and CORRECT Answers
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
A. an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
B. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk
sexual behavior
C. a 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft
D. A client with renal failure who receives hemodialysis three times weekly - CORRECT ANSWER A. an 81-year-
old client who has been receiving multiple antibiotics for the treatment of sepsis
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the
priority nursing action?
A. Remove the garments that are most contaminated.
B. Make contact between two contaminated surfaces.
C. Make contact between two clean surfaces.
D. Handwashing before leaving the client's room. - CORRECT ANSWER D. Handwashing before leaving the
client's room.
A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical
asepsis should the nurse keep in mind when preparing sterilized surgical instruments?
When a sterile item touches something that is not sterile, it may not be contaminated.
Any partially uncovered sterile package need not be considered contaminated.
A commercially packaged surgical item is not considered sterile if past expiration date.
Sterility may not be preserved even when one sterile item touches another sterile item. - CORRECT ANSWER A
commercially packaged surgical item is not considered sterile if past expiration date.
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse
provides for the client's organisms to be spread by which type of transmission?
Airborne
Contact
Vector
Vehicle - CORRECT ANSWER Contact
The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the
dressing?
With the double-bag technique
In the client's trash container
In a bag marked "biohazards"
In the sharps container - CORRECT ANSWER In a bag marked "biohazards"
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the
appropriate use of hand hygiene?
The nurse uses gloves in place of hand hygiene.
The nurse keeps fingernails less than 1/4 in (0.63 cm) long.
The nurse uses hand hygiene instead of gloves when in contact with blood.
, The nurse refrains from using hand moisturizer following hand hygiene. - CORRECT ANSWER The nurse keeps
fingernails less than 1/4 in (0.63 cm) long.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control
based on nursing practice standards for safety?
The nurse places the client in a private room with the door open.
The nurse uses droplet precautions when providing care for the client.
The nurse keeps visitors 3 feet away from the infected person.
The nurse places the client in a private room with monitored negative air pressure. - CORRECT ANSWER The
nurse places the client in a private room with monitored negative air pressure.
Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which
examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that
apply.
Nurses need only apply clean gloves when performing or assisting with invasive client procedures.
During some care activities for an individual client, nurses may need to change gloves more than once.
Nurses may use a waterproof gown more than one time.
Nurses should remove PPE at the doorway or in an anteroom, except for the respirator.
To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.
Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse. -
CORRECT ANSWER During some care activities for an individual client, nurses may need to change gloves more
than once.
Nurses should remove PPE at the doorway or in an anteroom, except for the respirator.
To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.
A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with
the client's normal flora. Why did this client most likely become ill from his resident microorganisms?
The resident microorganisms mutated and became virulent
The client's immune system became further weakened
The client's normal flora proliferated because of a nutritional deficit
The client's normal flora began producing spores - CORRECT ANSWER The client's immune system became
further weakened
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal
incision. Which concept should be the priority in the teaching plan?
hand washing
sterile technique
putting on gloves
signs of healing - CORRECT ANSWER Hand washing
A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of
client is most likely at increased risk for infection?