- A UAP is assigned to assist the client with a bed bath. Which action by the nurse is appropriate when supervising the UAP's infection control practices?
Answer: Verify that the UAP washes their hands with soap and water after leaving the room.
The nurse's supervisory responsibility is to ensure all staff providing care to this client adhere to the specific infection control requirements of C. diff — most critically, that hand hygiene is performed with soap and water (not ABHR) after every room exit. This is the non-negotiable action that prevents spore transmission. Choice A is incorrect; gown and gloves are required for all interactions involving contact with the client or contaminated surfaces, regardless of whether a bowel movement is occurring at that moment. Choice C is incorrect; a surgical mask is not indicated for C. diff, which is transmitted via the fecal-oral route, not respiratory droplets — the odor does not change the transmission category. Choice D is a serious infection control violation; the dedicated stethoscope must remain in the room and never be used on other clients without thorough disinfection.
- Which client should the nurse assess first to minimize the risk of cross-contamination?
Answer: A client who is three days postoperative and has an incision line.
To minimize the risk of cross-contamination, the nurse should assess clients in order from most susceptible to least susceptible — seeing non-infectious, vulnerable clients before clients with known or suspected infections. The post-operative client on Day 3 has an open incision line that serves as a direct portal of entry for pathogens; this wound vulnerability makes them the most at risk of acquiring an infection from organisms the nurse might inadvertently carry from other clients' rooms. Importantly, this client is not themselves a source of a transmissible infection. The clients with shingles (A), suspected pertussis (C), and MRSA (B) all have active infections that pose transmission risks — they should be assessed after the clean post-operative client, with appropriate PPE donned for each. Pertussis (C) warrants Droplet Precautions and is particularly contagious, reinforcing that it should not be the first room entered.
- Which instruction should the nurse provide to a family member who is planning to visit the client?
Answer: Please do not bring any fresh flowers or potted plants into the room.
Protective Environments are designed to shield profoundly immunocompromised clients from environmental organisms to which a healthy immune system would normally respond. Fresh flowers and potted plants are prohibited because the soil and stagnant water in which they grow harbor mold and fungi — particularly Aspergillus species — which can cause life-threatening invasive infections in neutropenic clients. Choice A is incorrect; visitors wear a surgical mask (not an N95) to protect the immunocompromised client from the visitor's respiratory organisms — N95 respirators are for airborne precautions protecting health care workers, not visitors in a protective environment. Choice C is incorrect; visitors wear clean (not sterile) gowns and gloves — sterile technique is reserved for invasive procedures. Choice D is directly contraindicated; the door must remain closed to maintain the positive pressure environment that keeps unfiltered hallway air from entering the room.
- Which action by the nurse would result in contamination of the sterile field?
Answer: Reaching across the sterile field to pick up a piece of sterile gauze.
Reaching across a sterile field is a direct violation of surgical aseptic technique. When the nurse's arm, sleeve, or unsterile portion of their body passes over the field, microorganisms and particles can fall from above onto the sterile surface — contaminating it even if no direct contact is made. Items on a sterile field should always be retrieved by approaching from the side, never by reaching across or over the field. Keeping the sterile field in the line of vision (A) is a correct principle of sterile technique — a sterile field that is out of sight is considered contaminated. Opening the glove package on a separate clean surface (C) is correct technique; it avoids potentially contaminating the sterile field during the glove application process. Dropping sterile items onto the center of the field (D) is acceptable technique for introducing supplies without contaminating the field, as long as the item lands within the sterile boundary and is not touched by an unsterile surface during the drop.
- Which combination of personal protective equipment (PPE) should the nurse don before entering the client's room?
Answer: A gown and clean gloves.
Contact Precautions require a gown and clean gloves for all interactions that may involve contact with the client or potentially contaminated surfaces in the client's environment. A mask is not required by Contact Precautions alone. However, if splashing or spraying of blood or body fluids is anticipated — which is a real consideration during wound care and linen change — a mask and goggles or face shield would additionally be indicated under Standard Precautions. A surgical mask without a gown (B) is inadequate for skin and surface contact protection. An N95 respirator (C) is required for Airborne Precautions, not Contact Precautions. Goggles and a surgical mask alone (D) provide respiratory and splash protection but no barrier against skin or clothing contact with contaminated surfaces.
- The nurse should verify that the room meets which requirement?
Answer: The room has a minimum of 6 to 12 air changes per hour.
Airborne Infection Isolation Rooms (AIIRs) are negative-pressure rooms with specific engineering requirements to safely contain airborne pathogens. A minimum of 6 to 12 air changes per hour is required — this range represents the acceptable standard for existing facilities, while current guidelines specify a minimum of 12 ACH for new construction. Frequent air exchange dilutes and removes airborne infectious particles from the room environment. Recirculating room air through the central HVAC system (A) is prohibited because it would spread infectious particles throughout the entire building. Recirculated air must pass through HEPA filtration if it re-enters any occupied space. The door must remain closed at all times (C) — this is essential to maintaining the negative pressure differential that prevents room air from flowing outward. Exhausting air directly into the hallway (D) is explicitly prohibited; exhaust must be directed outside the building or through a HEPA filter before any recirculation.
- The client's diarrhea has subsided for 48 hours and stool cultures are negative. The nurse determines the infection control measures were successful because:
Answer: No other clients or staff members on the unit developed similar symptoms.
The primary goal of transmission-based precautions is to prevent the spread of the infectious agent to others. The absence of secondary cases among other clients and staff on the unit is the most direct evidence that the Contact Precautions, hand hygiene, dedicated equipment, and environmental cleaning protocols successfully contained the pathogen. The client's clinical improvement — resolution of cramping (A) and return of skin turgor (C) — reflects effective treatment of the infection itself but does not measure whether transmission was prevented. These are clinical management outcomes, not infection control outcomes. The client's ability to explain handwashing (D) is an educational outcome that may support long-term prevention but does not confirm that containment was achieved during this admission.
- Which assessment finding should the nurse identify as the most significant indicator that the client requires immediate isolation?
Answer: The reports of 10 to 12 episodes of watery, foul-smelling diarrhea.
Frequent, unexplained watery diarrhea — particularly following recent antibiotic use, which disrupts normal gut flora and allows C. diff to proliferate — is the primary clinical cue that necessitates immediate Contact Precautions. The pattern of 10 to 12 daily episodes is both specific enough to raise strong suspicion for C. diff and directly indicates the fecal-oral transmission risk that isolation is designed to interrupt. Advanced age and antibiotic history (A) are significant risk factors that provide context, but they are predisposing factors rather than the active clinical finding that triggers isolation. Dry mucous membranes and poor skin turgor (C) and lethargy (D) are signs of dehydration and systemic illness — important for clinical management but not the cues that specifically indicate the need for transmission-based precautions.
- Which action should the nurse take next?
Answer: Reinforce that the hands must be rubbed together until the alcohol is dry.
Alcohol-based hand rub is effective only when applied correctly. The product must be rubbed vigorously over all surfaces of the hands — including the fingernails, between the fingers, and the backs of the hands — and allowed to air-dry completely through evaporation. Drying with a paper towel immediately after application physically removes the product before it can exert its antimicrobial effect, rendering the hand hygiene step ineffective. The correct response is immediate re-education on technique. Formal documentation (A) is not warranted for a technique error identified and corrected in real time; the appropriate action is bedside coaching. Instructing the staff member to use soap and water instead (C) is incorrect; ABHR is appropriate for routine hand hygiene and does not need to be replaced — it needs to be used correctly. Choice B confuses the two hand hygiene methods; paper towels are indeed used after soap-and-water washing to dry the hands mechanically, but this does not apply to ABHR.
- Which action by the UAP would require the nurse to intervene?
Answer: The UAP uses the client's phone to call the kitchen for a missing item.
The UAP is wearing contaminated gloves — having entered a Contact Precautions room and potentially touched contaminated surfaces — and is using the client's room phone, which is itself a contaminated surface. Using a contaminated phone brings it into contact with the face, potentially transferring organisms to mucous membranes. The correct action would be to exit the room, remove PPE, perform hand hygiene, and then make the call from outside the room using a clean phone or the nurse call system. Choice B (placing the meal tray on the table) is appropriate and expected. Choice C (removing gloves and gown inside the room before exiting) is acceptable technique per infection control guidelines and does not require intervention — it prevents dragging contaminated PPE out into the hallway. Choice D (ABHR after leaving) is correct hand hygiene practice for general Contact Precautions; this client is not specified as C. diff, so ABHR is appropriate.
- In a hospital medical-surgical unit, a 72-year-old client with a draining wound culture positive for methicillin-resistant Staphylococcus aureus (MRSA) has a temperature of 37.9°C (100.2°F) and WBC 13,200/mm³. The dressing is saturated with serosanguinous drainage. What is the priority action to prevent infection spread?
Answer: Implement contact precautions and wear gown and gloves for room entry
This question tests the application of infection control precautions. The key factor in determining the appropriate precaution is the contact transmission mode of MRSA through direct contact with the draining wound. Implementing contact precautions with gown and gloves for room entry is the priority because it prevents the spread of resistant bacteria via hands or clothing. Airborne precautions are for airborne pathogens like TB, droplet precautions address respiratory droplets, and sterile gloves without a gown do not fully protect against contact transmission, making them incorrect. Infection control principles emphasize using barrier precautions to interrupt contact transmission of multidrug-resistant organisms. Guidelines from the CDC recommend dedicating equipment and thorough cleaning to prevent cross-contamination. A transferable strategy is to don PPE before entering rooms of clients with known resistant infections and perform hand hygiene after removal to protect other clients and staff.
- Which action is most appropriate for the nurse to take regarding respiratory protection?
Answer: Wear a fit-tested N95 respirator for the duration of the room entry.
Pulmonary tuberculosis requires Airborne Precautions. Health care personnel entering the room must wear a fit-tested N95 respirator or higher-level respirator to protect against inhaling the small airborne droplet nuclei that carry Mycobacterium tuberculosis. A standard surgical mask (A) filters large particles and droplets but does not provide adequate protection against the small aerosol particles of TB — this is the critical distinction between Droplet and Airborne Precautions. Asking the client to wear a surgical mask (C) may help limit the client's output of infectious particles but does not replace the nurse's respiratory protection. Keeping the door open (D) is directly contraindicated — the door must remain closed to maintain negative pressure and prevent airborne organisms from escaping into the hallway.
- The nurse recognizes that the client's current symptoms and recent history put her at high risk for which primary complication?
Answer: Severe dehydration and electrolyte imbalance.
Ten to twelve episodes of watery diarrhea per day cause rapid loss of free water and electrolytes — particularly sodium, potassium, and bicarbonate — placing this elderly client at immediate risk for severe dehydration and potentially dangerous electrolyte disturbances. The admission findings of dry mucous membranes, poor skin turgor, and lethargy already indicate active fluid volume deficit. In older adults, electrolyte imbalances such as hyponatremia and hypokalemia can have serious cardiac and neurological consequences. Hospital-acquired pneumonia (A) is not related to the current presentation. Development of a pressure injury (C) is a secondary concern related to immobility and skin exposure to stool, but is not the immediate primary complication. Surgical site infection (B) is not applicable as the client has not had surgery.
- Which action should the nurse take to safely dispose of the used needle?
Answer: Place the needle and syringe in a puncture-resistant container immediately.
Standard Precautions require that all used sharps be immediately placed into a puncture-resistant, leak-proof sharps container without manipulation. This is the most effective way to prevent needle-stick injuries to the nurse and other personnel. Recapping using the two-handed technique (B) is explicitly prohibited by Standard Precautions; needle-stick injuries occur most commonly during recapping. The one-handed scoop technique is acceptable only as an absolute last resort when no sharps container is available. Breaking the needle (C) is dangerous and prohibited — it creates sharps fragments and aerosols that increase injury and exposure risk. Disposing in regular trash (D) is never acceptable for sharps regardless of whether blood is visible; all used sharps are considered contaminated.
- Based on the suspected C. diff infection, which nursing hypothesis is the priority for maintaining a safe care environment?
Answer: Risk for infection transmission to other clients and staff.
Within the Safe and Effective Care Environment domain, the priority nursing hypothesis is preventing the transmission of a highly contagious and environmentally hardy pathogen to other vulnerable clients and staff. C. diff spores can survive on environmental surfaces for months, and a single lapse in Contact Precautions can initiate an outbreak with serious consequences for immunocompromised patients on the unit. Risk for impaired skin integrity (A) is a real and important concern — prolonged fecal contact causes skin breakdown — but it is a clinical management priority rather than an environmental safety priority. Deficient knowledge (C) and disturbed sleep (D) are relevant but represent lower-acuity concerns that do not carry the same immediate safety implications for the broader care environment.
- Which action should the nurse take to maintain appropriate precautions during transport?
Answer: Notify the radiology department and have the client wear a surgical mask.
When a client on Droplet Precautions must leave their room, a surgical mask is placed on the client — not the transport personnel — to contain respiratory secretions at the source and prevent dispersal of droplets throughout the hallways and the receiving department. The receiving department must also be notified in advance so they can prepare the space and minimize contact with other patients. This is the standard approach for maintaining precautions during unavoidable transport. Requiring transport personnel to wear N95 respirators (B) is incorrect; N95s are for Airborne Precautions, and Droplet Precautions personnel wear surgical masks — the key distinction is that it is the client, not the staff, who wears the mask during transport. Placing a gown and goggles on the client (C) is not standard or necessary. Canceling medically necessary procedures (D) is inappropriate when safe transport with appropriate precautions is achievable.
- Which combination of precautions should the nurse implement for this client?
Answer: Airborne and Contact Precautions.
Disseminated Herpes Zoster — defined as lesions spanning multiple dermatomes or present in an immunocompromised client — requires both Airborne and Contact Precautions. Airborne Precautions are necessary because the varicella-zoster virus can be aerosolized from the lesions and transmitted via small airborne particles, in addition to direct contact with vesicular fluid. This is in contrast to localized shingles in an immunocompetent client, which requires only Contact Precautions. Standard Precautions alone (A) are insufficient for disseminated disease. Contact and Droplet (B) is incorrect because droplets are large-particle and short-range; varicella-zoster in disseminated form requires the higher level of respiratory protection provided by Airborne Precautions with a fit-tested N95. Protective Environment (D) is for immunocompromised clients who need protection from the environment, not for infectious clients who require isolation.
- Which type of transmission-based precautions should the nurse implement for this client?
Answer: Droplet Precautions.
Bacterial meningitis, most commonly caused by Neisseria meningitidis or Streptococcus pneumoniae, is transmitted via large respiratory droplets generated by coughing, sneezing, or close contact. Droplet Precautions are required — along with a private room and surgical mask for health care personnel within 3 feet of the client — until the client has received at least 24 hours of effective antibiotic therapy. Airborne Precautions (A) are used for pathogens transmitted via small-particle aerosols that can remain suspended in air, such as tuberculosis, measles, and varicella — not bacterial meningitis. Contact Precautions (B) are not the standard for meningitis unless a concurrent contact-transmitted organism is identified. Protective Environment (D) is reserved for profoundly immunocompromised clients such as those receiving stem cell transplants.
- Which statement by the UAP indicates a correct understanding of the doffing procedure?
Answer: I will remove my gloves first, as they are the most contaminated.
The standard doffing sequence — gloves first, then goggles or face shield, then gown, and finally the mask or respirator last — is designed to progress from the most contaminated items to the least contaminated. Gloves are considered the most heavily contaminated because they have had direct contact with the client and environmental surfaces throughout the interaction. Removing them first protects the hands from contaminating subsequently handled items. Choice A is incorrect because the mask is the last item removed, not the first; removing it first risks face contamination from the gown or gloves during subsequent removal. Choice C states the gown should come after the mask, which reverses the correct order — the gown should be removed before the mask. Choice B is incorrect because all PPE items except the mask/respirator should be removed before exiting the room; goggles should come off inside or at the doorway, not after leaving.
- The nurse is preparing the client's room. Which action should be included in the plan of care to comply with Contact Precautions?
Answer: Ensure a dedicated stethoscope and blood pressure cuff are in the room.
Contact Precautions require that dedicated or single-use client care equipment — such as a stethoscope and blood pressure cuff — remain in the client's room to prevent cross-contamination between clients. Reusable equipment that leaves the room must be thoroughly disinfected before use on another client. Choice B is incorrect; the appropriate sign is Contact Precautions, not Droplet Precautions — applying the wrong sign risks staff using inadequate PPE. Choice C is incorrect; cohorting clients requires a confirmed matching diagnosis, not just a symptom — C. diff should be isolated in a private room with its own bathroom if possible, and a history of diarrhea alone is not grounds for cohorting. Choice D is particularly dangerous in this context: stocking only ABHR implies it is sufficient for C. diff care, but ABHR is ineffective against C. diff spores; soap and water must be the primary hand hygiene method and must be available.
