Deck 31: Asepsis

Question 1

The nurse is setting up a sterile field.Which action by the nurse best exhibits surgical asepsis?

A)Disinfecting an item before adding it to a sterile field
B)Allowing sterile gloved hands to fall below the waist
C)Suctioning the oral cavity of an unconscious client
D)Touching only the inside surface of the first glove while pulling it onto the hand

Answer 1

Touching only the inside surface of the first glove while pulling it onto the hand

Question 2

The nurse is preparing to remove soiled gloves.What action should the nurse take first?

A)Drop the gloves into the appropriate waste receptacle.
B)Ease the fingers into the gloves.
C)Grasp the outside of the nondominant glove.
D)Hook the bare thumb inside the other glove.

Answer 2

Grasp the outside of the nondominant glove.

Question 3

The nurse is concerned that a break occurred in a sterile field.Which action occurred that caused this break?

A)Grasping the edge of the outermost flap and opening it away from oneself
B)Keeping objects on the field 1 inch from the edge
C)Keeping the sterile field in eyesight
D)Transferring a sterile object to a sterile field with a clean gloved hand

Answer 3

Transferring a sterile object to a sterile field with a clean gloved hand

Question 4

An older client with gallbladder disease has had a cholecystectomy.Which factor should the nurse realize would influence the development of an infection in this client?

A)Active bowel sounds
B)Dry intact skin
C)Intact mucous membranes
D)Susceptibility of the client

Question 5

The nurse wants to protect a client from developing an infection.Which action should the nurse take to break a link in the chain of infection?

A)Cover the mouth and nose when sneezing.
B)Place contaminated linens in a paper bag.
C)Use personal protective equipment (PPE)sparingly.
D)Wear gloves at all times.

Question 6

A patient is diagnosed with a systemic infection.What will the nurse most likely assess in this client?

A)Edema,rubor,heat,and pain
B)Fever,malaise,anorexia,nausea,and vomiting
C)Palpitations,irritability,and heat intolerance
D)Tingling,numbness,and cramping of the extremities

Question 7

The nurse is preparing discharge teaching for a client recovering from surgery.What instruction is the most important for the nurse to give this client who has a surgical wound?

A)Adjust the diet so it contains more fruits and vegetables.
B)Apply lubricating lotion to the edges of the wound.
C)Notify the physician of any edema,heat,or tenderness at the wound site.
D)Thoroughly irrigate the wound with hydrogen peroxide.

Question 8

The nurse is caring for a client with hepatitis A.Which technique should the nurse use to promote proper hand-washing technique with this client?

A)Allow the water to splatter forcibly when it is turned on.
B)Clean the faucet after use.
C)Hold the hands upward under the faucet.
D)Use approximately a teaspoon of soap.

Question 9

A client diagnosed with tuberculosis is being admitted to a care area.Which nursing action prevents the transmission of the disease?

A)Have the client wear a mask when coming from admission.
B)Stock the supply cart at the beginning of each shift.
C)Wash the hands only after leaving the room.
D)Wear a mask when exiting the room.

Question 10

The nurse is reviewing the care needs for a group of assigned clients.Which client should the nurse recognize as being most at risk for a nosocomial infection?

A)A client in the emergency department with abdominal pain
B)A 19-year-old woman in her first trimester of pregnancy
C)A 72-year-old male client with COPD
D)An 86-year-old female client on steroid therapy

Question 11

The nurse is preparing to leave a client's isolation room.Which action should the nurse take first when removing a grossly soiled gown?

A)Grasp the sleeve of the dominant arm,and remove it with a gloved hand.
B)Release the neck ties of the gown and allow the gown to fall forward.
C)Untie the strings at the neck first.
D)Untie the strings at the waist first.

Question 12

The nurse is preparing a presentation on standard precautions.Which statement should the nurse include in the presentation?

A)Cut the needle off a syringe after using it to give a client an injection.
B)Dispose of blood-contaminated materials in a biohazard container.
C)Gloves should not be worn for client care unless body fluids are seen.
D)Wear a mask when in direct contact with all clients.

Question 13

A client needs to be placed in contact isolation.What items should the nurse ensure are included in this client's room?

A)Cabinet stocked with gloves and gowns
B)Cards and records
C)Paper towels,sink,and blood pressure cuff
D)Sign on the door

Question 14

The nurse is using medical asepsis when providing client care.Which action did the nurse demonstrate?

A)Administering parenteral medications
B)Changing a dressing
C)Performing a urinary catheterization
D)Using personal protective equipment

Question 15

The nurse is planning care for a client.Which intervention would be appropriate to reduce the risk of infection?

A)Assess vital signs only once daily.
B)Raise the temperature in the client's room.
C)Wash hands.
D)Wear a mask for all client care.

Question 16

The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a client's room.What action should the nurse take first for this puncture wound?

A)Complete an injury report.
B)Encourage bleeding.
C)Initiate first aid.
D)Wash the area with soap and water.

Question 17

A client was bitten by a rabid raccoon.What care should the nurse prepare to provide to this client?

A)A tetanus toxoid injection
B)An immunization for rabies
C)An injection of immunoglobulin
D)Mother's breast milk with antibodies in it

Question 18

The nurse determines that a client has active immunity to a microorganism.What did the nurse assess that caused the client to develop this type of immunity?

A)Becoming ill with tetanus and receiving tetanus toxoid
B)Having chickenpox
C)Receiving a rabies shot after being bitten by a rabid dog
D)Receiving an injection of gamma globulin

Question 19

The nurse is removing personal protective equipment.Which nursing action demonstrates the appropriate technique for removing a mask?

A)Bend the strip at the top of the mask.
B)Loop the ties over the ears.
C)Tie the strings in a bow.
D)Touch the mask by the strings only.

Question 20

The nurse is reviewing collected data from a client.Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms?

A)Heavy smoking
B)Moisturizing the skin
C)Breakdown of skin
D)Voiding quantity sufficient

Question 21

A client is being discharged after a surgical procedure.On what should the nurse instruct the client to reduce the risk of infection?
Standard Text: Select all that apply.

A)Hand-washing technique
B)The importance of adequate nutrition
C)Covering the mouth and nose when coughing or sneezing
D)Increasing contact with others
E)Restricting rest period

Question 22

A client is diagnosed with a communicable disease,and must be placed in isolation.The nurse should identify which diagnosis as a priority for this client?

A)Social Isolation
B)Anxiety
C)Acute Pain
D)Imbalanced Nutrition: Less Than Body Requirements

Question 23

The nurse needs to apply personal protective equipment before entering a client's room.In which order should the nurse perform the following actions?
Standard Text: Place the steps in the order in which they should be performed.

A)Apply gloves.
B)Apply eyewear.
C)Apply the gown.
D)Apply the face mask.
E)Perform hand hygiene.

Question 24

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home.What diagnosis should the nurse select as a priority for this client?

A)Anxiety
B)Acute Pain
C)Social Isolation
D)Low Self-Esteem

Question 25

The nurse is reviewing the agents available to disinfect the hands after providing client care.Which agents should the nurse consider using?
Standard Text: Select all that apply.

A)Triclosan
B)Chlorine (bleach)
C)Isopropyl alcohol
D)Hydrogen peroxide
E)Chlorhexidine gluconate

Question 26

A client in isolation ambulates with assistance to the bathroom.After toileting,what should the unlicensed assistive personnel do?

A)Assist the client with hand washing.
B)Assist the client back to bed.
C)Change the client's bed.
D)Leave the client's room.

Question 27

A client diagnosed with an infectious disease asks the nurse how the infection "got inside" her body.Which responses would be appropriate for the nurse to make?
Standard Text: Select all that apply.

A)"It depends on the number of organisms present to cause a disease."
B)"It depends on how aggressive the organisms are to cause a disease."
C)"It depends upon how the organisms get inside the body to cause a disease."
D)"It depends upon where the person is at the time the disease is present."
E)"It depends upon where the person works."

Question 28

The nurse is concerned that a client is at risk for a nosocomial infection.What did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.

A)Client is receiving intravenous fluids.
B)Client has an indwelling urinary catheter.
C)Client is recovering from surgery.
D)Client is receiving pain medication.
E)Client is ambulating twice a day with assistance.

Question 29

The nurse determines that a client has adequate physiological barriers to defend the body against infection.What did the nurse assess in this client?
Standard Text: Select all that apply.

A)Intact and dry skin
B)Intact oral mucous membranes
C)Bowel sounds present in all four quadrants
D)Nasal congestion
E)Urinary retention

Question 30

While irrigating a client's abdominal wound,the irrigate splashes into the nurse's nose and eyes.What should the nurse do?

A)Flush the nose and eyes for 5 to 10 minutes with water or normal saline.
B)Begin HIV high-risk exposure prophylaxis within 24 hours.
C)Wash the areas with soap and water.
D)Have blood drawn for hepatitis B antibodies.