A nurse cares for several adults on a medical-surgical unit. Which actions are components of Standard Precautions used for every client, regardless of suspected or confirmed infection? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Standard Precautions apply to every client. They include respiratory hygiene and source-control measures at entry points (Choice 2), risk-based use and prompt removal of gloves followed by hand hygiene (Choice 4), and hand hygiene at the appropriate moments surrounding care (Choice 5). Gloves are changed between clients and between contaminated and clean tasks; visible soil is not required for transmission to occur (Choice 1). Used sharps are not routinely recapped and should be discarded immediately in a nearby sharps container; a one-handed scoop is reserved for the unusual situation in which recapping is unavoidable (Choice 3). Airborne precautions and an airborne infection isolation room are added when the suspected or confirmed pathogen requires them, not for fever alone (Choice 6).
Standard Precautions (Tier 1) — Apply to ALL Clients 1. Hand hygiene at WHO 5 Moments 2. PPE based on anticipated exposure: gloves, gown, mask, eye protection 3. Respiratory hygiene/cough etiquette 4. Sharps safety: never recap; sharps container at point of use 5. Safe injection practices: aseptic technique, single-dose vials when possible 6. Environmental cleaning and equipment reprocessing 7. Linen handling as if contaminated; handle reusable instruments with PPE 8. Client placement based on transmission risk
WHO 5 Moments for Hand Hygiene 1. Before client contact 2. Before aseptic procedure 3. After body fluid exposure risk 4. After client contact 5. After contact with client surroundings
Glove Use Rules - Use whenever contact with blood, body fluids, mucous membranes, non-intact skin, contaminated equipment is anticipated - Single-client use; never reuse between clients - Change gloves between dirty and clean tasks on the SAME client - Remove immediately after task; hand hygiene after removal
Sharps Safety - Never recap with two hands - One-hand scoop technique only when necessary - Sharps container at point of use (bedside) - Never overfill (replace at 3/4 full) - Use safety-engineered devices when available
When to Add Transmission-Based Precautions (Tier 2) Add ON TOP OF standard precautions when pathogen suspected: - Contact: MRSA, VRE, CRE, C. difficile, scabies - Droplet: influenza, pertussis, meningococcus, mumps - Airborne: TB, measles, varicella (negative-pressure room + N95)
Memory Tip "Standard for ALL; Hand hygiene + PPE-by-task + Respiratory etiquette + Sharps safety"
ScenarioGeneral med-surg unit; multiple adult clients; nurse applying standard precautions to ALL.
Action Map1. Hand hygiene WHO 5 Moments2. Gloves when contact with blood/fluids/mucous/non-intact skin/contaminated equipment anticipated3. Cough etiquette at entry; tissues, hand sanitizer, masks for coughing persons4. Sharps: never recap; sharps container at point of use5. Add transmission-based precautions (contact·droplet·airborne) when pathogen suspected
Avoid- Reusing gloves between clients- Recapping needles with two hands- Negative-pressure room for all febrile clients (only when airborne suspected)- Skipping hand hygiene at any of the 5 Moments
Standard Precautions — Foundational (Tier 1) infection prevention measures applied to ALL clients regardless of known infection status. Components: hand hygiene at WHO 5 Moments; PPE based on anticipated exposure (gloves, gown, mask, eye protection); respiratory hygiene/cough etiquette; sharps safety (no recap, container at point of use); safe injection practices; environmental cleaning and equipment reprocessing; linen handling as if contaminated; client placement based on transmission risk. Transmission-based precautions (contact, droplet, airborne) are added IN ADDITION when a specific pathogen is suspected.
WHO 5 Moments for Hand Hygiene — Standardized framework for when hand hygiene must occur during care: (1) BEFORE client contact, (2) BEFORE aseptic procedure, (3) AFTER body fluid exposure risk, (4) AFTER client contact, and (5) AFTER contact with client surroundings. Methods: alcohol-based hand rub for routine hand hygiene; soap and water when hands are visibly soiled, after contact with C. difficile, or after exposure to spore-forming organisms.
Sharps Safety and Needlestick Prevention — Used needles must NOT be recapped using two hands due to risk of needlestick injury and bloodborne pathogen exposure. One-hand scoop technique is acceptable only when absolutely necessary. Sharps containers must be located at the point of use (bedside or in the immediate care area), and replaced when 3/4 full. Use safety-engineered devices when available. Postexposure: wash with soap and water immediately, report, follow institutional postexposure prophylaxis protocol promptly.