk. Bottled solutions may be used repeatedly during
a 24-hour period; however, special care is needed to ensure
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that the solution in the bottle remains sterile. After 24 hours,
the solution should be discarded.
20. The nurse is caring for a patient in labor and delivery.
When near completing an assessment of the patient's
cervix, the electronic infusion device being used on the
intravenous (IV) infusion alarms. Which sequence of
actions is most appropriate for the nurse to take?
a. Complete the assessment, remove gloves, and
silence the alarm.
b. Discontinue the assessment, silence the alarm, and
assess the intravenous site.
c. Complete the assessment, remove gloves, wash
hands, and assess the intravenous infusion.
d. Discontinue the assessment, remove gloves, use
hand gel, and assess the intravenous infusion.
Completing the assessment while wearing gloves, removing
gloves, washing hands after contact with body fluids, and then
assessing the intravenous infusion will assist in the prevention
and transfer of any potential organisms to this intravenous line.
Completing the assessment, removing gloves, and silencing
the alarm leaves out the crucial step of decontaminating and
washing the hands. Discontinuing the assessment and
assessing the IV leaves out removing the gloves and
decontamination, as well as completing the assessment for the
patient. Discontinuing the assessment, removing gloves, using
hand gel, and assessing the IV is incorrect because upon
exposure to body fluids, washing hands is appropriate.
21. The nurse is dressed and is preparing to care for a patient
in the perioperative area. The nurse has scrubbed hands
and has donned a sterile gown and gloves. Which action
will indicate a break in sterile technique?
a. Touching clean protective eyewear
b. Standing with hands above waist area
c. Accepting sterile supplies from the surgeon
d. Staying with the sterile table once it is open
Touching nonsterile (clean) protective eyewear once gowned
and gloved with sterile gown and gloves would indicate a break
in sterile technique. Sterile objects remain sterile only when
touched by another sterile object. Standing with hands folded
on the chest is common practice and prevents arms and hands
from touching unsterile objects. Accepting sterile supplies from
the surgeon who has opened them with the appropriate
technique is acceptable. Staying with a sterile table once
opened is a common practice to ascertain that no one or
nothing has contaminated the table.
22. The nurse is caring for a patient with an incision. Which
actions will best indicate an understanding of medical and
surgical asepsis for a sterile dressing change?
a. Donning clean goggles, gown, and gloves to dress
the wound
b. Donning sterile gown and gloves to remove the
wound dressing
c. Utilizing clean gloves to remove the dressing and
sterile supplies for the new dressing
d. Utilizing clean gloves to remove the dressing and
clean supplies for the new dressing
Utilize clean gloves (medical asepsis) to remove contaminated
dressings and sterile supplies, including gloves and dressings
(surgical asepsis-sterile technique) to reapply sterile dressings.
Wearing sterile gowns and gloves is not necessary when
removing soiled dressings. Donning clean gloves to dress a
sterile wound would contaminate the sterile supplies. Utilizing
clean supplies for a sterile dressing would not help in
decreasing the number of microbes at the incision site.
23. The nurse is caring for a patient in the endoscopy area.
The nurse observes the technician performing these tasks.
Which observation will require the nurse to intervene?
a. Washing hands after removing gloves
b. Disinfecting endoscopes in the workroom
c. Removing gloves to transfer the endoscope
d. Placing the endoscope in a container for transfer
Standard precautions are used to prevent and control the
spread of infection. Transferring contaminated equipment
without the protection of gloves can assist in the spread of
microbes to inanimate objects and to the person doing the
transfer; therefore, the nurse must intervene. Utilizing gloves,
washing hands, covering contaminated supplies during
transfer, and disinfecting equipment in the appropriate way in
the appropriate places utilize principles of basic medical
asepsis and standard precautions and can break the chain of
infection.
24. The nurse is caring for a patient who is at risk for infection.
Which action by the nurse indicates correct understanding
about standard precautions?
a. Teaches the patient about good nutrition
b. Dons gloves when wearing artificial nails
c. Disposes an uncapped needle in the designated
container
d. Wears eyewear when emptying the urinary drainage
bag
Standard precautions include the wearing of eyewear
whenever there is a possibility of a splash or splatter, like when
emptying the urinary drainage bag. Teaching the patient about
good nutrition is positive but does not apply to standard
precautions. Standard precautions apply to contact with blood,
body fluid (except sweat), nonintact skin, and mucous
membranes from all patients. Artificial nails are not worn when
using standard precautions. Any needles should be disposed
of uncapped, or a mechanical safety device is activated for
recapping.
25. The nurse is caring for a patient who has just delivered a
neonate. The nurse is checking the patient for excessive
vaginal drainage. Which precaution will the nurse use?
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 a. Contact
b. Droplet
c. Standard
d. Protective environment
Standard precautions apply to contact with blood, body fluid,
nonintact skin, and mucous membranes of all patients. Contact
precautions apply to individuals with infections that can be
transmitted by direct or indirect contact. Protective environment
precautions apply to individuals who have undergone
transplantations and gene therapy. Droplet precautions focus
on diseases that are transmitted by large droplets.
26. The nurse is caring for a patient in the hospital. The nurse
observes the nursing assistive personnel (NAP) turning off
the handle faucet with bare hands. Which professional
practice principle supports the need for follow-up with the
NAP?
a. The nurse is responsible for providing a safe
environment for the patient.
b. Different scopes of practice allow modification of
procedures.
c. Allowing the water to run is a waste of resources and
money.
d. This is a key step in the procedure for washing
hands.
The nurse is responsible for providing a safe environment for
the patient. The effectiveness of infection control practices
depends on conscientiousness and consistency in using
effective aseptic technique by all health care providers. After
washing hands, turn off a handle faucet with a dry paper towel,
and avoid touching the handles with your hands to assist in
preventing the transfer of microorganisms. Wet towels and
hands allow the transfer of pathogens from faucet to hands.
The principles and procedures for washing hands are universal
and apply to all members of health care teams. Being
resourceful and aware of the cost of health care is important,
but taking shortcuts that may endanger an individual's health is
not a prudent practice.
27. The nurse is caring for a patient who becomes nauseated
and vomits without warning. The nurse has contaminated
hands. Which action is best for the nurse to take next?
a. Wash hands with an antimicrobial soap and water.
b. Clean hands with wipes from the bedside table.
c. Use an alcohol-based waterless hand gel.
d. Wipe hands with a dry paper towel.
The Centers for Disease Control and Prevention (CDC)
recommends that when hands are visibly soiled, one should
wash with a non-antimicrobial soap or with antimicrobial soap.
Cleaning hands with wipes or using waterless hand gel does
not meet this standard. If hands are not visibly soiled, use an
alcohol-based waterless antiseptic agent for routinely
decontaminating hands. Wiping hands with a dry paper towel
will occur after the nurse has washed both hands.
28. The nurse is performing hand hygiene before assisting a
health care provider with insertion of a chest tube. While
washing hands, the nurse touches the sink. Which action
will the nurse take next?
a. Inform the health care provider and recruit another
nurse to assist.
b. Rinse and dry hands, and begin assisting the health
care provider.
c. Extend the handwashing procedure to 5 minutes.
d. Repeat handwashing using antiseptic soap.
The inside of the sink and the edges of the sink, faucet, and
handles are considered contaminated areas. If the hands touch
any of these areas during handwashing, repeat the
handwashing procedure utilizing antiseptic soap. There is no
need to inform the health care provider or be relieved of this
assignment. If the hands are contaminated when touching the
sink, drying hands and proceeding with the procedure could
possibly contaminate and contribute to increased microbial
counts during the procedure, resulting in infection for the
patient. Extending the time for washing the hands (although
this is what will happen when the procedure is repeated) is not
the focus. The focus is to repeat the whole hand hygiene
procedure utilizing antiseptic soap.
29. The nurse on the surgical team and the surgeon have
completed a surgery. After donning gloves, gathering
instruments, and placing in the transport carrier, what is
the next step in handling the instruments used during the
procedure?
a. Sending to central sterile for cleaning and
sterilization
b. Sending to central sterile for cleaning and
disinfection
c. Sending to central sterile for cleaning and boiling
d. Sending to central sterile for cleaning
Surgical instruments need to be cleaned and sterilized.
Disinfecting, boiling, or cleaning is not utilized on critical items
that will be reused on patients in the hospital environment.
Items that are used on sterile tissue or in the vascular system
present a high risk of infection if they become contaminated
with bacteria.
30. The nurse is observing a family member changing a
dressing for a patient in the home health environment.
Which observation indicates the family member has a
correct understanding of how to manage contaminated
dressings?
a. The family member places the used dressings in a
plastic bag.
b. The family member saves part of the dressing
because it is clean.
c. The family member removes gloves and gathers
items for disposal.
d. The family member wraps the used dressing in toilet
tissue before placing in trash.
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Contaminated dressings and other infectious, disposable items
should be placed in impervious plastic or brown paper bags
and then disposed of properly in garbage containers. Gloves
should be worn during this process. Parts of the dressing
should not be saved, even though they may seem clean,
because microbes may be present.
31. The nurse is caring for a group of patients. Which patient
will the nurse see first?
a. A patient with Clostridium difficile in droplet
precautions
b. A patient with tuberculosis in airborne precautions
c. A patient with MRSA infection in contact precautions
d. A patient with a lung transplant in protective
environment precautions
A patient with Clostridium difficile should be on contact
precautions, not droplet; therefore, the nurse will see this
patient first to correct the precautions. All the rest are on
correct precautions. Patients with tuberculosis belong in
airborne precautions; patients with MRSA infection belong in
contact precautions; and patients with lung transplants belong
in protective environment precautions.
32. The surgical mask the perioperative nurse is wearing
becomes moist. Which action will the perioperative nurse
take next?
a. Apply a new mask.
b. Reapply the mask after it air-dries.
c. Change the mask when relieved by next shift.
d. Do not change the mask if the nurse is comfortable.
After the mask is worn for several hours, it can become moist.
The mask should be changed as soon as possible because
moisture does not provide a barrier to microorganisms and is
ineffective. Waiting to change the mask, air-drying it, or
wearing it because it is comfortable does not support the
principles of infection control.
33. The nurse is caring for a patient on contact precautions.
Which action will be most appropriate to prevent the
spread of disease?
a. Place the patient in a room with negative airflow.
b. Wear a gown, gloves, face mask, and goggles for
interactions with the patient.
c. Transport the patient safely and quickly when going
to the radiology department.
d. Use a dedicated blood pressure cuff that stays in the
room and is used for that patient only.
Contact precautions are a type of isolation precaution used for
patients with illness that can be transmitted through direct or
indirect contact. Patients who are on contact precautions
should have dedicated equipment wherever possible. This
would mean, for example, that one blood pressure cuff and
one stethoscope would stay in the room with the patient and
would be used for that patient only. A gown and gloves may be
required for interactions with a patient who is on contact
precautions. A face mask and goggles are not part of contact
precautions. A room with negative airflow is needed for
patients placed on airborne precautions; it is not necessary for
a patient on contact precautions. When a patient on contact
precautions needs to be transported, the patient should wear
clean gown, and hands cleaned, and the infectious material is
contained or covered.
34. The nurse is caring for a patient who has cultured positive
for Clostridium difficile. Which action will the nurse take
next?
a. Instruct assistive personnel to use soap and water
rather than sanitizer.
b. Wear an N95 respirator when entering the patient
room.
c. Place the patient on droplet precautions.
d. Teach the patient cough etiquette.
Clostridium difficile is a spore-forming organism that can be
transmitted through direct and indirect patient contact.
Because Clostridium difficile is a spore-forming organism, hand
sanitizer is not effective in preventing its transmission. Hands
must be washed with soap and water to prevent transmission.
This organism is not transmitted via the droplet route;
therefore, droplet precautions are not needed. An N95
respirator is used primarily for patients with airborne illness,
especially tuberculosis. While all patients should be taught
cough etiquette, this action is not specifically related to the
patient having Clostridium difficile.
35. The nurse is changing linens for a postoperative patient
and feels a prick in the left hand. A nonactivated safe
needle is noted in the linens. For which condition is the
nurse most at risk?
a. Diphtheria
b. Hepatitis B
c. Clostridium difficile
d. Methicillin-resistant Staphylococcus aureus
Bloodborne pathogens such as those associated with hepatitis
B and C are most commonly transmitted by contaminated
needles. Clostridium difficile and MRSA are spread by contact.
Diphtheria is spread by droplets when one is within 3 feet of
the patient.
36. The nurse is caring for a patient who has a bloodborne
pathogen. The nurse splashes blood above the glove to
intact skin while discontinuing an intravenous (IV) infusion.
Which step(s) will the nurse take next?
a. Obtain an alcohol swab, remove the blood with an
alcohol swab, and continue care.
b. Immediately wash the site with soap and running
water, and seek guidance from the manager.
c. Do nothing; accidentally getting splashed with blood
happens frequently and is part of the job.
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 d. Delay washing of the site until the nurse is finished
providing care to the patient.
After getting splashed with blood from a patient who has a
known bloodborne pathogen, it is important to cleanse the site
immediately and thoroughly with soap and running water and
notify the manager for guidance on next steps in the process.
Removing the blood with an alcohol swab, delaying washing,
and doing nothing because the splash was to intact skin could
possibly spread the blood within the room and could spread
the infection. Contain contamination immediately to prevent
contact spread.
37. Which process will be required after exposure of a nurse
to blood by a cut from a used scalpel in the operative
area?
a. Placing the scalpel in a needle safe container
b. Testing the patient and offering treatment to the
nurse
c. Removing sterile gloves and disposing of in kick
bucket
d. Providing a medical evaluation of the nurse to the
manager
Follow-up for risk of infection begins with patient testing.
Patients should be tested for HIV and hepatitis B and C.
Testing of the nurse is dependent on the results of patient
testing; if the patient is positive for one of these infections, the
nurse will be started on testing and treatment. Removing sterile
gloves and placing sharps in appropriate containers are always
part of the perioperative process and are not the process for
postexposure. A confidential medical evaluation is provided to
the nurse, not the manager.
38. The nurse is caring for a patient who needs a protective
environment. The nurse has provided the care needed
and is now leaving the room. In which order will the nurse
remove the personal protective equipment, beginning with
the first step?
1 - Remove eyewear/face shield and goggles.
2 - Perform hand hygiene, leave room, and close door.
3 - Remove gloves.
4 - Untie gown, allow gown to fall from shoulders, and do not
touch outside of gown; dispose of properly.
5 - Remove mask by strings; do not touch outside of mask.
6 - Dispose of all contaminated supplies and equipment in
designated receptacles.
a. 3, 1, 4, 5, 6, 2
b. 1, 4, 5, 3, 6, 2
c. 1, 4, 5, 3, 2, 6
d. 3, 1, 4, 5, 2, 6
The correct order for removing personal protective equipment
for a patient in a protective environment and for performing
associated tasks is to remove gloves, remove eyewear,
remove gown, remove mask, perform hand hygiene, leave
room and close doors, and dispose of all contaminated
supplies and equipment in a manner that prevents the spread
of microorganisms.
39. The nurse is caring for a patient in protective environment.
Which actions will the nurse take? (Select all that apply.)
a. Wear an N95 respirator when entering the patient's
room.
b. Maintain airflow rate greater than 12 air
exchanges/hr.
c. Place in special room with negative-pressure airflow.
d. Open drapes during the daytime.
e. Listen to the patient's interests.
f. Place dried flowers in a plastic vase.
This form of isolation requires a specialized room with positive
airflow. The airflow rate is set at greater than 12 air
exchanges/hr, and all air is filtered through a HEPA filter.
Isolation disrupts normal social relationships with visitors and
caregivers. Take the opportunity to listen to a patient's
concerns or interests. Open drapes or shades and remove
excess supplies and equipment. Patients are not allowed to
have dried or fresh flowers or potted plants in these rooms. All
health care personnel wear an N95 respirator every time they
enter the room for patients, and a private room with negative
airflow is required for patients on airborne precautions.
40. The nurse is assessing a new patient admitted to home
health. Which questions will be mostappropriate for the
nurse to ask to determine the risk of infection? (Select all
that apply.)
a. "Can you explain the risk for infection in your home?"
b. "Have you traveled outside of the United States?"
c. "Will you demonstrate how to wash your hands?"
d. "What are the signs and symptoms of infection?"
e. "Are you able to walk to the mailbox?"
f. "Who runs errands for you?"
In the home setting, the objective is that the patient and/or
family will utilize proper infection control techniques. Asking the
patient and family about handwashing, risk of infection, recent
travel, and signs and symptoms of infection is important in
evaluating the patient's knowledge based on infection control
strategies. Activity assessment is important for evaluation of
the overall status of the patient, and knowing who runs errands
gives you information on who is helping to meet the needs of
the patient, but neither of these relates to decreasing the risk of
infection.
41. The circulating nurse in the operating room is observing
the surgical technologist while applying a sterile gown and
gloves to care for a patient having an appendectomy.
Which behaviors indicate to the nurse that the procedure
by the surgical technologist is correct? (Select all that
apply.)
a. Ties the back of own gown
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 b. Touches only the inside of gown
c. Slips arms into arm holes simultaneously
d. Extended fingers fully into both of the gloves
e. Uses hands covered by sleeves to open gloves
f. Applies surgical cap and face mask in the operating
suite
To maintain sterility, the surgical technologist (ST) touches the
inside of the gown that will be against the body. Arms are
slipped simultaneously into the gown to prevent contamination.
Using the sleeves covering the hands maintains the principle of
sterile only touching sterile to open gloves. Extending the
fingers fully into both gloves ensures that the ST has full
dexterity while using the sterile gloved hand. Surgical cap, face
mask, and eye wear are applied before entering the surgical
area and completing the surgical scrub. Reaching behind to tie
the back of the gown will contaminate the sterile area of the
gown.
42. The nurse is preparing to insert a urinary catheter. The
nurse is using open gloving to apply the sterile gloves.
Which steps will the nurse take? (Select all that apply.)
a. While putting on the first glove, touch only the
outside surface of the glove.
b. With gloved dominant hand, slip fingers underneath
second glove cuff.
c. Remove outer glove package by tearing the package
open.
d. Lay glove package on clean flat surface above
waistline.
e. Glove the dominant hand of the nurse first.
f. After second glove is on, interlock hands.
Sterile objects held below the waist are considered
contaminated. Gloving the dominant hand helps to improve
dexterity. Slipping the fingers underneath the second glove cuff
helps to keep the gloved fingers sterile. Interlocking fingers
ensures a smooth fit over the fingers. Sterile supplies are
opened by carefully separating and peeling apart the sides of
the package. This prevents the sterile contents from
accidentally opening and touching contaminated objects. While
putting on the first glove, touching only the outside surface of
the glove will contaminate the sterile item; touch only the inside
of the glove—the piece that will be against the skin.
43. The nurse has received a report from the emergency
department that a patient with tuberculosis will be coming
to the unit. Which items will the nurse need to care for this
patient? (Select all that apply.)
a. Private room
b. Negative-pressure airflow in room
c. Surgical mask, gown, gloves, eyewear
d. N95 respirator, gown, gloves, eyewear
e. Communication signs for droplet precautions
f. Communication signs for airborne precautions
Caring for this patient requires a private room, negative-
pressure airflow in room, and wearing an N95 respirator that
has been fit-tested, gloves, gown, and eyewear. Tuberculosis
is a disease that is transmitted by droplets that remain in the
air for long periods of time, requiring airborne precautions. This
patient will not be in droplet precautions and instead requires
airborne precaution signs. This type of patient requires more
than the average surgical mask for protection.
44. The nurse and the student nurse are caring for two
different patients on the medical-surgical unit. One patient
is in airborne precautions, and one is in contact
precautions. The nurse explains to the student different
interventions for care. Which information will the nurse
include in the teaching session? (Select all that apply.)
a. Dispose of supplies to prevent the spread of
microorganisms.
b. Wash hands before entering and leaving both of the
patients' rooms.
c. Be consistent in nursing interventions since there is
only one difference in the precautions.
d. Apply the knowledge the nurse has of the disease
process to prevent the spread of microorganisms.
e. Have patients in airborne precautions wear a mask
during transportation to other departments.
f. Check the working order of the negative-pressure
room for the airborne precaution patient on
admission and at discharge.
Washing hands, properly disposing of supplies, applying
knowledge of the disease process, and having patients in
airborne precautions wear a mask during transfer are all
principles to follow when caring for patients in isolation.
Multiple differences are evident among these types of isolation,
including the type of room used for the patient and what the
nurse wears while caring for the patient. It is important to check
the working order of a negative-pressure room before admitting
a patient to the room, each shift the patient is in the room, and
if and when the device alarms. Checking the working order of
the negative-pressure rooms at discharge is not necessary.
Source: https://quizlet.com/315487013/fundamentals-chapter-29-infection-
prevention-and-control-flash-cards/
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