Asepsis T

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Sample questions from Asepsis T

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a 16-year-old with leukemia receiving chemotherapy has a temperature of 38.3 C, HR 122, BP 98/60, and ANC 300/mm3. A client with a draining MRSA wound is in the next room. Which action should the charge nurse take first?

   • A.Apply contact precautions to the neutropenic client and delay provider notification until blood cultures are collected.
   • B.Ask the unlicensed assistive personnel to obtain another temperature in 1 hour before changing the room assignment.
   • C.Place the neutropenic client in the room with the client who has MRSA, using separate equipment for each client.
   • D.Place the neutropenic client in a private room and initiate protective precautions while arranging prompt evaluation for febrile neutropenia.

   Rationale: The fever, tachycardia, borderline blood pressure, and ANC of 300/mm3 indicate a time-sensitive risk for serious infection; protect the client from exposure and arrange immediate evaluation. Cohorting with a client who has MRSA increases exposure risk, and waiting an hour delays care for a possible neutropenic emergency. Cultures may be obtained promptly as ordered, but they should not delay notification and evaluation.

2. 2.During a home-health visit, a 72-year-old with a healing abdominal incision asks the nurse to change the dressing. The client is stable, has no fever, and has limited hand dexterity from arthritis. Which task is appropriate to delegate to a trained assistive personnel?

   • A.Remove the soiled dressing and report the amount and appearance of drainage.
   • B.Teach the client how to maintain a sterile field when changing the dressing.
   • C.Irrigate the incision with sterile saline and pack the wound as prescribed.
   • D.Assess the incision for separation, warmth, and purulent drainage before the dressing change.

   Rationale: Removing a soiled dressing and reporting observable drainage are predictable tasks that can be delegated to trained assistive personnel, with the nurse retaining responsibility for assessment and follow-up. Evaluating the incision, irrigating and packing the wound, and teaching require nursing judgment or skill. Delegation does not transfer the nurse's responsibility to verify and act on reported findings.

3. 3.Refer to the client's chart. Which actions should the nurse take now to reduce infection risk and respond to the change in condition? Select all that apply.

   • A.Disconnect the catheter from the drainage tubing to obtain a cleaner urine specimen.
   • B.Collect a urine specimen from the sampling port using aseptic technique before starting a new antimicrobial, if this does not delay urgent treatment.
   • C.Notify the provider promptly about the fever, chills, and new suprapubic tenderness.
   • D.Keep the drainage bag below bladder level and ensure the tubing is not kinked.
   • E.Remove the catheter independently because the urine is cloudy.

   Rationale: The temperature rise from 37.1 C to 38.4 C, new chills, suprapubic tenderness, and pyuria warrant prompt provider notification and an aseptically collected specimen from the sampling port. Keeping the bag below the bladder and tubing unkinked helps prevent reflux and supports unobstructed drainage. Disconnecting the closed system increases contamination risk, and catheter removal requires an order or an applicable protocol rather than being based only on cloudy urine.

4. 4.The provider prescribes cefazolin for a 34-year-old scheduled for a clean-contaminated bowel procedure. The client has a history of immediate anaphylaxis to penicillin, and the first dose is due before incision. Which action should the nurse take?

   • A.Give the dose with an antihistamine and monitor the client in the preoperative area.
   • B.Delay the dose until after the incision so an allergic reaction can be distinguished from an anesthetic reaction.
   • C.Hold the dose and clarify the order with the prescriber and pharmacist before administration.
   • D.Administer the cefazolin now because prophylaxis is most effective before incision.

   Answer and rationale are in the full material.

5. 5.In a pediatric clinic, a 9-year-old with a forearm laceration is alert and stable. While preparing a sterile dressing tray, the nurse turns to answer a question and the sterile-gloved hand drops below waist level. What should the nurse do?

   • A.Apply antiseptic solution to the glove and proceed with the dressing.
   • B.Replace the glove and reestablish the sterile field before continuing.
   • C.Ask the parent to hold the sterile supplies while the nurse changes gloves.
   • D.Continue because the glove has not touched a visibly contaminated surface.

   Answer and rationale are in the full material.