Infection Control and Safety

Infection Control and Safety is the body of nursing knowledge concerned with preventing the transmission of infectious organisms and protecting patients, visitors, and staff from physical harm in the care environment. This article is the shared content article for both the NCLEX-RN and NCLEX-PN tracks. Track-specific practice questions and flashcards are linked at the bottom of the page.

Why This Subject Matters

Healthcare-associated infections (HAIs) are infections that a patient acquires while receiving treatment for another condition and that were not present or incubating on admission. They prolong length of stay, increase cost, and cause preventable death. The four HAIs most often targeted by prevention programs are catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI). Nearly every evidence-based prevention bundle for these infections is built out of nursing actions: hand hygiene, aseptic insertion and maintenance, daily assessment of whether the device is still needed, oral care, head-of-bed elevation, and skin antisepsis.

Safety content is grouped with infection control on licensure exams because both are forms of environmental risk control. The nurse who prevents a fall, avoids an unnecessary restraint, recognizes a frayed cord, and secures an oxygen cylinder is doing the same fundamental work as the nurse who performs hand hygiene between patients: identifying a hazard in the environment and interrupting it before it reaches the patient.

Application note. On both exams, the single most frequently correct infection control answer is hand hygiene, and the single most frequently correct safety answer is the least restrictive intervention that still protects the patient. When two options both look reasonable, choose the one that protects the patient without adding a new risk.

The Chain of Infection

Infection requires six links. Breaking any one link prevents transmission, and most nursing interventions are best understood as attacks on a specific link.

1. Infectious agent. The bacterium, virus, fungus, protozoan, prion, or helminth capable of causing disease. Virulence, invasiveness, and dose influence whether infection occurs. Nursing and system interventions: antimicrobial stewardship, disinfection and sterilization of equipment, environmental cleaning.
2. Reservoir. Where the organism lives and multiplies: humans (symptomatic patients and asymptomatic carriers), animals, water, soil, food, contaminated equipment, biofilm in sink drains. Interventions: cleaning and disinfection, proper waste and linen handling, treating infected hosts, food safety, water management programs (for example, for Legionella).
3. Portal of exit. How the organism leaves the reservoir: respiratory secretions, blood, stool, urine, wound drainage, breast milk, skin scales. Interventions: cough etiquette, covering wounds, containing drainage, careful handling of soiled linen (hold away from the uniform, never shake).
4. Mode of transmission. Contact (direct person to person, or indirect through a contaminated object or the hands of a healthcare worker), droplet (large respiratory particles that travel a short distance), airborne (small droplet nuclei that remain suspended and travel on air currents), vehicle (food, water, blood, medications), and vector (mosquito, tick, flea). Indirect contact by way of healthcare workers' hands is the most common mode of transmission of HAIs. Interventions: hand hygiene, personal protective equipment, precautions, dedicated equipment, patient placement.
5. Portal of entry. Broken skin, mucous membranes, the respiratory or gastrointestinal or genitourinary tract, and every indwelling device: intravenous catheters, urinary catheters, endotracheal tubes, drains, and surgical incisions. Interventions: aseptic technique, sterile dressings, removing devices as soon as they are no longer indicated, skin integrity care.
6. Susceptible host. Risk rises with extremes of age, immunosuppression (chemotherapy, corticosteroids, transplant, HIV, neutropenia), malnutrition, uncontrolled diabetes, chronic disease, invasive devices, surgery, prolonged hospitalization, and prior antibiotic exposure. Interventions: immunization, nutrition, glycemic control, sleep and mobility, treating underlying disease.

Application note. Exam items often describe a scenario and ask which link is being broken. Wearing gloves and a gown breaks the mode of transmission link. Placing a sterile dressing over a wound breaks the portal of entry link. Giving influenza vaccine to staff and patients addresses the susceptible host link. Discarding an open, dated bottle of irrigation solution addresses the reservoir link.

Stages and Types of Infection

Incubation period

From exposure to the first symptoms. The person may be contagious during this period even while feeling well.

Prodromal stage

Vague, nonspecific symptoms such as malaise and low-grade fever. Communicability is often highest here.

Illness (acute) stage

Signs and symptoms specific to the infection are present.

Convalescent stage

Symptoms resolve and the host recovers. Recovery may be incomplete if tissue damage occurred.

Infections may be localized (redness, warmth, swelling, pain, purulent drainage at one site) or systemic (fever, chills, tachycardia, tachypnea, leukocytosis, malaise, and in severe cases hypotension and organ dysfunction). Latent infections, such as latent tuberculosis or herpes viruses, persist without symptoms and may reactivate.

Application note for older adults. Older adults and immunosuppressed patients may not mount a fever. New-onset confusion, falls, decreased appetite, incontinence, lethargy, or a small drop in blood pressure may be the only sign of infection. Do not rule out infection because the temperature is normal.

Laboratory clues. An elevated white blood cell count with a rise in immature neutrophils (bands), sometimes called a left shift, suggests acute bacterial infection. Elevated lymphocytes suggest a viral process. Elevated eosinophils suggest parasitic infection or allergy. A rising C-reactive protein or procalcitonin supports bacterial inflammation. Neutropenia, generally an absolute neutrophil count below 1,500 cells per microliter and severe below 500, greatly raises infection risk while blunting the usual signs. In a neutropenic patient, fever is an emergency: obtain cultures and give the ordered broad-spectrum antibiotic without delay.

Hand Hygiene

Hand hygiene is the single most effective measure to prevent the spread of infection and is the most common correct answer on licensure exams.

When to perform hand hygiene

The World Health Organization describes five moments: before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching the patient's surroundings. Also perform hand hygiene before donning gloves and immediately after removing gloves, before handling medications or food, after using the restroom, and when moving from a contaminated body site to a clean body site on the same patient.

Choosing the product

Alcohol-based hand rub (60 to 95 percent alcohol)

Preferred for most clinical situations when hands are not visibly soiled. Apply enough product to cover all surfaces and rub until the hands are completely dry, roughly 20 to 30 seconds. Do not wipe or fan the hands dry.

Soap and water

Required when hands are visibly soiled or contaminated with blood or other body fluids, after caring for a patient with known or suspected Clostridioides difficile, norovirus, or Bacillus anthracis, after using the restroom, and before eating. Wet hands, apply soap, lather all surfaces including thumbs, fingertips, and between fingers for at least 20 seconds (WHO describes a 40 to 60 second whole procedure), rinse with the fingertips pointed down, dry with a paper towel, and use the towel to turn off the faucet.

Why the distinction matters. Alcohol does not kill bacterial spores. C. difficile spores must be physically removed by the friction of handwashing and killed on surfaces by an Environmental Protection Agency registered sporicidal agent such as a bleach product. Norovirus is likewise poorly inactivated by alcohol.

Supporting measures

Keep natural nail tips shorter than one-quarter inch. Artificial nails and extenders are not permitted for staff who have direct contact with high-risk patients because they harbor gram-negative organisms and fungi. Do not wear rings or wear them minimally in high-risk settings. Use lotion supplied by the facility, because petroleum-based lotions degrade latex gloves. Report skin breakdown on your own hands, since dermatitis increases carriage of pathogens.

Standard Precautions

Standard precautions apply to every patient, every time, regardless of diagnosis or presumed infection status. They treat blood, all body fluids and secretions and excretions except sweat, non-intact skin, and mucous membranes as potentially infectious. Standard precautions include:

• Hand hygiene.
• Personal protective equipment selected by anticipated exposure: gloves for contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated items; gown when clothing or exposed skin may be soiled; mask and eye protection or a face shield when splash or spray is likely, and always during procedures that generate splashes.
• Respiratory hygiene and cough etiquette: cover coughs, provide masks and tissues and hand hygiene supplies at entry points, separate symptomatic persons in waiting areas.
• Safe injection practices: one needle, one syringe, one time. Never reenter a vial with a used syringe. Single-dose vials are for one patient only. Use aseptic technique when preparing and administering medications. Disinfect the vial septum and needleless connectors before access.
• Safe handling of used equipment, linens, and the environment: clean and disinfect frequently touched surfaces and shared equipment between patients.
• Sharps safety: never recap a used needle (if recapping is unavoidable, use a one-handed scoop technique), activate safety devices, and dispose of sharps in a puncture-resistant container at the point of use. Replace containers when three-quarters full.
• Sterile technique for lumbar puncture and other procedures entering the spinal or epidural space, including a mask for the person inserting.
• Patient placement based on risk of transmission.

Transmission-Based Precautions

Transmission-based precautions are used in addition to standard precautions when the route of transmission is not fully interrupted by standard precautions alone. Begin them empirically on clinical suspicion. Do not wait for culture confirmation.

Contact Precautions

PPE: gown and gloves donned before entering the room and removed before exiting. Placement: single room preferred; cohort patients with the same organism if a single room is unavailable, keeping at least three feet of separation and a privacy curtain. Use dedicated or single-use equipment (stethoscope, blood pressure cuff, thermometer); disinfect any shared equipment before it leaves the room. Limit transport, and cover the infected or colonized area during transport.

Common indications: multidrug-resistant organisms (MRSA, vancomycin-resistant enterococci, extended-spectrum beta-lactamase producers, carbapenem-resistant Enterobacterales), C. difficile, norovirus and other infectious diarrhea in an incontinent or diapered patient, respiratory syncytial virus, scabies and lice, impetigo, draining wounds or abscesses that cannot be contained by a dressing, herpes simplex in a neonate, and viral conjunctivitis.

C. difficile specifics. Soap and water for hand hygiene, gown and gloves, private room with dedicated equipment, EPA-registered sporicidal disinfectant for the room, and continuation of precautions for at least 48 hours after diarrhea resolves (many facilities continue until discharge). Do not treat with antimotility agents such as loperamide, which can precipitate toxic megacolon. Antibiotic stewardship is the primary prevention strategy.

Droplet Precautions

PPE: surgical mask donned on entry to the room; add eye protection if splash or spray is likely. A respirator is not required. Placement: single room preferred; if cohorting, keep at least three to six feet between beds with a privacy curtain. The door may remain open. During transport, the patient wears a surgical mask.

Common indications: influenza, pertussis (until 5 days of effective therapy), Neisseria meningitidis meningitis and meningococcemia (until 24 hours of effective therapy), Haemophilus influenzae type b invasive disease, mumps, rubella, group A streptococcal pharyngitis or pneumonia or scarlet fever (until 24 hours of therapy), diphtheria (pharyngeal), Mycoplasma pneumonia, and adenovirus and rhinovirus (which are often contact plus droplet).

Application note. Close contacts of a patient with meningococcal disease, including staff who performed unprotected mouth-to-mouth resuscitation, intubation, or suctioning, require antimicrobial prophylaxis. Simply being in the room with a mask on does not.

Airborne Precautions

PPE: a fit-tested N95 filtering facepiece respirator or higher level respiratory protection (powered air-purifying respirator), donned before entering and removed after leaving the room. Perform a user seal check every time. Fit testing is required before first use and at least annually. Placement: an airborne infection isolation room (AIIR), meaning a negative-pressure room with at least 6 air changes per hour in existing facilities and at least 12 in new or renovated construction, air exhausted directly outdoors or through a HEPA filter, with the door kept closed and negative pressure monitored daily when in use. During transport, the patient wears a surgical mask, not an N95, and skin lesions are covered.

Common indications: pulmonary or laryngeal tuberculosis, measles (rubeola), varicella (chickenpox) and disseminated herpes zoster (both airborne plus contact), and smallpox. Localized herpes zoster in an immunocompetent patient requires only standard precautions with the lesions covered.

Application note. For measles and varicella, only immune staff should enter when possible. After an infectious patient leaves an AIIR, the room must remain vacant long enough for adequate air exchanges, roughly one hour at 6 air changes per hour and about 35 minutes at 12, before an unprotected person enters. Emphasize that the N95 protects the wearer, while the surgical mask on the patient protects everyone else by containing source droplets.

Tuberculosis specifics. Suspect active pulmonary tuberculosis with cough longer than three weeks, hemoptysis, night sweats, unintentional weight loss, and fever. Place in an AIIR immediately on suspicion, collect three sputum specimens for acid-fast bacilli, and teach adherence to multidrug therapy, since nonadherence drives resistance. A positive tuberculin skin test or interferon-gamma release assay indicates infection, not necessarily active disease; a chest radiograph and sputum are needed to distinguish latent from active disease.

Protective Environment

A protective environment is used for severely immunocompromised patients, classically allogeneic hematopoietic stem cell transplant recipients. It is positive-pressure relative to the corridor with HEPA-filtered incoming air, at least 12 air changes per hour, and sealed room construction. Keep the door closed, avoid fresh flowers, potted plants, standing water, and construction dust, and screen visitors for illness. This is not a transmission-based precaution; it protects the patient from the environment rather than protecting others from the patient.

Application note. A patient who needs both a protective environment and airborne precautions (for example, a transplant patient with varicella) requires an anteroom so the airflow requirements can both be met.

Precaution Combinations to Memorize

Condition	Precautions
C. difficile	Contact plus soap-and-water hand hygiene and sporicidal cleaning
MRSA, VRE, other MDROs	Contact
Norovirus, rotavirus	Contact
Scabies, lice, impetigo	Contact
Respiratory syncytial virus	Contact (droplet added by many facilities)
Influenza, pertussis, mumps, rubella	Droplet
Meningococcal disease	Droplet until 24 hours of effective antibiotics
Tuberculosis (pulmonary or laryngeal)	Airborne
Measles	Airborne
Varicella, disseminated zoster	Airborne plus contact
Neutropenia or stem cell transplant	Protective environment

Personal Protective Equipment

PPE is selected by the anticipated exposure, not by diagnosis alone. It is the last line of defense in the hierarchy of controls, which places elimination, engineering controls (ventilation, sharps devices, closed suction), and administrative controls (policies, staffing, vaccination, screening) ahead of PPE.

Donning sequence

1. Perform hand hygiene.
2. Gown: fasten at the neck and waist, cover the torso from neck to knees and the arms to the wrists, and wrap around the back.
3. Mask or respirator: secure ties or elastic bands, fit the flexible band to the nose bridge, fit snug to the face and below the chin, and perform a seal check for a respirator.
4. Goggles or face shield: place over the face and eyes and adjust to fit. Personal eyeglasses are not a substitute.
5. Gloves: don last and extend them to cover the cuff of the gown.

Doffing sequence

The principle is to remove the most contaminated items first and to avoid touching the front of any item.

1. Gloves: the outside is contaminated. Grasp the outside of one glove at the palm and peel it off, hold it in the gloved hand, slide ungloved fingers under the remaining glove at the wrist, and peel it off over the first. Discard.
2. Goggles or face shield: the outside is contaminated. Handle by the headband or earpieces only.
3. Gown: unfasten ties, pull away from the neck and shoulders touching the inside only, turn it inside out, and roll it into a bundle.
4. Mask or respirator: the front is contaminated. Untie or remove the bottom band first, then the top, and handle by the ties or bands only.
5. Perform hand hygiene immediately, and at any point during removal if the hands become contaminated.

Where to remove. Remove all PPE before leaving the patient room except a respirator, which is removed after exiting and closing the door. An acceptable alternative is to remove the gown and gloves together at the doorway by grasping the gown front, pulling away from the body so the ties break, and rolling it into a bundle with the gloves turned inside as they are peeled off.

Gloves are never a substitute for hand hygiene. Change gloves between patients and between a contaminated and a clean site on the same patient, and perform hand hygiene at every glove change. Latex allergy requires nitrile or vinyl gloves and a latex-safe environment; ask about allergy to bananas, avocados, kiwi, and chestnuts, which cross-react.

Medical and Surgical Asepsis

Medical asepsis (clean technique)

Practices that reduce the number of microorganisms and limit their spread. Hand hygiene, cleaning equipment, standard precautions, and routine dressing changes on chronic wounds are medical asepsis. The essential rule is clean to dirty: clean from the least contaminated area toward the most contaminated, and never return a used item to a clean supply.

Surgical asepsis (sterile technique)

Practices that eliminate all microorganisms, including spores. Required for surgery, insertion of urinary catheters and central lines, tracheostomy care, lumbar puncture, and dressing changes on fresh surgical wounds and burns.

Sterilization methods include steam under pressure (autoclave), ethylene oxide gas for heat-sensitive items, dry heat, and chemical sterilants. Disinfection is a lower level process for inanimate surfaces; antiseptics are used on skin.

Sterile Technique Principles

1. Only sterile items may touch a sterile field. If in doubt about sterility, consider the item contaminated.
2. The outer 1-inch (2.5 cm) border of a sterile field is considered contaminated, as is any part of the drape that hangs below the table edge.
3. Keep sterile items above waist level and within your line of vision at all times. Never turn your back on a sterile field and never reach across it.
4. Moisture carries organisms by capillary action. A wet sterile field over an unsterile surface is contaminated (strike-through contamination).
5. Air currents carry contaminants. Avoid coughing, sneezing, talking excessively, or reaching over the field. Wear a mask when required by the procedure.
6. Open the first flap of a sterile package away from your body, then the side flaps, then the flap toward you. When opening a wrapped package held in the hand, secure the loose edges.
7. When pouring sterile solution, remove the cap and place it face up on a clean surface, hold the bottle with the label toward the palm, pour a small amount off to the side to cleanse the lip, then pour without splashing and without touching the container. Once opened, the edge of the bottle is contaminated.
8. Sterile personnel stay within the sterile area, face one another, and pass back to back. Unsterile personnel stay at least one foot away from the field.
9. Never leave a sterile field unattended.

Application note. If a sterile glove touches the outside of the wrapper or the nurse's own bare arm, the glove is contaminated and must be replaced, not wiped or rinsed. If a drop of solution falls on the drape, that area is contaminated and should be covered by a new sterile drape or the field must be reestablished.

Sharps Safety and Bloodborne Pathogen Exposure

The primary bloodborne pathogens of occupational concern are hepatitis B virus, hepatitis C virus, and HIV. Prevention includes hepatitis B vaccination for healthcare workers, engineered sharps injury protection devices, no recapping, and immediate point-of-use disposal.

After a needlestick or mucous membrane exposure:

1. Wash the site immediately with soap and water; flush mucous membranes and eyes with water or saline. Do not squeeze or apply caustic agents.
2. Report the exposure immediately and follow the facility exposure protocol.
3. Source patient and exposed worker are tested per protocol.
4. HIV post-exposure prophylaxis should begin as soon as possible, ideally within hours. Hepatitis B post-exposure management depends on the worker's vaccination and antibody status. There is no post-exposure prophylaxis for hepatitis C, so serial testing is used.
5. Complete the incident report and follow-up testing schedule.

Fall Prevention

Falls are among the most common adverse events in hospitals and long-term care. Prevention begins with structured risk screening on admission, after any change in condition, after a transfer, and after a fall, using a validated tool such as the Morse Fall Scale or the Hendrich II Fall Risk Model.

Risk factors

• Intrinsic: history of falls (the strongest single predictor), age over 65, muscle weakness and gait or balance impairment, orthostatic hypotension, confusion or delirium or dementia, impaired vision or hearing, peripheral neuropathy, urinary urgency and incontinence or nocturia, pain, and fear of falling.
• Medications: benzodiazepines and other sedative-hypnotics, opioids, antipsychotics, antidepressants, anticholinergics, antihypertensives, diuretics, insulin and sulfonylureas, and above all polypharmacy. Anticoagulants and antiplatelets do not cause falls but greatly increase the harm from one.
• Extrinsic: clutter, wet floors, poor lighting, inadequate footwear, high beds, unlocked wheels, tubing and cords, unfamiliar environment, and equipment such as intravenous poles and drains.

Interventions

Keep the bed in the lowest position with wheels locked. Place the call light, phone, water, tissues, and glasses within reach and confirm the patient can demonstrate use of the call light. Provide nonskid footwear. Ensure adequate lighting including a night light and a clear path to the bathroom. Use hourly or purposeful rounding addressing the four Ps: pain, position, personal needs (toileting), and placement of belongings. Offer scheduled toileting rather than waiting for a request. Assist with the first ambulation after surgery, sedation, or prolonged bed rest, and check orthostatic blood pressures. Use a gait belt and appropriate assistive devices. Consider a bed or chair exit alarm, a low bed with floor mats, video monitoring, or placement near the nurses' station. Communicate risk with the facility's visual cue system and in handoff.

Side rails. Two upper side rails are generally used as a mobility aid and a reminder. Raising all four side rails, or any configuration that prevents the patient from leaving the bed voluntarily, is a restraint and carries the risk of entrapment and of a more injurious fall over the rail. Assess for entrapment risk in patients who are confused or small in stature.

After a fall

Assess the patient before moving them. Check level of consciousness, vital signs, pain, and for deformity, shortening or external rotation of a leg suggesting hip fracture, and head injury. Perform neurologic checks if the head was struck, the fall was unwitnessed, or the patient takes anticoagulants. Notify the provider and the family per policy, treat injuries, and reassess the fall prevention plan. Document objectively what was found, what the patient said, the assessment, and the actions taken. An incident or occurrence report is an internal quality document: complete it, but do not chart in the medical record that one was filed and do not place a copy in the chart.

Restraints and Restraint Alternatives

A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move the arms, legs, body, or head freely, or a drug used as a restriction to manage behavior that is not a standard treatment or dosage for the patient's condition. Restraints are a last resort after alternatives have failed.

Alternatives to try first

Identify and treat the cause of the behavior: pain, hypoxia, hypoglycemia, infection, full bladder, constipation, medication effect, sensory deprivation, or unmet need. Reorient frequently and provide clocks, calendars, glasses, and hearing aids. Provide familiar objects, family or sitter presence, and consistent caregivers. Use distraction and activity, diversional items, and regular toileting. Reduce noise and provide uninterrupted sleep. Camouflage tubing under clothing, use mittens or a wrap for dressing protection, use a lower bed with mats, and use bed and chair alarms and video monitoring.

Legal and regulatory requirements

• Requires an order from a physician or other licensed independent practitioner. PRN or standing restraint orders are prohibited.
• In an emergency, a trained registered nurse may apply a restraint and must obtain the order as soon as possible, generally within one hour.
• Violent or self-destructive behavior: a face-to-face evaluation by the physician, other licensed independent practitioner, or a trained registered nurse is required within one hour of initiation. Order time limits are 4 hours for adults 18 and older, 2 hours for ages 9 through 17, and 1 hour for children under 9. Orders may be renewed within these limits for up to 24 hours, after which a new in-person evaluation is required before a new order.
• Nonviolent, non-self-destructive (medical or surgical) restraint, such as protecting an endotracheal tube: the order is renewed according to hospital policy and at minimum the need is reassessed and the order renewed at least once each calendar day.
• Use the least restrictive device that is effective, obtain informed consent or notify the family per policy, and discontinue at the earliest possible time. Discontinuation does not require a new order.

Safe application and monitoring

Apply the restraint over clothing or padding, never directly on bare skin over a bony prominence. Allow two fingers to slide between the restraint and the limb. Secure ties to the movable bed frame, never to the side rails and never to a fixed part of the bed that would tighten when the bed is raised or lowered. Use a quick-release knot, never a square knot or a bow that can tighten. Keep scissors accessible. In a wheelchair, secure to the frame behind the chair out of the patient's reach.

Monitoring for nonviolent restraint is typically every 2 hours, and for violent restraint every 15 minutes with continuous observation, per facility policy. At each check assess circulation, sensation, and motion distal to the device, skin integrity, respiratory status, and correct placement. Release the restraint at least every 2 hours to provide range of motion, reposition, toilet, offer fluids and nutrition, and perform skin care, and release one limb at a time in a violent patient. Never restrain a patient in the prone position or in any way that impedes breathing. Never leave a restrained patient alone with the restraint released. Document the behavior that necessitated the restraint, the alternatives tried and their results, the type and placement, the patient's response, all monitoring, and the criteria for discontinuation.

Application note. Restraint reduces agitation only in appearance. Restrained patients are at higher risk of pressure injury, aspiration, deconditioning, delirium, strangulation, and death. If an exam option offers a genuine alternative that would keep the patient safe, that option is almost always correct.

Fire Safety

Fire requires three elements: fuel, heat or an ignition source, and oxygen. Removing any one extinguishes the fire.

RACE (the response sequence)

Rescue or remove anyone in immediate danger. Activate the alarm and call the emergency number. Confine the fire by closing doors and windows, and turn off oxygen and electrical equipment in the affected area. Extinguish only if the fire is small and contained and you have a clear exit.

PASS (using an extinguisher)

Pull the pin. Aim at the base of the fire. Squeeze the handle. Sweep from side to side.

Extinguisher classes: A for ordinary combustibles such as paper, wood, and cloth; B for flammable liquids and grease; C for electrical equipment; ABC is a multipurpose extinguisher appropriate for most healthcare settings. Never use water on an electrical or grease fire.

Evacuation priority: move ambulatory patients first, then those needing assistance, then bedbound and nonambulatory patients. Move horizontally beyond the nearest fire or smoke barrier doors first, and vertically down a stairwell only if needed. Never use elevators. Keep low under smoke.

Oxygen safety. Oxygen does not burn but vigorously supports combustion. Post "oxygen in use" signage, prohibit smoking and open flames, avoid electric razors, heating pads, and any equipment producing a spark, avoid petroleum-based products and alcohol-based or oil-based lotions near the face, use cotton bedding and clothing rather than wool or synthetics that generate static, secure cylinders upright in a holder or chained so they cannot fall, and store them away from heat.

Electrical and Environmental Safety

• Use three-prong grounded plugs and hospital-grade equipment. Do not use adapters that defeat the ground pin.
• Inspect cords before use. Remove frayed or damaged equipment from service, tag it, and report it. Do not attempt repair.
• Grasp the plug body, not the cord, when unplugging. Do not run cords under carpet, across walkways, or through doorways.
• Do not overload outlets or daisy-chain power strips. Keep electrical equipment away from water and never handle it with wet hands.
• Patients with invasive lines that reach the heart, such as pacing wires or a central catheter, are vulnerable to microshock from very small leakage currents. Reduce unnecessary electrical devices at the bedside and use only equipment cleared by biomedical engineering.
• Hazardous drugs such as antineoplastics require chemotherapy-rated gloves (double gloved), a closed-front gown, eye protection, a closed system transfer device, and preparation in a biological safety cabinet. Handle excreta with PPE for at least 48 hours after administration per policy, and use a spill kit for spills.
• Radiation safety: apply time, distance, and shielding. Limit time near the source, maximize distance, wear a lead apron and dosimeter, and for a patient with a sealed internal implant keep long-handled forceps and a lead container in the room, never touch a dislodged implant with bare hands, and restrict pregnant staff and visitors and children.
• Safety Data Sheets must be readily accessible for every chemical in the workplace.
• Latex allergy: identify at-risk patients (spina bifida, multiple surgeries, healthcare workers), schedule them as the first case of the day when possible, and stock a latex-safe cart.
• Biohazard and waste segregation: regulated medical waste in red bags, sharps in rigid puncture-resistant containers, and cytotoxic waste in yellow containers per policy.

Reporting, Surveillance, and Outbreak Response

Infection prevention programs use surveillance data to detect clusters, calculate device-associated infection rates per 1,000 device days, audit hand hygiene compliance, and drive improvement. Public health law requires reporting of designated communicable diseases, which vary by state but typically include tuberculosis, measles, pertussis, meningococcal disease, hepatitis A and B and C, HIV, foodborne illnesses, and any suspected outbreak.

Steps in an initial outbreak response:

1. Confirm the cases and verify the diagnosis; define a case.
2. Notify infection prevention and, when required, the health department.
3. Institute appropriate transmission-based precautions immediately and reinforce hand hygiene.
4. Cohort affected patients and, when feasible, cohort the staff caring for them; avoid floating staff between affected and unaffected units.
5. Identify the common exposure by describing cases in terms of person, place, and time (an epidemic curve and a line list).
6. Intensify environmental cleaning with an agent effective against the organism, and evaluate shared equipment, water, and product sources.
7. Restrict ill staff from work per policy, and offer prophylaxis or vaccination when indicated.
8. Educate staff, patients, and visitors and evaluate the effect of the interventions on the case rate.

Scope of Practice Notes

Registered nurse. Performs the initial and ongoing assessment, formulates the plan of care, initiates precautions based on clinical suspicion, evaluates outcomes, and provides the required assessment before and during restraint use. In many jurisdictions a trained registered nurse may perform the one-hour face-to-face evaluation for violent restraint. The RN delegates tasks but never delegates assessment, teaching, evaluation, or the nursing judgment about an unstable patient.

Licensed practical or vocational nurse. Works under the direction of the registered nurse or provider. Applies standard and transmission-based precautions, performs sterile procedures such as urinary catheterization and dressing changes within state scope, reinforces teaching that the RN initiated, monitors stable patients, applies and monitors restraints per policy, and contributes data to the plan of care. The LPN or LVN must report changes and concerns to the RN: new fever, new confusion, worsening drainage, a suspected exposure, an infection control breach, and any patient whose condition is deteriorating. Scope varies by state, so the state nurse practice act governs.

Unlicensed assistive personnel. May perform hand hygiene, apply PPE, transport, position, ambulate, take vital signs, and report findings, but may not assess, teach, or determine precautions.

High-Yield Test Tips

• When any option is hand hygiene, look very hard at it before choosing something else.
• Start precautions on suspicion, not on culture results.
• Airborne means N95 plus a negative-pressure room with the door closed. The patient wears a surgical mask during transport.
• Alcohol rub does not work on C. difficile or norovirus. Wash with soap and water.
• Donning is gown, mask, eyewear, gloves. Doffing is gloves, eyewear, gown, mask, with the respirator removed outside the room.
• The 1-inch border of a sterile field and anything below waist level or out of sight is contaminated.
• The lowest bed position with the call light in reach appears in the correct answer to most fall questions.
• Four side rails up is a restraint. There is no such thing as a PRN restraint order.
• RACE before PASS. Rescue the patient first, and never use an elevator.
• If a question asks who to see first, choose the patient with the most unstable airway, breathing, or circulation, not the one with the most dramatic infection label.

See Also

• Infection Control and Safety – RN Practice Questions
• Infection Control and Safety – LPN Practice Questions
• Infection Control and Safety – RN Flashcards
• Infection Control and Safety – LPN Flashcards

References

• Centers for Disease Control and Prevention. (2024). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings (2007, updated). U.S. Department of Health and Human Services.
• Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings. MMWR Recommendations and Reports, 51(RR-16), 1 to 45.
• Centers for Medicare & Medicaid Services. (2020). State operations manual appendix A: Interpretive guidelines for hospitals, 42 CFR 482.13(e), patient rights: Restraint or seclusion. U.S. Department of Health and Human Services.
• National Council of State Boards of Nursing. (2023). NCLEX-RN examination test plan and NCLEX-PN examination test plan. NCSBN.
• Occupational Safety and Health Administration. (n.d.). Bloodborne pathogens standard, 29 CFR 1910.1030. U.S. Department of Labor.
• World Health Organization. (2009). WHO guidelines on hand hygiene in health care. WHO Press.

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