NCLEX Questions Chapter 23: Asepsis Infection Control

NCLEX Questions Chapter 23: Asepsis & Infection Control

4.6 (25 reviews) Students also studied Terms in this set (15) Science MedicineNursing Save CH 29 Infection Prevention and Con...16 terms jennfasPreview Vital Signs Practice for NCLEX Ques...15 terms lizzyohmesPreview Skin Integrity & Wound Care - NCLE...21 terms P4542Preview Fundam 63 terms tay A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines?

• The nurse carries the patients' soiled bed linens close

to the body to prevent spreading microorganisms into the air.

• The nurse places soiled bed linens and hospital gowns

on the floor when making the bed.

• The nurse moves the patient table away from the

nurse's body when wiping it off after a meal.

• The nurse cleans the most soiled items in the patient's

bathroom first and follows with the cleaner items.

• The nurse moves the patient table away from the nurse's body when wiping it

off after a meal.A school nurse is performing an assessment of a student

who states: "I'm too tired to keep my head up in class."

The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection?

• Incubation period
• Prodromal stage
• Full stage of illness
• Convalescent period
• Prodromal

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol- based handrub to decontaminate the hands? Select all that apply.

• The nurse is providing a bed bath for a patient.
• The nurse has visibly soiled hands after changing the

bedding of a patient.

• The nurse removes gloves when patient care is

completed.

• The nurse is inserting a urinary catheter for a female

patient.

• The nurse is assisting with a surgical placement of a

cardiac stent.

• The nurse removes old magazines from a patient's

table.

• The nurse is providing a bed bath for a patient.
• The nurse removes old magazines from a patient's table.
• The nurse is inserting a urinary catheter for a female patient
• The nurse removes gloves when patient care is completed

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled.Which steps in this procedure are performed correctly?Select all that apply.

• The nurse removes all jewelry including a platinum

wedding band.

• The nurse washes hands to one inch above the wrists.
• The nurse uses approximately two teaspoons of liquid

soap.

• The nurse keeps hands higher than elbows when

placing under faucet.

• The nurse uses friction motion when washing for at

least 15 seconds.

• The nurse rinses thoroughly with water flowing toward

fingertips.all except D (keeping hands higher than elbows under faucet; dirty water would run down your arms) and A The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a

procedure that requires surgical asepsis. The nurse must:

• Keep splashes on the sterile field to a minimum.
• Cover the nose and mouth with gloved hands if a

sneeze is imminent.

• Use forceps soaked in a disinfectant.
• Consider the outer 1 inch of the sterile field as

contaminated.

• Consider the outer 1 inch of the sterile fielda s contaminated

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?

• Only patients with diagnosed infections
• Only patients with visible blood, body fluids, or sweat
• Only patients with nonintact skin
• All patients receiving care in hospitals
• all patients receiving care in hospitals

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply.

• A patient diagnosed with rubella
• A patient diagnosed with diptheria
• A patient diagnosed with varicella
• A patient diagnosed with tuberculosis
• A patient diagnosed with MRSA
• An infant diagnosed with adenovirus infection
• A patient diagnosed with rubella
• A patient diagnosed with diptheria
• An infant diagnosed with adenovirus infection

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation?

• Ask another nurse to hold the hand of the patient and

continue setting up the field.

• Remove the instrument that was touched by the patient

and continue setting up the sterile field.

• Discard the supplies and prepare a new sterile field

with another person holding the patient's hand.

• No action is necessary since the patient has touched

his or her own sterile field.

• Discard the supplies and prepare a new sterile field with another person

holding the patient's hand.A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task?

• Place the bottle cap on the table with the edges

down.

• Hold the bottle inside the edge of the sterile field.
• Hold the bottle with the label side opposite the palm

of the hand.

• Pour the solution from a height of 4 to 6 inches (10 to

15 cm).

• Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?

• Remove gown, goggles, mask, gloves, and exit the

room.

• Remove gloves, perform hand hygiene, then remove

gown, mask, and goggles.

• Untie gown waiststrings, remove gloves, goggles,

gown, mask; perform hand hygiene.

• Remove goggles, mask, gloves, gown, and perform

hand hygiene.

• Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand

hygiene.

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the priority action of the nurse following the exposure?

• Report the incident to the appropriate person and file

an incident report.

• Wash the exposed area with warm water and soap.
• Consent to postexposure prophylaxis at appropriate

time.

• Set up counseling sessions regarding safe practice to

protect self.

• Wash the exposed area with warm water and soap.

The nurse assesses patients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection?

• A 60-year-old patient who smokes two packs of

cigarettes daily

• A 40-year-old patient who has a white blood cell count

of 6,000/mm3

• A 65-year-old patient who has an indwelling urinary

catheter in place

• A 60-year-old patient who is a vegetarian and slightly

underweight

• A 65-year-old patient who has an indwelling urinary catheter in place

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient?

A. Imbalanced Nutrition: More Than Body Requirements

related to immobility

• Impaired Physical Mobility related to pain and

discomfort

• Chronic Pain related to immobility
• Risk for Infection related to altered skin integrity
• Risk for Infection related to altered skin integrity

A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is

considered:

• The nurse's preference
• Safe for the home setting
• Unethical behavior
• Grossly negligent
• Safe for the home setting