CURRENT
CURRENTMedical
Medical Diagnosis andTreatment
Diagnosis and Treatment 6. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous
antibiotics to treat a systemic infection. Which type of infection has the patient developed?
Test 2019
Bank/Complete Guide
Testbank/Studyguide 1) Endogenous nosocomial
2) Exogenous nosocomial
Chapter 1. Disease Prevention & Health Promotion 3) Latent
4) Primary
1. Which of the following behaviors indicates the highest potential for spreading infections
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2
among clients? The nurse:
days. His condition has stabilized, and his temperature has returned to normal. Which stage of
1) disinfects dirty hands with antibacterial soap. infection is the patient most likely experiencing?
2) allows alcohol-based rub to dry for 10 seconds. 1) Incubation
3) washes hands only after leaving each room. 2) Prodromal
4) uses cold water for medical asepsis. 3) Decline
2. What is the most frequent cause of the spread of infection among institutionalized 4) Convalescence
patients?
8. The nurse assists a surgeon with central venous catheter insertion. Which action is
1) Airborne microbes from other patients necessary to help maintain sterile technique?
2) Contact with contaminated equipment 1) Closing the patients door to limit room traffic while preparing the sterile field
3) Hands of healthcare workers 2) Using clean procedure gloves to handle sterile equipment
4) Exposure from family members 3) Placing the nonsterile syringes containing flush solution on the sterile field
3. Which of the following nursing activities is of highest priority for maintaining medical 4) Remaining 6 inches away from the sterile field during the procedure
asepsis?
9. A patient develops localized heat and erythema over an area on the lower leg. These
1) Washing hands findings are indicative of which secondary defense against infection?
2) Donning gloves 1) Phagocytosis
3) Applying sterile drapes 2) Complement cascade
4) Wearing a gown 3) Inflammation
4. A patient infected with a virus but who does not have any outward sign of the disease is 4) Immunity
considered a:
10. The patient suddenly develops hives, shortness of breath, and wheezing after receiving
1) pathogen. an antibiotic. Which antibody is primarily responsible for this patients response?
2) fomite. 1) IgA
3) vector. 2) IgE
4) carrier. 3) IgG
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse 4) IgM
institute when caring for this patient?
11. What type of immunity is provided by intravenous (IV) administration of
1) Droplet transmission immunoglobulin G?
2) Airborne transmission 1) Cell-mediated
3) Direct contact 2) Passive
4) Indirect contact 3) Humoral
4) Active
, 12. A patient asks the nurse why there is no vaccine available for the common cold. Which 18. To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution
response by the nurse is correct? over all surfaces of the hands?
1) The virus mutates too rapidly to develop a vaccine. 1) When fingers feel sticky
2) Vaccines are developed only for very serious illnesses. 2) After 5 to 10 seconds
3) Researchers are focusing efforts on an HIV vaccine. 3) When leaving the clients room
4) The virus for the common cold has not been identified. 4) Once fingers and hands feel dry
1 . A patient who has a temperature of 101F (38.3C) most likely requires: 19. A patient is admitted to the hospital for chemotherapy and has a low white blood cell
1) acetaminophen (Tylenol). count. Which precaution should the staff take with this patient?
2) increased fluids. 1) Contact
3) bedrest. 2) Protective
4) tepid bath. 3) Droplet
14. Why is a lotion without petroleum preferred over a petroleum-based product as a skin 4) Airborne
protectant? It: 20. While donning sterile gloves, the nurse notices the edges of the glove package are
1) Prevents microorganisms from adhering to the skin. slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on
the outside of the glove package. What is the best action for the nurse to take at this point?
2) Facilitates the absorption of latex proteins through the skin.
1) Continue using the gloves inside the package because the package is intact.
3) Decreases the risk of latex allergies.
2) Remove gloves from sterile field and use a new pair of sterile gloves.
4) Prevents the skin from drying and chaffing.
3) Throw all supplies away that were to be used and begin again.
15. For which range of time must a nurse wash her hands before working in the operating
room? 4) Use the gloves and make sure the yellow edges of the package do not touch the client.
1) 1 to 2 minutes 21. The nurse is removing personal protective equipment (PPE). Which item should be
removed first?
2) 2 to 4 minutes
1) Gown
3) 2 to 6 minutes
2) Gloves
4) 6 to 10 minutes
3) Face shield
16. How should the nurse dispose of the breakfast tray of a patient who requires airborne
isolation? 4) Hair covering
1) Place the tray in a specially marked trash can inside the patients room. 22. A nurse is splashed in the face by body fluid during a procedure. Prioritize the nurses
actions, listing the most important one first.
Place the tray in a special isolation bag held by a second healthcare worker at the A. Contact employee health
2) patients door. B. Complete an incident report
Return the tray with a note to dietary services so it can be cleaned and reused for the C. Wash the exposed area
3) next meal. D. Report to another nurse that she is leaving the immediate area.
Carry the tray to an isolation trash receptacle located in the dirty utility room and 1) 1, 2, 3, 4
4) dispose of it there. 2) 2, 3, 4, 1
1 . How much liquid soap should the nurse use for effective hand washing? At least: 3) 3, 4, 1, 2
1) 2 mL
4) 4, 1, 2, 3
2) 3 mL Multiple Response
3) 6 mL Identify one or more choices that best complete the statement or answer the question.
4) 7 mL 1. In which situation would using standard precautions be adequate? Select all that apply.
, 1) While interviewing a client with a productive cough patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use
antibacterial soap with warm water to remove dirt and debris from the skin surface. When no
2) While helping a client to perform his own hygiene care visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15
3) While aiding a client to ambulate after surgery seconds.
4) While inserting a peripheral intravenous catheter 2. ANS: 3
2. Which of the following protect(s) the body against infection? Select all that apply. Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other
patients, family members, and contaminated healthcare equipment. Some of these are pathogenic
1) Eating a healthy well-balanced diet (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing
2) Being an older adult or an infant infection among patients are spread by direct contact on the hands of healthcare workers.
3) Leisure activities three times a week 3. ANS: 1
Scrupulous hand washing is the most important part of medical asepsis. Donning gloves,
4) Exercising for 30 minutes 5 days a week applying sterile drapes before procedures, and wearing a protective gown may be needed to
3. The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about ensure asepsis, but they are not the mostimportant aspect because microbes causing most
proper hand washing. The nurse will know that the teaching was effective if the NAP healthcare-related infections are transmitted by lack of or ineffective hand washing.
demonstrate what? Select all that apply. The NAP: 4. ANS: 4
1) uses a paper towel to turn off the faucet. Some people might harbor a pathogenic organism, such as the human immunodeficiency virus
within their body, and yet do not acquire the disease/infection. These individuals, called carriers,
2) holds fingertips above the wrists while rinsing off the soap. have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an
3) removes all rings and watch before washing hands. organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen,
4) cleans underneath each fingernail. such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a
pathogen to a susceptible host through a portal for entry into the body. An example of a vector is
4. Alcohol-based solutions for hand hygiene can be used to combat which types of a mosquito or tick that bites or stings.
organisms? Select all that apply. 5. ANS: 2
1) Virus The organisms responsible for measles and tuberculosis, as well as many fungal infections, are
2) Bacterial spores spread through airborne transmission. Neisseria meningitidis, the organism that causes
meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such
3) Yeast as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect
4) Mold contact or droplet transmission.
5. A patient with tuberculosis is scheduled for computed tomography (CT). How should the 6. ANS: 1
nurse proceed? Select all that apply. Thrush in this patient is an example of an endogenous, nosocomial infection. This type of
1) Question the order because the patient must remain in isolation. infection arises from suppression of the patients normal flora as a result of some form of
treatment, such as antibiotics. Normal flora usually keep yeast from growing in the mouth. In
2) Place an N-95 respirator mask on the patient and transport him to the test. exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent
3) Place a surgical mask on the patient and transport him to CT lab. infection causes no symptoms for long periods. An example of a latent infection is human
immunodeficiency virus infection. A primary infection is the first infection that occurs in a
4) Notify the computed tomography department about precautions prior to transport.
patient.
True/False 7. ANS: 3
Indicate whether the statement is true or false. The stage of decline occurs when the patients immune defenses, along with any medical
1. Bacteria are necessary for human health and well-being. therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes.
Chapter 1. Disease prevention As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between
Answer Section the invasion by the organism and the onset of symptoms. During the incubation stage, the patient
MULTIPLE CHOICE does not know he is infected and is capable of infecting others. The prodromal stage is
1. ANS: 3 characterized by the first appearance of vague symptoms. Convalescence is characterized by
Patients acquire infection by contact with other patients, family members, and healthcare tissue repair and a return to heal as the organisms disappear.
equipment. But most infection among patients is spread through the hands of healthcare workers. 8. ANS: 1
Hand washing interrupts the transmission and should be done before and after all contact with
, To maintain sterile technique, the nurse should close the patients door and limit the number of contents inside a special isolation bag that is held by a second healthcare worker at the patients
persons entering and exiting the room because air currents can carry dust and microorganisms. door. The items must be placed on the inside of the bag without touching the outside of the bag.
Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile 17. ANS: 2
syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.
people and the sterile field to prevent contamination. 18. ANS: 4
9. ANS: 3 The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution
The classic signs of inflammation, a secondary defense against infection, are erythema (redness) dries, usually 10 to 15 seconds, to ensure effectiveness.
and localized heat. The secondary defenses phagocytosis (process by which white blood cells 19. ANS: 2
engulf and destroy pathogens) and the complement cascade (process by which blood proteins Protective isolation is used to protect those patients who are unusually vulnerable to organisms
trigger the release of chemicals that attack the cell membranes of pathogens) do not produce brought in by healthcare workers. Such patients include those with low white blood cell counts,
visible findings. Immunity is a tertiary defense that protects the body from future infection. with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care
units and labor and delivery suites, also use forms of protective isolation.
10. ANS: 2 20. ANS: 2
The patient is most likely experiencing an allergic response to the antibiotic. IgE is the antibody The gloves should be thrown away because the gloves are likely to be contaminated from an
primarily responsible for this allergic response. The antibodies IgA, IgG, and IgM are not outside source. The supplies do not have to be thrown away because they have not been
involved in the allergic response. IgA antibodies protect the body from in fighting viral and contaminated.
bacterial infections. IgG antibioties are the only type that cross the placenta in a pregnant women 21. ANS: 2
to protect her unborn baby (fetus). IgM are the first antibodies made in response to infection. The gloves are removed first because they are usually the most contaminated PPE and must be
11. ANS: 2 removed to avoid contamination of clean areas of the other PPE during their removal. The gown
Intravenous administration of immunoglobulin G provides the patient with passive immunity. is removed second, then the mask or face shield, and finally, the hair covering.
Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive 22. ANS: 3
immunity occurs when antibodies are transferred by antibodies from an immune host, such as If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she is
from a placenta to a fetus. Passive immunity is short-lived. Active immunity is longer lived and leaving the area, contact the infection control or employee health nurse immediately, and
comes from the host itself. Humoral immunity occurs by secreted antibodies binding to antigens. complete an incident report. It is most important to remove the source of contamination (body
Cell-mediated immunity does not involve antibodies but rather fight infection from macrophages fluid) as soon as possible after exposure to help prevent the nurses from becoming infected. The
that kills pathogens. other activities can wait until that is done.
12. ANS: 1 MULTIPLE RESPONSE
More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to 1. ANS: 3, 4
develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV Standard precautions should be instituted with all clients whenever there is a possibility of
infection, others continue to research the common cold. coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous
membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a
13. ANS: 2 client, if the disease is not spread by air or droplets, there is no likelihood of the nurses
Fever, a common defense against infection, increases water loss; therefore, additional fluid is encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne
needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low- precautions would be needed in addition to standard precautions. If giving a complete bed bath
grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely
bedrest, is necessary with a fever. assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely
14. ANS: 3 when helping a client to ambulate after surgery.
Nonpetroleum-based lotion is preferred because it prevents the absorption of latex proteins 2. ANS: 1, 3, 4
through the skin, which can cause latex allergy. Both types of lotion prevent the skin from drying Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against
and becoming chafed. Neither prevents microorganisms from adhering to the skin. infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and
15. ANS: 3 various lifestyle factors can make the body more susceptible to infection.
In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap 3. ANS: 1, 3, 4
used. Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of
16. ANS: 2 the hands and fingers to be effective. The fingers should be held lower than the wrists.
Patients who require airborne isolation are served meals on disposable dishes and trays. To 4. ANS: 1, 3, 4
dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its
CURRENTMedical
Medical Diagnosis andTreatment
Diagnosis and Treatment 6. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous
antibiotics to treat a systemic infection. Which type of infection has the patient developed?
Test 2019
Bank/Complete Guide
Testbank/Studyguide 1) Endogenous nosocomial
2) Exogenous nosocomial
Chapter 1. Disease Prevention & Health Promotion 3) Latent
4) Primary
1. Which of the following behaviors indicates the highest potential for spreading infections
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2
among clients? The nurse:
days. His condition has stabilized, and his temperature has returned to normal. Which stage of
1) disinfects dirty hands with antibacterial soap. infection is the patient most likely experiencing?
2) allows alcohol-based rub to dry for 10 seconds. 1) Incubation
3) washes hands only after leaving each room. 2) Prodromal
4) uses cold water for medical asepsis. 3) Decline
2. What is the most frequent cause of the spread of infection among institutionalized 4) Convalescence
patients?
8. The nurse assists a surgeon with central venous catheter insertion. Which action is
1) Airborne microbes from other patients necessary to help maintain sterile technique?
2) Contact with contaminated equipment 1) Closing the patients door to limit room traffic while preparing the sterile field
3) Hands of healthcare workers 2) Using clean procedure gloves to handle sterile equipment
4) Exposure from family members 3) Placing the nonsterile syringes containing flush solution on the sterile field
3. Which of the following nursing activities is of highest priority for maintaining medical 4) Remaining 6 inches away from the sterile field during the procedure
asepsis?
9. A patient develops localized heat and erythema over an area on the lower leg. These
1) Washing hands findings are indicative of which secondary defense against infection?
2) Donning gloves 1) Phagocytosis
3) Applying sterile drapes 2) Complement cascade
4) Wearing a gown 3) Inflammation
4. A patient infected with a virus but who does not have any outward sign of the disease is 4) Immunity
considered a:
10. The patient suddenly develops hives, shortness of breath, and wheezing after receiving
1) pathogen. an antibiotic. Which antibody is primarily responsible for this patients response?
2) fomite. 1) IgA
3) vector. 2) IgE
4) carrier. 3) IgG
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse 4) IgM
institute when caring for this patient?
11. What type of immunity is provided by intravenous (IV) administration of
1) Droplet transmission immunoglobulin G?
2) Airborne transmission 1) Cell-mediated
3) Direct contact 2) Passive
4) Indirect contact 3) Humoral
4) Active
, 12. A patient asks the nurse why there is no vaccine available for the common cold. Which 18. To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution
response by the nurse is correct? over all surfaces of the hands?
1) The virus mutates too rapidly to develop a vaccine. 1) When fingers feel sticky
2) Vaccines are developed only for very serious illnesses. 2) After 5 to 10 seconds
3) Researchers are focusing efforts on an HIV vaccine. 3) When leaving the clients room
4) The virus for the common cold has not been identified. 4) Once fingers and hands feel dry
1 . A patient who has a temperature of 101F (38.3C) most likely requires: 19. A patient is admitted to the hospital for chemotherapy and has a low white blood cell
1) acetaminophen (Tylenol). count. Which precaution should the staff take with this patient?
2) increased fluids. 1) Contact
3) bedrest. 2) Protective
4) tepid bath. 3) Droplet
14. Why is a lotion without petroleum preferred over a petroleum-based product as a skin 4) Airborne
protectant? It: 20. While donning sterile gloves, the nurse notices the edges of the glove package are
1) Prevents microorganisms from adhering to the skin. slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on
the outside of the glove package. What is the best action for the nurse to take at this point?
2) Facilitates the absorption of latex proteins through the skin.
1) Continue using the gloves inside the package because the package is intact.
3) Decreases the risk of latex allergies.
2) Remove gloves from sterile field and use a new pair of sterile gloves.
4) Prevents the skin from drying and chaffing.
3) Throw all supplies away that were to be used and begin again.
15. For which range of time must a nurse wash her hands before working in the operating
room? 4) Use the gloves and make sure the yellow edges of the package do not touch the client.
1) 1 to 2 minutes 21. The nurse is removing personal protective equipment (PPE). Which item should be
removed first?
2) 2 to 4 minutes
1) Gown
3) 2 to 6 minutes
2) Gloves
4) 6 to 10 minutes
3) Face shield
16. How should the nurse dispose of the breakfast tray of a patient who requires airborne
isolation? 4) Hair covering
1) Place the tray in a specially marked trash can inside the patients room. 22. A nurse is splashed in the face by body fluid during a procedure. Prioritize the nurses
actions, listing the most important one first.
Place the tray in a special isolation bag held by a second healthcare worker at the A. Contact employee health
2) patients door. B. Complete an incident report
Return the tray with a note to dietary services so it can be cleaned and reused for the C. Wash the exposed area
3) next meal. D. Report to another nurse that she is leaving the immediate area.
Carry the tray to an isolation trash receptacle located in the dirty utility room and 1) 1, 2, 3, 4
4) dispose of it there. 2) 2, 3, 4, 1
1 . How much liquid soap should the nurse use for effective hand washing? At least: 3) 3, 4, 1, 2
1) 2 mL
4) 4, 1, 2, 3
2) 3 mL Multiple Response
3) 6 mL Identify one or more choices that best complete the statement or answer the question.
4) 7 mL 1. In which situation would using standard precautions be adequate? Select all that apply.
, 1) While interviewing a client with a productive cough patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use
antibacterial soap with warm water to remove dirt and debris from the skin surface. When no
2) While helping a client to perform his own hygiene care visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15
3) While aiding a client to ambulate after surgery seconds.
4) While inserting a peripheral intravenous catheter 2. ANS: 3
2. Which of the following protect(s) the body against infection? Select all that apply. Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other
patients, family members, and contaminated healthcare equipment. Some of these are pathogenic
1) Eating a healthy well-balanced diet (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing
2) Being an older adult or an infant infection among patients are spread by direct contact on the hands of healthcare workers.
3) Leisure activities three times a week 3. ANS: 1
Scrupulous hand washing is the most important part of medical asepsis. Donning gloves,
4) Exercising for 30 minutes 5 days a week applying sterile drapes before procedures, and wearing a protective gown may be needed to
3. The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about ensure asepsis, but they are not the mostimportant aspect because microbes causing most
proper hand washing. The nurse will know that the teaching was effective if the NAP healthcare-related infections are transmitted by lack of or ineffective hand washing.
demonstrate what? Select all that apply. The NAP: 4. ANS: 4
1) uses a paper towel to turn off the faucet. Some people might harbor a pathogenic organism, such as the human immunodeficiency virus
within their body, and yet do not acquire the disease/infection. These individuals, called carriers,
2) holds fingertips above the wrists while rinsing off the soap. have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an
3) removes all rings and watch before washing hands. organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen,
4) cleans underneath each fingernail. such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a
pathogen to a susceptible host through a portal for entry into the body. An example of a vector is
4. Alcohol-based solutions for hand hygiene can be used to combat which types of a mosquito or tick that bites or stings.
organisms? Select all that apply. 5. ANS: 2
1) Virus The organisms responsible for measles and tuberculosis, as well as many fungal infections, are
2) Bacterial spores spread through airborne transmission. Neisseria meningitidis, the organism that causes
meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such
3) Yeast as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect
4) Mold contact or droplet transmission.
5. A patient with tuberculosis is scheduled for computed tomography (CT). How should the 6. ANS: 1
nurse proceed? Select all that apply. Thrush in this patient is an example of an endogenous, nosocomial infection. This type of
1) Question the order because the patient must remain in isolation. infection arises from suppression of the patients normal flora as a result of some form of
treatment, such as antibiotics. Normal flora usually keep yeast from growing in the mouth. In
2) Place an N-95 respirator mask on the patient and transport him to the test. exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent
3) Place a surgical mask on the patient and transport him to CT lab. infection causes no symptoms for long periods. An example of a latent infection is human
immunodeficiency virus infection. A primary infection is the first infection that occurs in a
4) Notify the computed tomography department about precautions prior to transport.
patient.
True/False 7. ANS: 3
Indicate whether the statement is true or false. The stage of decline occurs when the patients immune defenses, along with any medical
1. Bacteria are necessary for human health and well-being. therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes.
Chapter 1. Disease prevention As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between
Answer Section the invasion by the organism and the onset of symptoms. During the incubation stage, the patient
MULTIPLE CHOICE does not know he is infected and is capable of infecting others. The prodromal stage is
1. ANS: 3 characterized by the first appearance of vague symptoms. Convalescence is characterized by
Patients acquire infection by contact with other patients, family members, and healthcare tissue repair and a return to heal as the organisms disappear.
equipment. But most infection among patients is spread through the hands of healthcare workers. 8. ANS: 1
Hand washing interrupts the transmission and should be done before and after all contact with
, To maintain sterile technique, the nurse should close the patients door and limit the number of contents inside a special isolation bag that is held by a second healthcare worker at the patients
persons entering and exiting the room because air currents can carry dust and microorganisms. door. The items must be placed on the inside of the bag without touching the outside of the bag.
Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile 17. ANS: 2
syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.
people and the sterile field to prevent contamination. 18. ANS: 4
9. ANS: 3 The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution
The classic signs of inflammation, a secondary defense against infection, are erythema (redness) dries, usually 10 to 15 seconds, to ensure effectiveness.
and localized heat. The secondary defenses phagocytosis (process by which white blood cells 19. ANS: 2
engulf and destroy pathogens) and the complement cascade (process by which blood proteins Protective isolation is used to protect those patients who are unusually vulnerable to organisms
trigger the release of chemicals that attack the cell membranes of pathogens) do not produce brought in by healthcare workers. Such patients include those with low white blood cell counts,
visible findings. Immunity is a tertiary defense that protects the body from future infection. with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care
units and labor and delivery suites, also use forms of protective isolation.
10. ANS: 2 20. ANS: 2
The patient is most likely experiencing an allergic response to the antibiotic. IgE is the antibody The gloves should be thrown away because the gloves are likely to be contaminated from an
primarily responsible for this allergic response. The antibodies IgA, IgG, and IgM are not outside source. The supplies do not have to be thrown away because they have not been
involved in the allergic response. IgA antibodies protect the body from in fighting viral and contaminated.
bacterial infections. IgG antibioties are the only type that cross the placenta in a pregnant women 21. ANS: 2
to protect her unborn baby (fetus). IgM are the first antibodies made in response to infection. The gloves are removed first because they are usually the most contaminated PPE and must be
11. ANS: 2 removed to avoid contamination of clean areas of the other PPE during their removal. The gown
Intravenous administration of immunoglobulin G provides the patient with passive immunity. is removed second, then the mask or face shield, and finally, the hair covering.
Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive 22. ANS: 3
immunity occurs when antibodies are transferred by antibodies from an immune host, such as If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she is
from a placenta to a fetus. Passive immunity is short-lived. Active immunity is longer lived and leaving the area, contact the infection control or employee health nurse immediately, and
comes from the host itself. Humoral immunity occurs by secreted antibodies binding to antigens. complete an incident report. It is most important to remove the source of contamination (body
Cell-mediated immunity does not involve antibodies but rather fight infection from macrophages fluid) as soon as possible after exposure to help prevent the nurses from becoming infected. The
that kills pathogens. other activities can wait until that is done.
12. ANS: 1 MULTIPLE RESPONSE
More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to 1. ANS: 3, 4
develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV Standard precautions should be instituted with all clients whenever there is a possibility of
infection, others continue to research the common cold. coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous
membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a
13. ANS: 2 client, if the disease is not spread by air or droplets, there is no likelihood of the nurses
Fever, a common defense against infection, increases water loss; therefore, additional fluid is encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne
needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low- precautions would be needed in addition to standard precautions. If giving a complete bed bath
grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely
bedrest, is necessary with a fever. assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely
14. ANS: 3 when helping a client to ambulate after surgery.
Nonpetroleum-based lotion is preferred because it prevents the absorption of latex proteins 2. ANS: 1, 3, 4
through the skin, which can cause latex allergy. Both types of lotion prevent the skin from drying Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against
and becoming chafed. Neither prevents microorganisms from adhering to the skin. infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and
15. ANS: 3 various lifestyle factors can make the body more susceptible to infection.
In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap 3. ANS: 1, 3, 4
used. Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of
16. ANS: 2 the hands and fingers to be effective. The fingers should be held lower than the wrists.
Patients who require airborne isolation are served meals on disposable dishes and trays. To 4. ANS: 1, 3, 4
dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its
