Fundamentals Chapter 27:
The nurse is conducting assessment on a client with cancer who is undergoing chemotherapy treatments. The client is complaining of having the flu. Which question should be asked? Select all that apply. "Could the drugs used in your treatment be causing the flu?" "Has anyone in the family recently been sick?" "Have you been frequently out in the community?" "Are you taking steroids?" "Have you recently received blood transfusion?"
"Has anyone in the family recently been sick?", "Have you been frequently out in the community?", "Are you taking steroids?" Closely screen the client for infection risk and document any recent exposure to infectious illness. Sometimes this means asking questions such as, "Has anyone in your immediate family recently been infected with [specify disease]?" Consider school records and community documentation of infectious disease outbreaks in evaluating each client for risk. Include questions about the client's general health, such as normal sleep and exercise patterns; nutritional history; use of drugs, cigarettes, or alcohol; and sexual practices. Note any recent travel, especially to foreign counties. Explore any chronic health conditions, such as heart disease, lung disease, or diabetes, and their treatment. Determine whether the client has received chemotherapy or radiation because such treatments often increase the risk of infection by suppressing the immune system. Also, obtain a medication history, focusing on immunosuppressive drugs (e.g., steroids) and current or previous use of antibiotics.
A nurse is reviewing the laboratory test results of a client who is at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis? 0.8 mmol/L 2.6 mmol/L 1.4 mmol/L 4.2 mmol/L
4.2 mmol/L Lactic acid, present in blood as lactate, is a by-product of metabolism that is usually metabolized in the liver. Normal levels are 0.3 to 2.6 mmol/L. In sepsis, lactate levels increase secondary to anaerobic metabolism due to hypoperfusion. All clients with lactate values of more than 4 mmol/L should be treated with the severe sepsis resuscitation bundle.
While the nurse is conducting morning rounds, the nurse notices that the client's temperature has gradually increased for the past 3 days. Which assessments should the nurse do next? Select all that apply. Check site of wound. Check IV site for infiltration. Review how compliant the client has been with ambulation. Call the laboratory for blood culture test. Auscultate lung sounds.
Check site of wound., Check IV site for infiltration., Review how compliant the client has been with ambulation., Auscultate lung sounds. Auscultation of breath sounds can help detect respiratory infections. Pneumonia can alter normal breath sounds, producing crackles (rales), rhonchi, and wheezes. Atelectasis, which can predispose a client to respiratory infection, is noted by crackles or diminished breath sounds. Determine whether the client is comfortable or in obvious pain. Detect any signs of fatigue in the client's posture and movement. Look for abnormal skin color, rashes or lesions, and any swelling and signs of inflammation.
When describing the inflammatory response to a group of nursing students, what would the instructor most likely include as a local effect? Select all that apply. Malaise Fever Erythema Pain Edema
Erythema, Pain, Edema Local effects of the inflammatory response include erythema, warmth, edema, pain, and impaired function. Fever and malaise are systemic effects.
A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason? Helps to determine prescribed antibiotic therapy Permits selection of antibiotic concentration Narrows the therapeutic range to avoid prolonged use Helps in reducing proliferation of multidrug-resistant organisms
Helps to determine prescribed antibiotic therapy Gram staining helps to order antibiotic therapy while waiting for specific culture results, whereas minimum inhibitory concentration permits selection of antibiotic concentration, helps in reducing proliferation of multidrug-resistant organisms, narrows the therapeutic range, and avoids prolonged use.
A nurse is preparing a class for a group of new parents about infections and infants. When reviewing the development of the infant's immune system, what would the nurse be least likely to include? Resistance to infection is primarily due to maternal antibodies. Viral diseases early on can cause severe widespread disease. It takes about 6 months for the system to become fully functional. Newborns have little difficulty localizing infections.
Newborns have little difficulty localizing infections. The immune system does not become fully operational until a baby reaches about 6 months of age. Before then, the infant's resistance to infection comes from the antibodies passed by way of the placenta and breast milk. Newborns have difficulty localizing infections (preventing the spread of organisms from the site of contact). Their phagocytes have difficulty trapping microbes, and they do not produce enough antibodies. At this time, viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.
The local high school has been exposed to methicillin-resistant Staphylococcus aureus (MRSA) infection, and the school nurse is preparing an education plan on prevention of MRSA. Which steps should the nurse include? Select all that apply. Online research on MRSA Covering of draining wounds Handwashing Use of hand sanitizer when necessary Seeing physician for blister sores
Online research on MRSA, Covering of draining wounds, Handwashing, Use of hand sanitizer when necessary Nurses work at various levels to plan, implement, and evaluate measures to prevent and control infection. Four levels are the person and family (household), the community, the nation, and the world. Often, nurses are the first to identify symptoms indicating infection in clients and to institute precautions to prevent transmission. In addition to stressing the need for hand hygiene, instruct clients and their families about proper methods for disposal of body secretions such as sputum, feces, urine, and wound drainage.
A nurse is providing care for a client who has had gallbladder surgery. It is the first day postoperative and the client is exhibiting a fever. The nurse suspects what as the most likely cause? Urinary tract infection Physiologic stress Pneumonia Wound infection
Physiologic stress During the first postoperative day, an elevated temperature is most likely caused by the physiologic stress of surgery or by atelectasis. Fever during the 2nd to 5th postoperative days most likely results from pneumonia. A fever on the 2nd to 8th postoperative days suggests urinary tract infection, while one occurring from the 3rd to the 11th postoperative days often suggests a wound infection.
During an interaction with a client who is HIV positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period? Prodromal period Acute phase of illness Incubation period Convalescent period
Prodromal period The client is in the prodromal period of communicable disease, which is characterized by nonspecific symptoms such as nausea, fever, general weakness, or aches and pains. The incubation period is the time between the pathogen's entrance and the appearance of symptoms. The acute phase of an illness occurs when specific symptoms appear. Convalescence completes the progress of an infection.
The nurse assessing a client who had an elevated temperature 1 hour ago determines that the client is in the crisis phase of fever. What would lead the nurse to this conclusion? Profuse diaphoresis General malaise Chills and shivering Evidence of gooseflesh
Profuse diaphoresis The client will have profuse diaphoresis during the crisis phase of fever. Gooseflesh and shivering are evident during the chill phase. During the fever phase, the skin is warm and flushed, and the client feels general malaise.
A group of students is reviewing information about cellular and humoral immunity. The group demonstrates understanding of these concepts when they identify what as a function of cellular immunity? Help lysis of bacterial cell walls. Encourage inflammatory response. Enhance phagocytosis of microbes. Reactivate if the same antigen reappears.
Reactivate if the same antigen reappears. The function of cellular immunity is to reactivate if the same antigen reappears. The complement system enhances phagocytosis of microbes, helps lysis of bacterial cell walls, and encourages inflammatory response.
A nurse is assessing a client with an infection and suspects that the client may be developing systemic inflammatory response syndrome. What would support the nurse's suspicions? Select all that apply. Temperature of 37.4°C Respiratory rate of 26/minute Polyuria Heart rate 110 beats/minute Chills
Respiratory rate of 26/minute, Heart rate 110 beats/minute, Chills Early presenting signs of systemic inflammatory response syndrome include a temperature greater than 38°C or less than 36°C, heart rate greater than 90 beats per minute, a respiratory rate greater than 20/minute or a PACO2 less than 32 mm Hg, a white blood cell count greater than 12,000 or less than 4,000. Other symptoms include chills, decreased urine output, poor capillary refill, mottling, and unexplained change in mental status.
A school nurse is conducting a program for the parents of school-age children. As part of the program, the nurse would address which disease as common for this age group? Streptococcal infection Human papillomavirus Herpes simplex disease Chlamydia disease
Streptococcal infection Streptococcal infection is a common infection of school-age children. Herpes simplex disease, chlamydia disease, and human papillomavirus are common diseases in adolescents.
A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins? Monocytes Neutrophils T lymphocytes Eosinophils
T lymphocytes T lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.
Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely: above 38.2°C. between 35°C and 36.8°C. between 37.1°C and 38.2°C. greater than 40.5°C.
greater than 40.5°C. A temperature greater than 40.5°C is referred to as hyperpyrexia. A low-grade fever is a temperature that is slightly elevated, 37.1°C to approximately 38.2°C. A temperature elevation above 38.2°C is considered a high-grade fever. A temperature between 35°C and 36.8°C is a subnormal temperature.
A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection? 10,000 cells/mm 8,000 cells/mm 18,000 cells/mm 5,000 cells/mm
18,000 cells/mm The leukocyte count of 18,000 cells/mm indicates infection in the client. A rise in circulating white blood cells (WBCs) above the normal adult range of 5,000 to 10,000 cells/mm is called leukocytosis. A count of 8,000 cells/mm, 5,000 cells/mm, and 10,000 cells/mm would be considered normal.
The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that the client has developed Clostridium difficile infection." Which part of the SBAR communication will this statement fall into? R = Recommendation B = Background A = Assessment S = Situation
A = assessment SBAR: Situation, Background, Assessment, and Recommendations (SBAR) is a shared mental model for improving communication between and among clinicians. Note that situation, background, and assessment are all based on the collection of complete and accurate assessment data. The last piece, recommendations, encompasses the nurse's suggestions for the next interventions. Situations: What is happening at the present time? Background: What are the circumstances leading up to this situation? Assessment: What do I think the problem is? Recommendations: What should we do to correct the problem?
The mother of a client who is acutely ill and is responding well to the antibiotic treatment states "I know this antibiotic will heal my child." The mother requires further education based on which statement? Select all that apply. Antibiotics causes loose stools all the time. Antibiotics slow the growth or kill the microorganism. Antibiotics do not heal. The antibiotics help the body develop antigens. Antibiotics prevent further damage to the system affected.
Antibiotics slow the growth or kill the microorganism., Antibiotics do not heal., Antibiotics prevent further damage to the system affected. Antibiotics cannot cure the client; at best, they slow the growth of or kill the infecting organism, which is necessary for clients to recover from infection. They control the size of the microbial population against which the client's immune system must contend. Antibiotics "buy time" during which the client's own immune system can mobilize. Eliminating the microbes may prevent further injury, but a return to normal depends on the body's healing capacity.
A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area? Area of active drainage Deep into the cavity Edge of the wound Soiled dressing
Area of active drainage When obtaining a specimen for an aerobic wound culture, the nurse would obtain the specimen from deep in an area of active drainage. The specimen for an anaerobic culture is obtained from deep in the cavity to identify organisms that may grow where oxygen is not present. Cultures are not taken from the edges of the wound or from the soiled dressing.
A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client? Encouraging wearing a mask when out of the room Avoiding razors with blades Providing gentle oral care Obtaining rectal temperatures
Obtaining rectal temperatures Rectal temperatures should be avoided to prevent trauma and subsequent infection. The nurse should encourage the client to wear a mask to prevent airborne infection. Providing gentle oral care and avoiding razors helps to keep the membranes intact and prevent infection.
