1 . The nurse assesses the hospitalized client and surveys the client’s room.
The client is Muslim. Which findings require the nurse’s immediate attention to
remove possible sources of infection? Select all that apply.
A. A capped bottle of saline solution with a label stating that it was opened 10 hours ago.
B. The abdominal dressing is saturated and seeping through to the client’s gown and bed.
C. An infusing intravenous (IV) tubing has no notation of the date when it was last changed.
D. A container located in the bathroom that is labeled urine and has the client’s initials.
E. Opened packages of gauze sponges and abdominal pads sitting on the window sill.
F. An uncovered cup of figs on the bedside table brought by a family member last evening.
ANSWER: B, C , E, F
A. Open bottles of solutions for wound care are considered aseptic and suitable for
use with wound care for 24 hours.
B. The saturated dressing represents a risk for contamination since
microorganisms can move through the moist environment through the dressing
to the wound and back.
C. Recommendations for IV tubing changes are every 72 to 96 hours. If the date of
the tubing change is unknown, it represents a potential infection risk.
D. Care equipment, especially items contaminated with body fluids, should be
labeled and used for just one client.
E. Opened packages of dressings are considered contaminated and should not be
used for dressing changes.
F. Although figs have special meaning to someone who is Muslim, uncovered food
items can harbor microorganisms. This finding requires the immediate attention
of the nurse. The nurse should discuss the food items with the client.
2. The nurse is preparing for a dressing change using surgical aseptic
technique. Which action by the nurse is correct when setting up the sterile field?
A. Dons sterile gloves before opening the package that contains the sterile drape.
B. Uses alcohol to cleanse a bottle of irrigating solution before placing it on the sterile
drape.
C. Holds an opened sterile package 6 inches above the field to drop the item into the sterile
field.
, D. Leaves the sterile field unattended to obtain the correct size of sterile gloves.
ANSWER: C
A. The sterile drape should be opened before donning sterile gloves, utilizing a
technique of just touching the outer inch of the drape.
B. The irrigation solution should be poured into a sterile container on the field. Only
sterile items should be placed on the sterile field.
C. Holding the opened sterile package with the item 6 inches above the surface of
the sterile field prevents contamination of the field. If opened correctly, the inside
of the sterile wrapper would be over the sterile field.
D. A sterile field should be considered contaminated if not visualized.
3. The client is placed on contact precautions. When should the nurse caring for
the client plan to put on disposable examination gloves?
A. As soon as the nurse enters the client’s room
B. Only if anticipating contact with the client’s wound
C. Only if anticipating contact with blood or body fluids
D. Only if providing care within 3 feet of the client
ANSWER: A
A. Gloves should be donned by the nurse upon entry into the room of the client
requiring contact precautions.
B. Gloves should be donned upon entering the room, not just if anticipating contact
with the client’s wound.
C. Gloves should be donned upon entering the room, not just if anticipating contact
with blood or body fluids.
D. Gloves should be donned upon entering the room, not just if providing care within
3 feet of the client.
4. The nurse sees multiple items on the client’s bedside table. Which items
should the nurse remove because they pose a risk of infection for the client?
Select all that apply.
A. The menu from the client’s last meal
B. A glass of water without a cover
, C. An empty urinal that had been rinsed
D. A sealed package of soda crackers
E. A pitcher of water covered with a lid
F. A bloody alcohol swab from an injection
ANSWER: B, C, F
A. A menu does not pose a risk for infection.
B. Fluid containers should be covered because prolonged exposure leads to
contamination and promotes microbial growth.
C. The urinal on the bedside table is a vehicle for microorganism transmission and
a potential source for nosocomial infection.
D. The soda crackers are sealed and still edible without transmitting
microorganisms.
E. The container is covered, preventing environmental contamination.
F. A bloody alcohol swab can harbor microorganisms.
5. The clinic nurse encounters the client who has a congested cough and
rhinorrhea. The nurse follows droplet precautions/cough protocol by taking
which action? Select all that apply.
A. Offering the client sterile disposable tissues
B. Wearing a mask while examining the client
C. Offering the client water to drink while waiting
D. Teaching how to cover the mouth when coughing
E. Performing hand hygiene before and after client contact
F. Separating the client by at least 3 feet from others in the area
ANSWER: B , D, E , F
A. Sterile disposable tissues are unnecessary; unsterile tissues are sufficient.
B. Droplet precautions are a component of respiratory hygiene; this includes
wearing a mask when caring for the client.
C. Clients with URls should increase their fluid intake, but this will not limit
, transmission of pathogens.
D. Droplet precautions/cough protocol measures include educating clients about
source control measures including how to cover the mouth when coughing.
E. Hand hygiene should be performed before and after client contact to prevent the
transmission of microorganisms.
F. Separating ill persons by 3 feet will prevent transmission of microorganisms.
6. The nurse is caring for hospitalized clients. Which nursing actions require the
nurse to use sterile gloves? Select all that apply.
A. Insertion of a nasogastric tube
B. Administration of an enema
C. Administration of a subcutaneous injection
D. Insertion of an indwelling urinary catheter
E. Suctioning of a tracheostomy tube
ANSWER: D, E
A. The nurse uses nonsterile, not sterile, examination gloves when inserting an NG
tube for self-protection from blood and body fluids. The GI tract contacts
microorganisms and is not sterile.
B. The nurse uses nonsterile, not sterile, examination gloves when administering an
enema for self- protection from blood and body fluids.
C. The nurse maintains sterility of the needle with a subcutaneous injection by not
touching the needle and disinfecting the client’s skin prior to the injection. Sterile
gloves are not needed. Nonsterile gloves are worn for self-protection against the
client’s blood.
D. The urinary tract is at great risk for nosocomial infection. Therefore, use of sterile
gloves and sterile technique during insertion of an indwelling urinary catheter
decreases the risk of introducing microorganisms.
E. The respiratory tract is at great risk for nosocomial infection. Use of sterile
gloves and sterile technique while suctioning a tracheostomy decreases the risk
of introducing microorganisms.
The client is Muslim. Which findings require the nurse’s immediate attention to
remove possible sources of infection? Select all that apply.
A. A capped bottle of saline solution with a label stating that it was opened 10 hours ago.
B. The abdominal dressing is saturated and seeping through to the client’s gown and bed.
C. An infusing intravenous (IV) tubing has no notation of the date when it was last changed.
D. A container located in the bathroom that is labeled urine and has the client’s initials.
E. Opened packages of gauze sponges and abdominal pads sitting on the window sill.
F. An uncovered cup of figs on the bedside table brought by a family member last evening.
ANSWER: B, C , E, F
A. Open bottles of solutions for wound care are considered aseptic and suitable for
use with wound care for 24 hours.
B. The saturated dressing represents a risk for contamination since
microorganisms can move through the moist environment through the dressing
to the wound and back.
C. Recommendations for IV tubing changes are every 72 to 96 hours. If the date of
the tubing change is unknown, it represents a potential infection risk.
D. Care equipment, especially items contaminated with body fluids, should be
labeled and used for just one client.
E. Opened packages of dressings are considered contaminated and should not be
used for dressing changes.
F. Although figs have special meaning to someone who is Muslim, uncovered food
items can harbor microorganisms. This finding requires the immediate attention
of the nurse. The nurse should discuss the food items with the client.
2. The nurse is preparing for a dressing change using surgical aseptic
technique. Which action by the nurse is correct when setting up the sterile field?
A. Dons sterile gloves before opening the package that contains the sterile drape.
B. Uses alcohol to cleanse a bottle of irrigating solution before placing it on the sterile
drape.
C. Holds an opened sterile package 6 inches above the field to drop the item into the sterile
field.
, D. Leaves the sterile field unattended to obtain the correct size of sterile gloves.
ANSWER: C
A. The sterile drape should be opened before donning sterile gloves, utilizing a
technique of just touching the outer inch of the drape.
B. The irrigation solution should be poured into a sterile container on the field. Only
sterile items should be placed on the sterile field.
C. Holding the opened sterile package with the item 6 inches above the surface of
the sterile field prevents contamination of the field. If opened correctly, the inside
of the sterile wrapper would be over the sterile field.
D. A sterile field should be considered contaminated if not visualized.
3. The client is placed on contact precautions. When should the nurse caring for
the client plan to put on disposable examination gloves?
A. As soon as the nurse enters the client’s room
B. Only if anticipating contact with the client’s wound
C. Only if anticipating contact with blood or body fluids
D. Only if providing care within 3 feet of the client
ANSWER: A
A. Gloves should be donned by the nurse upon entry into the room of the client
requiring contact precautions.
B. Gloves should be donned upon entering the room, not just if anticipating contact
with the client’s wound.
C. Gloves should be donned upon entering the room, not just if anticipating contact
with blood or body fluids.
D. Gloves should be donned upon entering the room, not just if providing care within
3 feet of the client.
4. The nurse sees multiple items on the client’s bedside table. Which items
should the nurse remove because they pose a risk of infection for the client?
Select all that apply.
A. The menu from the client’s last meal
B. A glass of water without a cover
, C. An empty urinal that had been rinsed
D. A sealed package of soda crackers
E. A pitcher of water covered with a lid
F. A bloody alcohol swab from an injection
ANSWER: B, C, F
A. A menu does not pose a risk for infection.
B. Fluid containers should be covered because prolonged exposure leads to
contamination and promotes microbial growth.
C. The urinal on the bedside table is a vehicle for microorganism transmission and
a potential source for nosocomial infection.
D. The soda crackers are sealed and still edible without transmitting
microorganisms.
E. The container is covered, preventing environmental contamination.
F. A bloody alcohol swab can harbor microorganisms.
5. The clinic nurse encounters the client who has a congested cough and
rhinorrhea. The nurse follows droplet precautions/cough protocol by taking
which action? Select all that apply.
A. Offering the client sterile disposable tissues
B. Wearing a mask while examining the client
C. Offering the client water to drink while waiting
D. Teaching how to cover the mouth when coughing
E. Performing hand hygiene before and after client contact
F. Separating the client by at least 3 feet from others in the area
ANSWER: B , D, E , F
A. Sterile disposable tissues are unnecessary; unsterile tissues are sufficient.
B. Droplet precautions are a component of respiratory hygiene; this includes
wearing a mask when caring for the client.
C. Clients with URls should increase their fluid intake, but this will not limit
, transmission of pathogens.
D. Droplet precautions/cough protocol measures include educating clients about
source control measures including how to cover the mouth when coughing.
E. Hand hygiene should be performed before and after client contact to prevent the
transmission of microorganisms.
F. Separating ill persons by 3 feet will prevent transmission of microorganisms.
6. The nurse is caring for hospitalized clients. Which nursing actions require the
nurse to use sterile gloves? Select all that apply.
A. Insertion of a nasogastric tube
B. Administration of an enema
C. Administration of a subcutaneous injection
D. Insertion of an indwelling urinary catheter
E. Suctioning of a tracheostomy tube
ANSWER: D, E
A. The nurse uses nonsterile, not sterile, examination gloves when inserting an NG
tube for self-protection from blood and body fluids. The GI tract contacts
microorganisms and is not sterile.
B. The nurse uses nonsterile, not sterile, examination gloves when administering an
enema for self- protection from blood and body fluids.
C. The nurse maintains sterility of the needle with a subcutaneous injection by not
touching the needle and disinfecting the client’s skin prior to the injection. Sterile
gloves are not needed. Nonsterile gloves are worn for self-protection against the
client’s blood.
D. The urinary tract is at great risk for nosocomial infection. Therefore, use of sterile
gloves and sterile technique during insertion of an indwelling urinary catheter
decreases the risk of introducing microorganisms.
E. The respiratory tract is at great risk for nosocomial infection. Use of sterile
gloves and sterile technique while suctioning a tracheostomy decreases the risk
of introducing microorganisms.
