ATI Engage Fundamentals: Infection Control and Isolation, ATI Engage Fundamentals: Mobility, ATI - Engage Fundamentals RN 2.0: Safety, Comprehensive Nursing Care for Immobility: Musculoskeletal, Cardiac, Respiratory, and Infection Prevention

Which of the following factors are examples of reservoirs in the chain of infection?

A. Health care workers

B. Clients

C. Bacteria

D. Furniture

E. Equipment

F. Viruses

A. Health care workers

B. Clients

D. Furniture

E. Equipment

A client has a draining, infected wound. The drainage touches a cut on a nurse's skin, leading to an infection. What type of transmission is this?

Direct contact transmission

A client who has a respiratory infection sneezes without covering the mouth and nose. A person a few feet away becomes infected when large mucus particles land in their mouth. What type of transmission is this?

Droplet transmission

A client who coughed on their hand touches a door handler. Another person touches the same door handle and becomes infected with the same pathogen as the client. What type of transmission is this?

Indirect contact transmission

A nurse enters a room where a client who has a respiratory infection was present for several hours. The nurse inhales small particles that remain in the air and develops an infection. What type of transmission is this?

Airborne transmission

A client who has extremely dry, flaky skin asks why the nursing staff continually applies lotion. How should the nurse respond?

The skin is the largest organ of the body and is the body's primary physical defense. Keeping the skin moisturized helps to keep skin intact, which reduces the risk of infection. The skin performs three major functions, reducing water loss, protecting against abrasion and microbes, and providing a permeable barrier against the environment.

Place the findings in the order in which they occur during the inflammatory response.

- Bacteria invade an open wound

- Pus develops

- Phagocytosis occurs

- Histamine, Kinins, and Prostaglandins arrive at the site

- Plasma from the blood enters the site

1. Bacteria invade an open wound

2. Histamine, Kinins, and Prostaglandins arrive at the site

3. Plasma from the blood enters the site

4. Phagocytosis occurs

5. Pus develops

A home health nurse is caring for a client who had a left knee replacement surgery 5 days ago. Which of the following findings should the nurse report to the provider?

A. The client can walk with a walker 40 feet

B. The client elevates the left leg when sitting and sleeping

C. The client's temperature is 98.6 degrees

D. The client's left knee is warm to touch and erythematous

D. The client's left knee is warm to touch and erythematous

A nurse is washing the hands with antimicrobial soap and water. How long should the nurse rub the hands together?

As long as is needed to sing "Happy Birthday" two times (about 15 to 30 seconds)

A nurse is caring for a client whose family member asks why nurses cannot wear gel nail polish or have long fingernails. How should the nurse respond to the family member?

Keeping the fingernails short helps to protect clients by preventing the growth of bacteria under the fingernails. Nail polish, if worn, must not be chipped, because this also promotes bacteria growth. Gel nail polish is especially difficult to clean around, even with proper handwashing practices. Even with good hand hygiene, bacteria are not reduced effectively when health care workers wear gel nail polish.

What term describes the clean technique used in healthcare?

Medical asepsis; It reduces the number of micro-organisms on surfaces.

A nurse is caring for a client with a large draining foot wound. Which of the following PPE equipment should the nurse don prior to entering the client's room?

A. Sterile gloves and mask

B. Non-sterile gloves and gown

C. Mask and face shield

D. Gown and face shield

B. Non-sterile gloves and gown

A nurse needs to assign rooms for two new clients needing contact isolation, but only one semi-private room is currently available. One client to being admitted due to diarrhea from Clostridium difficile. The other client has a large draining abdominal wound, but the pathogen has not yet been identified from the culture. Can these two clients be placed in the same room? Why or why not?

No. These two clients both require contact isolation, but for different reasons. It is preferable that clients requiring isolation be assigned a private room. However, if that is not possible, the clients could be placed in the same room, but only if they have the same pathogen. In addition, cohorting clients is a last resort, and the infection control nurse in the facility should be consulted also to assist in the final decision.

A client suspected of having tuberculosis should have what type of isolation?

Airborne

A client with a draining wound infected with MRSA should have what type of isolation?

Contact

A client who is sneezing, and is suspected of having seasonal influenza should have what type of isolation?

Droplet

A client who needs to have vital signs taken should have what type of isolation?

Standard

A client who had a hematopoietic stem cell transplant this week should have what type of isolation?

Protective

A client with frequent, large diarrheal stools and is incontinent should have what type of isolation?

Contact

A client diagnosed with adenovirus should have what type of isolation?

Droplet

A client with a broken bone should have what type of isolation?

Standard

What PPE should the nurse put on prior to performing care for a client who requires contact precautions?

A nurse caring for a client who requires contact precautions should don PPE (gown and gloves at minimum) prior to entering the room if the nurse expects to come in contact with the client or any contaminated items in the room.

Place the steps in the correct order for removing nonsterile gloves:

- Peel glove away from the body turning it inside-out and hold it in the other hand

- Use bare fingers to slide under cuff of the glove

- Use fingers of opposite hand to grasp the outside of the glove at cuff

- Perform hand hygiene

- Dispose of gloves in trash receptacle inside client's room

- Peel the glove inside out, leaving the first glove inside the second glove

1. Use fingers of opposite hand to grasp the outside of the glove at cuff

2. Peel glove away from the body turning it inside-out and hold it in the other hand

3. Use bare fingers to slide under cuff of the glove

4. Peel the glove inside out, leaving the first glove inside the second glove

5. Dispose of gloves in trash receptacle inside client's room

6. Perform hand hygiene

Which of these situations require gloves?

- Reviewing discharge instruction with a client who had a heart attack

- Emptying a client's bedpan

- Administering an oral medication to a client who has an MDRO in their urine

- Changing a diaper on an infant who has a heart defect

- Assisting a client who has a seizure disorder to a bedside chair

- Emptying a client's bedpan

- Administering an oral medication to a client who has an MDRO in their urine

- Changing a diaper on an infant who has a heart defect

Which of these situations do not require gloves?

- Reviewing discharge instruction with a client who had a heart attack

- Emptying a client's bedpan

- Administering an oral medication to a client who has an MDRO in their urine

- Changing a diaper on an infant who has a heart defect

- Assisting a client who has a seizure disorder to a bedside chair

- Reviewing discharge instruction with a client who had a heart attack

- Assisting a client who has a seizure disorder to a bedside chair

How many times can a gown be worn?

Once.

Place the steps for removing PPE and performing hand hygiene in the correct order.

- Remove mask

- Perform hand hygiene

- Remove gloves

- Remove goggles or face shield

1. Remove gloves

2. Remove goggles or face shield

3. Remove mask

4. Perform hand hygiene

What PPE should a nurse use when administering medications to a client on contact precautions?

Gloves and gown

What PPE should a nurse use when performing a wound irrigation where splashing is expected in the facial area?

Gloves, gown, and face shield

What PPE should a nurse use when transporting a client on droplet precautions to the x-ray department?

Face mask

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?

A. Empty sharps containers when they become full

B. Report needlestick injuries to the nursing supervisor

C. Engage the safety device on a needle after documenting the medication administration

D. Recap needles after medication administration

B. Report needlestick injuries to the nursing supervisor

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections. Which of the following interventions should the nurse include in the bundle?

A. Try to use alternatives before inserting indwelling urinary catheters

B. Use clean technique for insertion of indwelling urinary catheters

C. Check clients every 2 days to evaluate the need for indwelling urinary catheters

D. Disconnect the system to obtain urine samples from indwelling urinary catheters

A. Try to use alternatives before inserting indwelling urinary catheters

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?

A. Wear an N95 respirator when caring for the client

B. Place the client in a private room

C. Place a mask on the client when they leave their room

D. Place the client in a negative airflow room

B.Place the client in a private room

A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the links in the chain of infection does the faucet represent?

Reservoir

A nurse is admitting a client who has vancomycin-resistant enterococcus of the urine. The nurse should place the client on which precautions?

Contact

A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?

A. You can wear artificial fingernails if they are kept short

B. Leave rings on your fingers when performing surgical hand asepsis

C. Keep your fingernails less than half an inch in length

D. Remove nail polish on your fingernails if it is chipped

D. Remove nail polish on your fingernails if it is chipped

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that what is an infectious trigger?

A. Burn

B. Frostbite

C. Bacteria

D. Radiation

C. Bacteria

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized information. The nurse should include which of the following laboratory tests?

A. C-reactive protein

B. Troponin

C. Creatine kinase

D. Lactic Acid

A. C-reactive protein

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that what types of precautions requires the use of an N95 mask?

Airborne

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

A. Washed their hands for 10 seconds

B. Turns off the faucet with a towel

C. Uses hot water to wash their hands

D. Holds their hands above their elbows while rinsing off the soap

B. Turns off the faucet with a towel

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms. Which of the following information should the nurse indicate?

A. The door to the AIIR should remain closed

B. Clients who are on contact precautions require AIIR

C. An AIIR has at least 4 air exchanges each hour

D. A mask is not needed to care for clients who are in an AIIR

A. The door to the AIIR should remain closed

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hours. The nurse suspects the client has acquired an infection. What stage of infection is the client likely experiencing?

Prodromal

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?

A. Use a brush to scrub the surface of the hands

B. Rinse antiseptic solution from the hands before it dries

C. Apply chlorhexidine and ethanol to the hands

D. Leave jewelry on the hands when cleansing them

C. Apply chlorhexidine and ethanol to the hands

A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment. What should the nurse instruct to remove first?

Gloves

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?

A. Gowns can be reused on the same client

B. Masks should be removed after leaving a clients room

C. Gloves should be removed from the inside out

D. Eyeglasses can be used in place of goggles

C. Gloves should be removed from the inside out

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?

A. Open the first flap on the sterile package away from their body

B. Place objects on the sterile field at least 0.5 inches from the edge

C. Unwrap both sides of the sterile package at the same time

D. Set up the sterile field next to a wall in the client's room

A. Open the first flap on the sterile package away from their body

A nurse is planning to admit a client who has a respiratory syncytial virus. What transmission-based precautions should the nurse plan to implement?

Contact

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by what mode of transmission?

Airborne

A nurse is caring for a client who has influenza. The client asked how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by what mode?

Droplet

A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in what stage of infection?

Convalescence

A nurse is performing hang hygiene after caring for a client who has Clostridium difficile. What hand hygiene method should the nurse use?

Soap and water

A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?

A. After donning a gown and before collecting vital signs on the client

B. After removing food items off the client's tray and before removing soiled linens from the client's bed

C. After helping the client stand up and before helping them brush their teeth

D. After changing a dressing on the client and before documenting findings on a computer

D. After changing a dressing on the client and before documenting findings on a computer

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include int he teaching that pertussis is transmitted by what mode of transmission?

Droplet

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of what link in the chain of infection?

Susceptible host

A nurse is performing a throat culture on a client. Which os the following actions should the nurse take?

A. Swab the back of the client's pharyngeal wall

B. Place the swab in a clean container after obtaining the culture

C. Insert the swab in the culture medium within 1 hour of obtaining the sample

D. Don sterile gloves to obtain the culture from the client

A. Swab the back of the client's pharyngeal wall

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?

Remind the client to use incentive spirometer

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Muscles

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?

"The top of the walker should be at the level of your wrist."

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

Prone

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?

Toileting

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?

1. Stand as close to the object as possible

2. Keep abdominal muscles contracted and lower the back straight

3. Look straight ahead with shoulders raised up

4. Bend hips slightly and squat

5. Push up from the knees when lifting the object

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowler's

A nurse in a long term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

Atrophy

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage into the skin layer

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

1. A stable center of gravity increases stability and balance

2. A wide base lowers the center of gravity

3. Proper body alignment involves tightening the abdomen

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

Mechanical lift

A nurse is preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face-to-face when transferring the client

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at a Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward

A nurse is caring for a client who had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Occupational Therapist

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

Tendons connect muscle to bone

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfaction

A nurse is performing a focused assessment to an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

The client has the crutches resting 5 cm (2 in) below their axilla

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

The contraction of a muscle results in flexion of a joint

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Mechanical lift

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? (Select all that apply.)

The date the medication was mixed

The dose of the mixed medication

The time the medication was mixed

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (Select all that apply.)

Place the client on round-the-clock surveillance.

Remove objects from the room that the client could use to harm themselves.

Search items brought into the client's room by visitors.

Screen the client for suicidal ideation.

A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take?

Remove the restraints with each vital sign check.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

Record the time and length of the seizure.

A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (Select all that apply.)

The client's full name

The client's date of birth

The client's telephone number

A nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include?

Frequent reports of not being treated fairly

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (Select all that apply.)

Locks the brakes on the client's bed

Checks the maximum weight of the lift before using it

Performs a safety check before lifting the client

A nurse is planning to implement the Transforming Care at the Beside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan?

Use a standardized communication tool.

A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is a hospital-acquired injury? (Select all that apply.)

Blood transfusion incompatibility

Wrong site surgery

Ineffective insulin usage

A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

The nurse holds onto the plug to unplug a client's electronic blood pressure machine.

A nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR?

The client's laboratory test results

A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (Select all that apply.)

A client's visitor falls in the hallway

A client develops an unexpected reaction to a medication

A client's dentures are lost

A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next?

Activate the fire alarm.

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)

Fall history

Medical diagnosis

Use of assistive devices

Mental status

A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety?

The edges of stairs are marked with brightly colored tape.

A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take?

Rinse the client's skin with water.

A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? (Select all that apply.)

Catheter-associated urinary tract infection

Central line-associated bloodstream infection

Surgical site infection

A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection?

Perform hand hygiene.

A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for fire to occur? (Select all that apply.)

Cooking oil

Oxygen

Heat

A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events?

Near-miss event