Nursing: A Concept-Based Approach to Learning Vol. 1 & 2, 3e (Pearson)
Module 9 Infection
The Concept of Infection
1) Which actions should the nurse take to help the client with bowel and bladder dysfunction
reduce the risk of infection? Select all that apply.
A) Isolate the client using transmission-based precautions.
B) Monitor intake and output.
C) Provide hygienic care after episodes of incontinence.
D) Use standard precautions when handling linen after episodes of incontinence.
E) Limit fluid intake.
Answer: B, C, D
Explanation: A) Monitoring intake and output is important because it can help reveal whether a
client is experiencing dehydration. Dehydration may lead to urinary stasis, which increases the
risk of infection. Similarly, intake and output levels can help reveal urinary retention, which also
heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder
incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper
biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an
infection. In contrast, limiting fluid intake increases infection risk by putting the client at greater
risk for dehydration. Isolating the client using transmission-based precautions is not necessary
because these precautions are meant to prevent the spread of infection from the client to others,
and this client is not currently experiencing infection.
B) Monitoring intake and output is important because it can help reveal whether a client is
experiencing dehydration. Dehydration may lead to urinary stasis, which increases the risk of
infection. Similarly, intake and output levels can help reveal urinary retention, which also
heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder
incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper
biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an
infection. In contrast, limiting fluid intake increases infection risk by putting the client at greater
risk for dehydration. Isolating the client using transmission-based precautions is not necessary
because these precautions are meant to prevent the spread of infection from the client to others,
and this client is not currently experiencing infection.
C) Monitoring intake and output is important because it can help reveal whether a client is
experiencing dehydration. Dehydration may lead to urinary stasis, which increases the risk of
infection. Similarly, intake and output levels can help reveal urinary retention, which also
heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder
incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper
biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an
infection. In contrast, limiting fluid intake increases infection risk by putting the client at greater
risk for dehydration. Isolating the client using transmission-based precautions is not necessary
because these precautions are meant to prevent the spread of infection from the client to others,
and this client is not currently experiencing infection.
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,D) Monitoring intake and output is important because it can help reveal whether a client is
experiencing dehydration. Dehydration may lead to urinary stasis, which increases the risk of
infection. Similarly, intake and output levels can help reveal urinary retention, which also
heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder
incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper
biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an
infection. In contrast, limiting fluid intake increases infection risk by putting the client at greater
risk for dehydration. Isolating the client using transmission-based precautions is not necessary
because these precautions are meant to prevent the spread of infection from the client to others,
and this client is not currently experiencing infection.
E) Monitoring intake and output is important because it can help reveal whether a client is
experiencing dehydration. Dehydration may lead to urinary stasis, which increases the risk of
infection. Similarly, intake and output levels can help reveal urinary retention, which also
heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder
incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper
biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an
infection. In contrast, limiting fluid intake increases infection risk by putting the client at greater
risk for dehydration. Isolating the client using transmission-based precautions is not necessary
because these precautions are meant to prevent the spread of infection from the client to others,
and this client is not currently experiencing infection.
Page Ref: 574
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and
standardized practices that support safety and quality. | AACN Essential Competencies: IX.12
Create a safe environment that results in high quality patient outcomes. | NLN Competencies:
Knowledge and Science: Relationships between knowledge/science and quality and safe patient
care. | Nursing Process: Implementation
Learning Outcome: 9.3 Outline the relationship between infection and other concepts.
MNL LO: Analyze the concept of infection and its application to nursing care.
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,2) A nurse is planning an in-service on preventing infection for the staff nurses on a hospital's
medical-surgical unit. Which of the following should be the priority teaching point for this in-
service?
A) Raising the temperature in each client's room
B) Assessing vital signs once daily
C) Wearing a mask for client care
D) Performing hand hygiene
Answer: D
Explanation: A) Hand hygiene is always the first and best way to stop the spread of
microorganisms, which cause infections. Raising the temperature in a client's room would
contribute to the growth of microorganisms. Assessing vital signs is important but should be
done more frequently than once daily. Wearing a mask for all clients is not practical and is
unnecessary unless a microorganism is airborne and the client is in isolation.
B) Hand hygiene is always the first and best way to stop the spread of microorganisms, which
cause infections. Raising the temperature in a client's room would contribute to the growth of
microorganisms. Assessing vital signs is important but should be done more frequently than once
daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is
airborne and the client is in isolation.
C) Hand hygiene is always the first and best way to stop the spread of microorganisms, which
cause infections. Raising the temperature in a client's room would contribute to the growth of
microorganisms. Assessing vital signs is important but should be done more frequently than once
daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is
airborne and the client is in isolation.
D) Hand hygiene is always the first and best way to stop the spread of microorganisms, which
cause infections. Raising the temperature in a client's room would contribute to the growth of
microorganisms. Assessing vital signs is important but should be done more frequently than once
daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is
airborne and the client is in isolation.
Page Ref: 574
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and
standardized practices that support safety and quality. | AACN Essential Competencies: IX.12
Create a safe environment that results in high quality patient outcomes. | NLN Competencies:
Quality & Safety: Current best practices. | Nursing Process: Planning
Learning Outcome: 9.4 Explain health promotion and infection prevention.
MNL LO: Analyze the concept of infection and its application to nursing care.
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, 3) The nurse is assessing a client who is recovering following surgery. Which factor would
increase this client's susceptibility to infection?
A) Intact mucous membranes
B) Presence of an incision
C) Dry skin
D) Active bowel sounds
Answer: B
Explanation: A) This client has a surgical incision, so the body's first line of defense, the skin, is
not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help
defend the body against infection.
B) This client has a surgical incision, so the body's first line of defense, the skin, is not intact.
Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the
body against infection.
C) This client has a surgical incision, so the body's first line of defense, the skin, is not intact.
Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the
body against infection.
D) This client has a surgical incision, so the body's first line of defense, the skin, is not intact.
Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the
body against infection.
Page Ref: 564
Cognitive Level: Understanding
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods
and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care
that reflects an understanding of human growth and development, pathophysiology,
pharmacology, medical management and nursing management across the health-illness
continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and
Science: Relationships between knowledge/science and quality and safe patient care. | Nursing
Process: Assessment
Learning Outcome: 9.2 Differentiate alterations in infection.
MNL LO: Analyze the concept of infection and its application to nursing care.
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