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Chapter 28: Infection Prevention and Control

Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a patient with pneumonia with a new nurse in orientation. Which of the

following statements by the new nurse would indicate an understanding of the nature 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 negative pressure room.
c. The patient will not be able to return home.
d. Clinical signs and symptoms are not present in pneumonia.
ANS: A

Infections are infectious 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 diseasea disease that is transmitted directly from one individual to the next;
so there is no need for isolation. Clinical signs and symptoms are present in pneumonia and
include but are not limited to elevated temperature, shortness of breath, fatigue, and coughing;
in addition, the patient may have rhonchi and crackles upon auscultation. Frequently, patients
with pneumonia do return home unless there are extenuating circumstances.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 399-401


Explain the relationship between the chain of infection and transmission of infection.
Evaluation
Safe and Effective Care Environment: Patient Safety and Infection Control

2. The patient and the nurse are discussing Rickettsia rickettsiiRocky Mountain spotted fever.

Which patient statement to the nurse indicates understanding regarding the mode of
transmission of this disease?
a. When I go camping, I will be sure to wear sunscreen.
b. When I go camping, I will drink bottled water.
c. When I go camping, I will be sure to wear insect repellent.
d. When I go camping, I will be sure to use hand gel on my hands.
ANS: C

Each infectious disease has a specific mode of transmissiona component of the chain of
infection. 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.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 399-401


Explain the relationship between the chain of infection and transmission of infection.
Evaluation
Safe and Effective Care Environment: Patient Safety and Infection Control

3. The nurse is providing an educational session for a group of preschool workers. The nurse

reminds the group that the most important thing to do to prevent the spread of infection is to
Encourage preschool children to eat a nutritious diet.
Encourage parents to provide a multivitamin to the children.
Clean the toys every afternoon before putting them away.
Wash their hands between each interaction with children.

a.
b.
c.
d.

ANS: D

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, as well as after cleaning toys or tables, after picking up after the children, 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 physician, 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.
DIF:
OBJ:
TOP:
MSC:

Remember
REF: 399-401
Give an example of preventing infection for each element of the infection chain.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

4. The nurse is admitting a patient with an infectious disease process. What question would be

appropriate for a nurse to ask this patient?


Do you have a chronic disease, and how long have you had it?
Do you have any children living in the home?
What is your marital statussingle, married, or divorced?
Do you have any cultural or religious beliefs that will influence your care?

a.
b.
c.
d.

ANS: A

Some factors increase the susceptibility of an individual to acquire an infection. These include
age, nutritional status, presence of chronic disease, trauma, and smoking. The other questions
are part of an admission assessment process but are not pertinent to the infectious disease
process.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 399-401| 404-405


Give an example of preventing infection for each element of the infection chain.
Assessment
Safe and Effective Care Environment: Patient Safety and Infection Control

5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep.

Two days postoperatively, the nurses assessment indicates that the incision is red and has a
small amount of purulent drainage. The patient reports tenderness at the incision site. The
patients temperature is 100.5 F and the WBC is 10,500/mm3. Which nursing action should
the nurse take?
a. Plan to change the surgical dressing during the shift.
b. Check to see what solution was used for skin preparation in surgery.
c. Collect supplies to culture the surgical incision.
d. Utilize SBAR to call and communicate the patients needs to the physician.
ANS: D

Organisms enter the body in several different ways. Proper skin preparation for surgery is
essential to decrease the chance of infection. The nursing assessment indicates signs and
symptoms of infection. The physician needs to be called and notified of the patients needs.
SBARSituation, Background, Assessment, and Recommendationcan be utilized to
organize thoughts and data and to provide a through explanation of the patients current status.
Changing the dressing may be a need during the shift but is not a first priority. Checking to
see about the skin prep used 2 days ago may or may not be useful information at this time.
Collecting supplies for culture may be necessary after talking with the physician.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 400-401
Give an example of preventing infection for each element of the infection chain.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

6. The nurse is providing an education session to an adult community group about the effects of

smoking. Which of the following is the most important point to be included 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 tobacco products can be very expensive.
d. Smoking can affect the color of the patients fingernails.
ANS: B

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 patients 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 patients nails. This information can be included in the
education but does not constitute the most important point.
DIF: Understand REF: 401-403
OBJ: Identify the bodys normal defenses against infection.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
7. A female adult patient presents to the clinic with reports of a white discharge and itching in

the vaginal area. During the health history, which of these questions should the nurse
prioritize?
a. When was the last time you visited the physician?
b. Has this condition affected your eating habits?
c. What medications are you currently taking?
d. Are you able to sleep at night?
ANS: C

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. This inhibits the growth of many microorganisms.
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. Visiting the physician is
important for the patients health maintenance. Learning about the patients eating and
sleeping habits will assist in the plan of care.
DIF: Apply
REF: 401-403
OBJ: Identify the bodys normal defenses against infection.
TOP: Assessment
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
8. The nurse is caring for a school-aged child who has injured his leg after a bicycle accident. To

determine whether the child is experiencing a localized inflammatory response, the nurse
should assess for which of these signs and symptoms?
a. Fever, malaise, anorexia, and nausea and vomiting
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
ANS: D

The bodys cellular response to an injury is seen as inflammation. Inflammation can be


triggered by physical agents, chemical agents, or microorganisms. 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 nausea and vomiting. 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.
DIF: Remember
REF: 402-403
OBJ: Discuss the events in the inflammatory response.
TOP: Assessment
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
9. Which interventions utilized by the nurse would indicate the ability to recognize the

inflammatory response?
Rest, ice, compression, and elevation
Turn, cough, and deep breathe
Orient to date, time, and place
Passive range-of-motion exercises

a.
b.
c.
d.

ANS: A

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 extremityand elevating the injured area will help to decrease swelling
or edema. Turn, cough, and deep breathe is 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. Passive range of motion is utilized for individuals who need to improve
movement of their extremities, including immobilized patients.

DIF: Understand REF: 402-403


OBJ: Discuss the events in the inflammatory response.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
10. The nurse is caring for a group of medical-surgical patients. The patient most at risk for

developing an infection is the patient who


a. Is in observation for chest pain.
b. Is recovering from a right total hip arthroplasty.
c. Has been admitted with dehydration.
d. Has been admitted for stabilization of atrial fibrillation.
ANS: B

The patient who is recovering from a right total hip arthroplasty has had a surgical procedure
wherein bone was removed from the body and an implant was placed within the patient. The
patient has a large incision from surgery. The patient also has an intravenous infusion to
provide fluids and medication. All these breaks in the skin increase the likelihood of infection.
The patient has had anesthesia and medication for pain. Both of these depress the respiratory
system and have the potential to decrease the expansion of alveoli and to increase the chance
of infection in the respiratory system. The other patients may have one break in the skin when
an intravenous infusion is used.
DIF: Apply
REF: 403-404
OBJ: Identify patients most at risk for infection.
TOP: Assessment
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a

vascular access device. Which nursing intervention is priority in this procedure?


Position the patient comfortably.
Maintain aseptic technique.
Gather available supplies.
Review the procedure with the patient.

a.
b.
c.
d.

ANS: B

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. It is priority that anytime an
intravenous device is accessed, aseptic technique must be maintained with wearing of
appropriate personal protective equipment, preparation of the skin, and use of sterile gloves,
sterile supplies, appropriate flushing, and appropriate discontinuation. 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.
DIF: Apply
REF: 404-405
OBJ: Identify patients most at risk for infection.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
12. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of

flooding. The patient presents with signs and symptoms of a urinary tract infection. Along
with needed education surrounding this diagnosis, the nurse teaches the patient about rest,
exercise, eating properly, and how to utilize deep breathing and visualization. Which of these
explanations would best support these nursing interventions?

a. Urinary tract infections are painful, and these techniques would help with

managing the pain.


b. Interventions listed are standard topics taught during health care visits.
c. Stress for long periods of time can lead to exhaustion and decreased resistance to

infection.
d. The patient requested this information to teach to extended family at home.
ANS: C

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 the interventions listed are not all
standard interventions taught at every health care visit.
DIF: Analyze
REF: 405
OBJ: Identify patients most at risk for infection.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
13. The nurse is caring for a patient who is susceptible to infection. Which of the following

nursing interventions will assist in decreasing the risk of infection?


Teaching the patient about fall prevention
Teaching the patient to select nutritious foods
Teaching the patient to take a temperature
Teaching the patient about the effects of alcohol

a.
b.
c.
d.

ANS: B

When protein intake is inadequate as a result of poor diet, the rate of protein breakdown
exceeds that of tissue synthesis. A reduction in the intake of protein and other nutrients such as
carbohydrates and fats reduces the bodys defenses against infection and impairs wound
healing. Teaching the patient about fall prevention, how to take a temperature, or about the
effects of alcohol does not decrease the risk of infection.
DIF: Apply
REF: 405
OBJ: Identify patients most at risk for infection.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
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 of these interventions would be most
appropriate for the nurse to provide?
a. Position the patient comfortably on the stretcher.
b. Explain the procedure for dressing change to the patient.
c. Don gloves and other appropriate personal protective equipment.
d. Review the medication list that the patient brought from home.
ANS: C

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. Positioning the patient, explaining the
procedure, and reviewing the medication list are all tasks that need to be completed, but
preventing the spread of infection takes precedence.
DIF: Apply

REF: 406

OBJ: Describe the signs/symptoms of a localized infection and those of a systemic infection.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
15. Which of these interventions would take priority and should be included in a plan of care for a

patient who presents with pneumonia?


a. Observe the patient for decreased activity tolerance.
b. Assume that the patient is in pain and treat accordingly.
c. Maintain the temperature at 65 F.
d. Provide the patient ice chips as requested.
ANS: A

Systemic infection 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 patients level of activity and responsiveness. Respiratory infection may result in a
productive cough with purulent sputum, shortness of breath, and activity intolerance. Nurses
do not assume but assess and communicate with the patient about pain, temperature, and ice
chips. Asking these questions would not be a priority as much as assessing the patient and
determining the effect that the systemic infection is having on the patient.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 405-406


Describe the signs/symptoms of a localized infection and those of a systemic infection.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

16. The nurse is inserting a peripherally inserted central catheter (PICC) into the patient. Aware of

the potential for health careassociated infection, the nurse is careful to


Prepare the skin with 2% chlorhexidine gluconate.
Select a catheter of appropriate size for the appropriate vein.
Use nonallergenic tape and dressings on the patient.
Utilize local anesthetic on the site as ordered.

a.
b.
c.
d.

ANS: A

One of the sites for health careassociated infection is the bloodstream. Bloodstream infection
can be caused by improper care of the needle insertion site. Two percent chlorhexidine
gluconate is an antiseptic solution that when applied properly and allowed to dry reduces
microbial counts at the insertion site. Selecting the correct catheter size, using nonallergenic
tape and dressings, and utilizing local anesthetic are important steps for individualized patient
care and are typically part of the procedure, but they do not affect the cause of a health care
associated infection by, for example, decreasing microbial counts at the insertion site.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 403-404
Explain conditions that promote the transmission of health careassociated infection.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices a

spike in postoperative infections on this unit and categorizes this type of health care
associated infection as _____ infections.
a. Iatrogenic
b. Exogenous

c. Endogenous
d. Nosocomial
ANS: B

An exogenous organism is one that is present outside the patient. A postoperative infection is
an exogenous infection because the organism that has caused the infection presents from
outside the body. An example is Staphylococcus aureus. An endogenous organism is part of
the normal flora of residing virulent organisms that could cause infection. An endogenous
infection can occur when part of the patients flora becomes altered, and overgrowth results.
Iatrogenic infection results from a diagnostic or therapeutic procedure such as a colonoscopy.
Nosocomial infection is the term formerly used for health careacquired infection.
DIF:
OBJ:
TOP:
MSC:

Remember
REF: 403
Explain conditions that promote the transmission of health careassociated infection.
Evaluation
Safe and Effective Care Environment: Patient Safety and Infection Control

18. The patient has contracted a urinary tract infection while in the hospital. Which of these

actions would most likely increase the risk of a patient contracting a urinary tract infection
(UTI)?
a. Emptying the urinary drainage bag once a shift
b. Reusing the patients graduated receptacle to empty the drainage bag
c. Allowing the drainage bag port to touch the graduated receptacle
d. Providing perineal hygiene at least once a shift
ANS: C

Allowing the urinary drainage bag port to touch contaminated items may introduce bacteria
into the system and contribute to a urinary tract infection. The urinary drainage bag should be
emptied at least once every 8 hours. Each patient should have his own receptacle for
measurement to prevent cross-contamination. Perineal hygiene should be provided every 8
hours and after bowel movements to assist in preventing a UTI.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 404


Explain conditions that promote the transmission of health careassociated infection.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

19. Which of the following nursing actions would most increase a patients risk for developing a

health careassociated infection?


Use of surgical aseptic technique to suction an airway
Urinary catheter drainage bag placed below the level of the bladder
Clean technique for inserting a urinary catheter
Use of a sterile bottled solution more than once within a 24-hour period

a.
b.
c.
d.

ANS: C

Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at
risk for a health careassociated infection. Urinary catheters need to be inserted using sterile
technique, also referred to as surgical asepsis. This involves eliminating all microorganisms,
including pathogens and spores, from an object or area. Placing a catheter into a sterile body
cavity such as the bladder requires sterile technique. Surgical aseptic technique (also called
sterile technique) should be used when suctioning an airway because it is considered a sterile
body cavity. Keeping the urinary catheter drainage bag below the bladder helps decrease the
risk of developing a health careassociated infection because it prevents reflux of urine from
the bag back into the bladder. Bottled solutions may be used repeatedly during a 24-hour
period; however, special care is needed to ensure that the solution in the bottle remains sterile.
After 24 hours, the solution should be discarded.
DIF:
OBJ:
TOP:
MSC:

Analyze
REF: 404| 421| 423
Explain conditions that promote the transmission of health careassociated infection.
Evaluation
Safe and Effective Care Environment: Patient Safety and Infection Control

20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of

the patient for dilatation and effacement, the electronic infusion device being used on the
intravenous infusion alarms. Which of these actions is most appropriate for the nurse to take?
a. Complete the assessment, remove gloves, and silence the alarm.
b. Discontinue the assessment, and assess the intravenous infusion.
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.
ANS: C

Medical asepsis or clean technique includes procedures to decrease the number of organisms
present and to prevent the transfer of organisms. Wearing gloves while assessing the dilatation
and effacement of a labor and delivery patient, 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.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 410-411


Explain the difference between medical and surgical asepsis.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

21. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse

has scrubbed her hands and has donned a sterile gown and gloves. Which action would
indicate a break in sterile technique?
a. Touching protective eyewear
b. Standing with hands folded on chest
c. Accepting sterile supplies from the surgeon
d. Staying with the sterile table once it is open

ANS: A

Touching nonsterile 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 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.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 410-411| 421-424


Explain the difference between medical and surgical asepsis.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

22. The nurse is caring for a patient with an incision. Which of the following actions would best

indicate an understanding of medical and surgical asepsis?


a. Donning sterile gown and gloves to remove the wound dressing
b. Utilizing clean gloves to remove the dressing and sterile supplies for the new

dressing
c. Donning clean goggles, gown, and gloves to dress the wound
d. Utilizing clean gloves to remove the dressing and clean supplies for the new
dressing
ANS: B

Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies,
including gloves and dressings (surgical asepsissterile 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.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 410


Explain the difference between medical and surgical asepsis.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

23. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician

performing these tasks. Which of these observations would require the nurse to intervene?
Washing hands after removing gloves
Placing the endoscope in a container for transfer
Removing gloves to transfer the endoscope
Disinfecting endoscopes in the workroom

a.
b.
c.
d.

ANS: C

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. 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.

DIF: Apply
REF: 410-412| 414
OBJ: Explain the rationale for standard precautions.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
24. The nurse is caring for a patient with a nursing diagnosis of risk for infection. Aware of the

need for Standard Precautions, the nurse is careful to


a. Teach the patient about good nutrition.
b. Wear eyewear when emptying a urinary drainage bag.
c. Avoid contact with intact skin without wearing gloves.
d. Don gloves when wearing artificial nails.
ANS: B

Standard Precautions include the wearing of eyewear whenever there is a possibility of a


splash or splatter. Teaching the patient about good nutrition is positive but does not apply to
Standard Precautions. The term Standard Precautions applies to all blood and body fluids
except sweat, even if blood is not present. It also applies to nonintact skin and mucous
membranes.
DIF: Understand REF: 414
OBJ: Explain the rationale for standard precautions.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the

patient for excessive vaginal drainage. It is important for the nurse to utilize _____
Precautions.
a. Contact
b. Protective
c. Droplet
d. Standard
ANS: D

Standard Precautions apply to contact with blood, body fluid, nonintact skin, and mucous
membranes of all patients. Contact Precautions apply to individuals with colonization of
infection such as MRSA. Protective Precautions apply to individuals who have undergone
transplantations. Droplet Precautions focus on diseases that are transmitted by large droplets.
DIF: Remember
REF: 401| 414-415
OBJ: Explain the rationale for standard precautions.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistant

turning off the handle faucet with his hands. What professional practice supports the need for
follow-up with the nursing assistant?
a. The nurse is responsible for providing a safe environment for the patient.
b. This is a key step in the procedure for washing hands.
c. Allowing the water to run is a waste of resources and money.
d. Different scopes of practice allow modification of procedures.
ANS: A

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. It is human nature to forget key procedural steps or to take shortcuts.
However, failure to comply with basic procedures places the patient at risk for infection that
can impair recovery or lead to death. 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 individuals health is not a prudent
practice.
DIF: Analyze
REF: 411| 425-427
OBJ: Perform proper procedures for hand hygiene.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The

nurse has contaminated hands. The nurses best next step is to


Clean hands with wipes from the bedside table.
Wash hands with an antimicrobial soap and water.
Use an alcohol-based waterless hand gel.
Instruct the patient to wash his face and hands.

a.
b.
c.
d.

ANS: B

The Centers for Disease Control 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. The patient may
very well need to wash his face and hands, but this is not the best next step.
DIF: Apply
REF: 411| 425-427
OBJ: Perform proper procedures for hand hygiene.
TOP: Planning
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
28. The nurse is performing hand hygiene before assisting a physician with insertion of a chest

tube. While washing hands, the nurse touches the sink. What is the next action the nurse
should take?
a. Inform the physician and recruit another nurse to assist.
b. Rinse and dry hands, and begin assisting the physician.
c. Repeat handwashing using antiseptic soap,
d. Extend the handwashing procedure to 5 minutes.
ANS: C

The inside of the sink and the counter at 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
physician 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.
DIF: Apply
REF: 411| 425-427
OBJ: Perform proper procedures for hand hygiene.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
29. The nurse is caring for a patient on the medical-surgical unit. The nurse and the physician

have completed an invasive procedure. What is the next step in handling the instruments used
during the procedure?
a. Don gloves, gather instruments, place in transport carrier, and send to central sterile
for cleaning and sterilization.
b. Don gloves, gather instruments, place in transport carrier, and send to central sterile
for cleaning and disinfection.
c. Don gloves, gather instruments, place in transport carrier, and send to central sterile
for cleaning and boiling.
d. Don gloves, gather instruments, place in transport carrier, and send to central sterile
for cleaning.
ANS: A

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.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 412
Explain how infection control measures may differ in the home versus the hospital.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

30. The nurse is observing a family member changing a dressing for a patient in the home health

environment. Which of these observations would indicate that the family member has a
correct understanding of how to manage contaminated dressings?
a. The family member removes gloves and gathers items for disposal.
b. The family member places the used dressings in a plastic bag.
c. The family member saves part of the dressing because it is clean.
d. The family member wraps the used dressing in toilet tissue before placing in the
trash.
ANS: B

Contaminated dressings and other infectious 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.

DIF:
OBJ:
TOP:
MSC:

Evaluate
REF: 411-412| 421
Explain how infection control measures may differ in the home versus the hospital.
Evaluation
Safe and Effective Care Environment: Patient Safety and Infection Control

31. The nurse is caring for a home health patient. After completing an assessment, the nurse has

diagnosed the patient as being at risk for infection. Which of the following orders would the
nurse question?
a. Urinary catheter to bedside drainage bag. May change to leg bag during the day.
b. May reuse nebulizer equipment. Clean with mild soap and warm water, and allow
to dry.
c. Prepare enough enteral feedings for 12 hours. Rinse feeding bag and tubing daily.
d. Call for temperature greater than 100.5, heart rate greater than 100, and respiratory
rate greater than 24.
ANS: C

For patients who receive tube feedings in the home, to decrease the risk of bacterial
contamination it is important to prepare enough commercially prepared formula for only 8
hours and home-prepared formula for 4 hours. Sometimes the urinary drainage system is
disrupted in the home to place the patient on a leg bag system when up and about. Nebulizer
equipment is cleaned and reused in the home health environment. Notifying the physician
about potential signs and symptoms of infection would be common practice in the home
health environment.
DIF:
OBJ:
TOP:
MSC:

Analyze
REF: 421
Explain how infection control measures may differ in the home versus the hospital.
Diagnosis
Safe and Effective Care Environment: Patient Safety and Infection Control

32. 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


And after shaking hands.
And after treatments.
Opening the refrigerator.
And after using a computer.

a.
b.
c.
d.

ANS: B

Patients should perform hand hygiene before and after treatments and when coming in contact
with body fluids. Depending on the type of patient, holding hands does not require washing of
hands before but is advisable before touching eyes, nose, or mouthwashing hands afterward
would be a good practice. Washing hands before and after opening the refrigerator and using
the computer is not required but during cold and flu season might be advisable.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 414| 425-427
Explain how infection control measures may differ in the home versus the hospital.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

33. The nurse has been caring for a patient in the perioperative area for several hours. The surgical

mask the nurse is wearing has become moist. The nurses best next step is to
a. Change the mask when relieved.

b. Air-dry the mask while at lunch, and reapply.


c. Ask for relief, step out of the surgical area, and apply a new mask.
d. Not change the mask, if the nurse is comfortable.
ANS: C

A mask should fit snugly around the face and nose. After the mask is worn for several hours, it
can become moist. The mask should be changed as soon as possible because moisture
encourages the growth of microorganisms. Waiting to change the mask, air-drying it, or
wearing it because it is comfortable does not support the principles of infection control.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 419
Properly don a surgical mask, sterile gown, and sterile gloves.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

34. The nurse is caring for a patient on Contact Precautions. Which of the following actions

would be appropriate to prevent the spread of disease?


a. Wear a gown, gloves, face mask, and goggles for interactions with the patient.
b. Use a dedicated blood pressure cuff that stays in the room and is used for that

patient only.
c. Place the patient in a room with negative airflow.
d. Transport the patient quickly when going to the radiology department.
ANS: B

Contact Precautions are a type of Isolation Precaution used for patients with illness that can be
transmitted through direct or indirect contact. A patient is placed on Contact Precautions if a
disease is present 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, he should wear clean gowns, and wheelchairs
or gurneys should be covered with an extra layer of sheets. Anyone who might come in
contact with the patient needs to be protected, and equipment must be cleaned with an
approved germicide after patient use and before another patient uses the shared equipment.
DIF: Apply
REF: 414-416| 420
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of

the following nursing actions would be appropriate given this organism?


a. Instruct assistive personnel to use soap and water rather than sanitizer to clean

hands.
b. Place the patient on Droplet Precautions.
c. Wear an N95 respirator when entering the patient room.
d. Teach the patient cough etiquette.
ANS: A

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. All patients should be taught cough etiquette; this action is not one to be take
especially because the patient has Clostridium difficile.
DIF: Apply
REF: 413-414
OBJ: Explain procedures for each isolation category.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
36. The nurse is changing linens for a postoperative patient and feels a stick in her hand. A

nonactivated safe needle is noted in the linens. This scenario would indicate that the nurse
may be at risk for
a. Hepatitis B.
b. Clostridium difficile.
c. Methicillin-resistant Staphylococcus aureus.
d. Diphtheria.
ANS: A

Bloodborne pathogens such as those associated with hepatitis B and C are most commonly
transmitted by contaminated needles. Clostridium difficile is spread by contact with and
ingestion of this microbe, and MRSA is spread by contact. Diphtheria is spread by droplets
when one is within 3 feet of the patient.
DIF: Remember
REF: 424-425
OBJ: Understand the definition of occupational exposure.
TOP: Diagnosis
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
37. 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 infusion. The nurses best
next step is to
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. Delay washing of the site until the nurse is finished providing care to the patient.
d. Do nothing; accidentally getting splashed with blood happens frequently and is part
of the job.
ANS: B

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 and employee health 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.
DIF: Apply
REF: 424-425
OBJ: Explain the postexposure process.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control

38. What would be required after exposure of a nurse to blood by a cut from a scalpel in the

perioperative area?
Removing sterile gloves and disposing of in kick bucket
Placing the scalpel in a needle safe container
Testing the patient and offering treatment to the nurse
Providing a medical evaluation of the nurse to the manager

a.
b.
c.
d.

ANS: C

Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV
and hepatitis B and C. Syphilis may be indicated if the patient is HIV positive. 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. A
confidential medical evaluation is provided to the nurse.
DIF: Remember
REF: 424-425
OBJ: Explain the postexposure process.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
MULTIPLE RESPONSE
1. The nurse is caring for a patient in Contact Precautions. The nurse includes hand hygiene as

part of the plan of care to (Select all that apply).


Provide an uninterrupted chain of infection.
Decrease the incidence of health careassociated infection.
Protect the nurse from transmission of the microbes.
Decrease the transmission of microbes to other patients.
Prevent contamination of clean supplies.
Decrease the drying effects of soap.

a.
b.
c.
d.
e.
f.

ANS: B, C, D, E

Handwashing is part of Contact Precautions and assists in interrupting the chain of infection.
Washing hands can assist in decreasing the incidence of health careassociated infection,
protect the nurse from the transfer of microorganisms, decrease the transmission of microbes
to other patients, and prevent contamination of clean supplies. Hands are a common means of
transmission of bacteria from one place to another. Proper hand hygiene does not decrease the
drying effects of soapin fact, it increases the drying effects of soap.
DIF: Remember
REF: 411| 425-427
OBJ: Perform proper procedures for hand hygiene.
TOP: Planning
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
2. The nurse is assessing a new patient admitted to home health. To decrease the risk of

infection, which of these questions would be most appropriate to ask? (Select all that apply.)
Will you demonstrate how to wash your hands?
Do you have a working refrigerator?
Can you explain the risk for infection in your home?
What are the signs and symptoms of infection?
Who runs errands for you?
Are you able to walk to the mailbox?

a.
b.
c.
d.
e.
f.

ANS: A, B, C, D

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 hand washing, risk of infection, and
signs and symptoms of infection is important in evaluating the patients knowledge base on
infection control strategies. Refrigeration is essential in keeping perishables cold and in
preventing foodborne illnesses and in allowing storage of enteral feedings or refrigerated
medications. 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 relate to decreasing the risk of infection.
DIF:
OBJ:
TOP:
MSC:

Remember
REF: 421
Explain how infection control measures may differ in the home versus the hospital.
Assessment
Safe and Effective Care Environment: Patient Safety and Infection Control

3. The circulating nurse in the perioperative area is observing the surgical technologist while

applying a sterile gown and gloves to care for a patient having an appendectomy. Which of the
following behaviors indicate to the nurse that the procedure has been done correctly? (Select
all that apply.)
a. Surgical cap and face mask are in place.
b. Surgical technologist ties the back of the gown.
c. Surgical technologist touches only inside of gown.
d. Surgical technologist slips arms into arm holes simultaneously.
e. Surgical technologist uses hands covered by sleeves to open gloves.
f. Fingers are extended fully into both gloves.
ANS: C, D, E, F

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.
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.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 431-436
Properly don a surgical mask, sterile gown, and sterile gloves.
Assessment
Safe and Effective Care Environment: Patient Safety and Infection Control

4. The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to don the

sterile gloves. Which steps are included in this process? (Select all that apply.)
a. Lay glove package on clean flat surface above waistline.
b. Remove outer glove package by tearing the package open.
c. Glove the dominant hand of the nurse first.
d. While putting on the first glove, touch only the outside surface of the glove.
e. With gloved dominant hand, slip fingers underneath second glove cuff.
f. After second glove is on, interlock hands.
ANS: A, C, E, F

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
protect the gloved fingers. Sterile touching sterile prevents glove contamination. 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 presents the sterile contents from
accidentally opening and touching contaminated objects. Touching the outside of the glove
surface will contaminate the sterile item; touch only the inside of the glovethe piece that
will be against the skin.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 436-437
Properly don a surgical mask, sterile gown, and sterile gloves.
Implementation
Safe and Effective Care Environment: Patient Safety and Infection Control

5. The nurse has received a report from the emergency department that a patient with

tuberculosis will be coming to the unit. What items will the nurse need to care for this patient?
(Select all that apply.)
a. Private room
b. Negative-pressure airflow in room
c. Communication signs for Droplet Precautions
d. Communication signs for Airborne Precautions
e. Surgical mask, gown, gloves, eyewear
f. N95 respirator, gown, gloves, eyewear
ANS: A, B, D, F

Tuberculosis is a disease that is transmitted by droplets that remain in the air for long periods
of time. 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. 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.
DIF: Remember
REF: 414
OBJ: Explain procedures for each isolation category.
TOP: Planning
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
6. 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. What should the nurse include in her
teaching? (Select all that apply).
a. Be consistent in nursing interventions; there is only one difference in the
precautions.
b. Wash hands before entering and leaving both of the patients rooms.
c. Dispose of supplies to prevent the spread of microorganisms.
d. Apply the knowledge the nurse has of the disease process to prevent the spread of
microorganisms.
e. Patients in Airborne Precautions wear a mask during transportation to departments.
f. Checking the working order of the negative-pressure room is done on admission
and at the time of discharge.
ANS: B, C, D, E

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 between 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. Even when no patient is in this type of room, regular and routine
checks are important to ensure the working order.
DIF: Apply
REF: 414
OBJ: Explain procedures for each isolation category.
TOP: Planning
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
OTHER
1. 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. Select the correct order for removal of the
personal protective equipment and associated tasks. (All answers are utilized.)
a. Remove eyewear/face shield and goggles.
b. Perform hand hygiene.
c. Remove gloves.
d. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose
of properly.
e. Remove mask by strings; do not touch outside of mask.
f. Dispose of all contaminated supplies and equipment in designated receptacles.
g. Leave room and close the door.
ANS:

C, A, D, E, B, G, F
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.
DIF: Remember
REF: 417-418
OBJ: Explain procedures for each isolation category.
TOP: Implementation
MSC: Safe and Effective Care Environment: Patient Safety and Infection Control
2. The nurse manager is evaluating current infection control data for the intensive care unit. The

nurse compares past patient data with current data to look for trends. The nurse manager
examines the chain of infection for possible solutions. Arrange these items in the proper order.
(All answers are utilized.)
a. A mode of transmission
b. An infectious agent or pathogen
c. A susceptible host
d. A reservoir or source for pathogen growth
e. A portal of entry to a host
f. A portal of exit from the reservoir

ANS:

B, D, F, A, E, C
The nurse manager is evaluating the chain of infection to determine actions that could be
implemented to influence the spread of infection in the intensive care unit. Understanding the
spread of infection and directing actions toward those steps have the potential to decrease
infection in the setting. For spread of infection, the chain has to be uninterrupted with an
infectious agent, a reservoir and portal of exit, a mode of transmission, a portal of entry, and a
susceptible host.
DIF:
OBJ:
TOP:
MSC:

Remember
REF: 399-401
Explain the relationship between the chain of infection and transmission of infection.
Evaluation
Safe and Effective Care Environment: Patient Safety and Infection Control