Chapter 19 and 31 Nursing 102

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?

"Stress leads to increased secretion of cortisol, which suppreses your immune response."

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps, in the correct order, that the nurse should take when donning sterile gloves. All options must be used.

Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?

The new nurse touches 1.5 in (4 cm) from the outer edges.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

WBC of 25,000 Mcl

The nurse is providing an inservice educational program for the interprofessional healthcare team about infection control precautions. What teaching will the nurse include? (Select all that apply.)

Wear PPE. Practice hand hygiene. Keep client's environment clean.

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?

change to airborne precautions

A client has a concentration of Staphylococcus aureus located on his skin. He is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which stage?

colonization

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

decreased cellular immunity

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?

discard the supplies and the field and prepare a new sterile field

A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.

exposure to the pathogen nonspecific symptoms positive laboratory tests return of appetite

The nurse is caring for a client who developed a urinary tract infection while hospitalized. How will the nurse document this condition?

healthcare associated infection

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?

noncommunicable disease

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?

one that remains in the clients room

A nurse assessing a client with an injured ankle observes edema and pus formation around the injury. Which of the following are systemic responses to inflammation? Select all that apply.

presence of fever and fatigue loss of appetite presence of aches in muscles

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

remove fresh fruit from the room

The nurse is assessing a client with an elevated temperature. Which of the following would lead the nurse to determine that the client is in the fever phase?

skin warm and flush

The nurse is observing a sterile field that was prepared by another staff member. Which of the following, if present, would indicate that the sterile field is contaminated?

sterile drape positioned with the moisture-proof side facing up

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate?

the client will state how to safely take the prescribed antibiotic

The nurse works on a long-term care unit. In the last 2 weeks more than half the clients on the unit have been diagnosed with gastroenteritis. What is the most likely reason?

the infection is being transferred by health care personnel