Fundamentals of Success Infection Control
Which should the nurse do to interrupt the transmission link in the chain of infection? A. Wash the hands before providing care to a client. B. Position a commode next to a client's bed. C. Provide education about a balanced diet. D. Change a dressing when it is soiled.
Answer: A Rationale: A. This is an example of controlling the mode of transmission. Direct transmission of microorganisms from one person to another is interrupted when microorganisms are removed from the skin surface by hand washing. Hand washing is part of hand hygiene, which also includes nail care, skin lubrication, and wearing of minimal jewelry in a health-care environment. Hand hygiene should be performed before and after client care and whenever contamination has occurred. B. The use of a commode is an example of controlling the portal of exit link in the chain of infection. C. Ingesting a balanced diet is an example of reducing the susceptibility of the host link in the chain of infection. D. Changing a soiled dressing is an example of controlling the portal of exit link in the chain of infection.
A nurse plans to remove a client's wound dressing. The nurse identifies the client, explains what is going to be done and why, washes the hands, collects equipment, provides for the client's privacy, and places the client in an appropriate and comfortable position. Place the following steps in the order in which they should be implemented when removing the soiled dressing. 1. Don clean gloves. 2. Pull the tape away from the skin gently. 3. Assess the volume, color, and odor of exudate. 4. Place the soiled dressing and gloves in a biohazardous waste receptacle. 5. Remove the dressing by lifting the edge of the dressing upward and toward the center of the wound. 6. Loosen the edges of the tape around the dressing, starting from the outside and moving toward the center of the dressing.
Answer: 1, 6, 2, 5, 3, 4 Rationale: 1. Clean gloves protect the nurse from the client's blood and body fluids. 2. Pulling the tape away from the skin gently reduces discomfort and skin trauma during tape removal. 3. Assessing the status of the exudate provides data for evaluating the progress of wound healing. 4. Placing soiled dressings and contaminated gloves in an appropriate waste receptacle breaks the chain of infection at the transmission link. 5. Gently lifting the dressing upward and toward the center of the wound avoids dragging the edges of the dressing into the center of the wound and thus contaminating the wound. 6. Loosening the edges of the tape around the entire dressing prepares the tape to be removed by the nurse. Moving from the edge toward the center of the wound avoids pulling on the wound.
A nurse is caring for a client who has a prescription for shortening a Penrose drain 1 inch daily. The nurse washes the hands, removes the soiled dressing, sets s sterile field, dons sterile gloves, and cleans around the drain with sterile saline solution as prescribed. Place the following steps in the order in which they should be implemented by the nurse. 1. Complete dressing the wound. 2. Pull the drain out 1 inch, gently and steadily 3. Grip the Penrose drain with a pair of sterile forceps. 4. Remove the pin and reattach it to the drain closer to the surface of the wound. 5. Cut off the excess drain using sterile scissors, ensuring that 2 inches remain outside the wound.
Answer: 3, 2, 4, 5, 1 Rationale: 1. Completing the dressing protects the wound and provides an environment conducive for wound healing. 2. Gentle, steady pulling on the drain avoids accidental withdrawal of the drain further than intended. 3. Using sterile forceps maintains sterility of the drain. 4. Removing and reattaching the pin to the drain closer to the surface of the wound prevents the drain from sliding back into the wound, where it could become inaccessible. If this were to occur, a surgical procedure would be required to access the drain. 5. Cutting off the excess drain by using sterile scissors maintains sterility of the drain. Leaving 2 inches to the length of the drain allows an adequate length of drain to grasp when shortening or removing the drain in the future.
A school nurse is teaching a class of adolescents about the function of the integumentary system. Which fact about how the skin protects the body against infection is important to include in this discussion? A. Cells of the skin are constantly being replaced, thereby eliminating external pathogens. B. Epithelial cells are loosely compacted on skin, providing a barrier against pathogens. C. Moisture on the skin surface prevents colonization of pathogens. D. Alkalinity of the skin limits the growth of pathogens.
Answer: A Rationale: A. Epithelial cells of the skin are regularly shed, along with potentially dangerous microorganisms that adhere to the skin's outer layers, thereby reducing the risk of infection. B. Epithelial cells on the skin are closely, not loosely, compacted, providing a barrier against pathogens. C. Moisture on the skin surface facilitates, not prevents, colonization of pathogens. D. Acidity, not alkalinity, of the skin limits the growth of pathogens.
A nurse educator is evaluating whether a new staff nurse understands the relationship between a fever and an infection. Which statement by the new staff nurse indicates an understanding of this relationship? A. "Phagocytic cells release pyrogens that stimulate the hypothalamus." B. "Leukocyte migration precipitates the inflammatory response." C. "Erythema increases the flow of blood throughout the body." D. "Pain activates the sympathetic nervous system."
Answer: A Rationale: A. Microorganisms or endotoxins (lipopolysaccharides that are a component of the cell wall of gram-negative bacteria) stimulate phagocytic cells, which release pyrogens that stimulate the hypothalamic thermoregulatory center, causing fever. B. Leukocyte migration does not precipitate the inflammatory response, but it is a phase of the inflammatory response. White blood cells reach a wound within a few hours after the injury to ingest bacteria and clean a wound of debris through the process of phagocytosis. C. Erythema does not increase the flow of blood throughout the body. Increased blood flow to a localized area causes diffuse redness (erythema). D. Pain does not cause an increase in body temperature directly.
When brushing a client's hair, the nurse identifies white oval particles attached to the hair behind the ears. Which condition with additional clinical manifestations that support it should lead the nurse to assess the client further? A. Pediculosis B. Hirsutism C. Dandruff D. Scabies
Answer: A Rationale: A. Pediculosis (Pediculus humanus capitis) is characterized by white oval particles attached to the hair. When this condition is identified, the nurse should assess the client further for the presence of scratch marks on the scalp and by asking the client if the head feels itchy. Also, the nurse must assess the extent of infestation and if any other areas of the body are infested with other types of lice (P. humanus corporis [body hair] and Phthirus pubis [pubic and axillary hair]). A client with this infestation should be on contact isolation to prevent spread of the infestation to others. B. White oval particles attached to hair are not indicative of hirsutism. Hirsutism is the excessive growth of hair or hair growth in unusual places, particularly in female clients. In female clients, usually it is caused by excessive androgen production or metabolic abnormalities. C. White oval particles attached to hair are not indicative of dandruff. Dandruff is the excessive shedding of dry white scales as a result of the expected exfoliation of the epidermis of the scalp. Dandruff scales do not attach to the hair and are easily brushed away from the hair shaft. D. White oval particles attached to hair are not indicative of scabies. Scabies is a communicable skin disease caused by an itch mite (Sarcoptes scabiei) and is characterized by skin lesions (e.g., small papules, pustules, excoriations, and burrows ending in a vesicle) with intense itching.
A nurse must collect the following specimens. Which specimen does not require the use of surgical aseptic technique? Select all that apply. A. Stool for occult blood B. Stool for ova and parasites C. Oropharyngeal mucus for a culture D. Urine from a retention catheter for a urinalysis E. Exudate from a wound for culture and sensitivity
Answer: A, B Rationale: A. Stool for occult blood does not have to be sterile because test results for the presence of blood are not altered if the specimen is contaminated with exogenous organisms. B. Stool for ova and parasites does not have to be sterile because test results for the presence of parasitic eggs and parasites are not altered if the specimen is contaminated with exogenous microorganisms. C. Sterile technique is used to collect a throat culture to avoid contaminating the specimen with exogenous organisms that may alter the accuracy of test results. D. The bladder is a sterile cavity, and the nurse must use sterile technique to collect urine from the port of a retention catheter (Foley) so as not to introduce any pathogens. In addition, it is important not to introduce exogenous organisms that may contaminate the specimen and alter the accuracy of test results. E. Sterile technique is used to collect exudate from a wound to avoid contaminated the specimen with exogenous organisms that may alter the accuracy of test results.
Which client information collected by the nurse reflects a systemic response to a wound infection? Select all that apply. A. Increased body temperature B. Increased heart rate C. Leukocytosis D. Fatigue E. Chills
Answer: A, B, C, D, E Rationale: A. Fever is a common systemic response to infection. Microorganisms or endotoxins stimulate phagocytic cells that release pyrogens, which stimulate the hypothalamic thermoregulatory center, resulting in fever. B. An increased heart rate (tachycardia) occurs in response to the increase in the metabolic rate associated with an infection. In addition, blood volume increases as peripheral and visceral vasoconstriction enhances blood flow to the heart and lungs as the body prepares to fight the infection. C. The number of white blood cells increases above the expected range (leukocytosis) to help fight the infection. D. Fatigue or lack of energy are systemic responses to a wound infection. Systemic responses to infection increase the metabolic rate and vital signs, which in turn cause an increase in energy expenditure. In addition, a wound may be painful and require multiple daily dressing changes, which are physiologically demanding. All these factors can contribute to fatigue. E. Chills are caused by rapid muscle contraction and relaxation associated with the onset (cold or chill) phase of a fever. With infection, the brain increases the body's temperature set-point, and contractions and relaxation of muscles (chills) generates heat in an attempt to achieve the new set-point.
Which primary defense protects the body from infection? Select all that apply. A. Tears in the eyes B. Healthy, intact skin C. Cilia of respiratory passages D. Acidity of gastric secretions E. Dry environment of the epidermis
Answer: A, B, C, D, E Rationale: A. Tears flush the eyes of microorganisms and debris and are a primary defense that protects the body from infection. B. Healthy, intact skin prevents entry of many pathogens. In addition, the normal flora of the skin hinder growth of disease-causing microorganisms that settle on the skin. C. Cilia line the nasal passages, sinuses, trachea, and larger bronchi and are tiny hairlike cells that sweep microorganisms up from the lower airways. These microorganisms are then expelled from the body by coughing and sneezing. D. Acidity of gastric secretions is a primary defense mechanism that protects the body from infection. E. A dry epidermis is a primary defense mechanism that protects the body from infection. The exposure to moisture can cause softening and breakdown of skin (maceration), causing skin to become more easily infected with bacteria or fungi.
Which nursing action protects clients from infection at the portal of entry portion of the chain of infection? Select all that apply. A. Positioning an indwelling urine collection bag below the level of the client's pelvis B. Using sterile technique when administering an intramuscular injection C. Enclosing a urine specimen in a biohazardous transport bag D. Wearing clean gloves when handling a client's excretions E. Washing the hands after removal of soiled gloves F. Maintaining a dressing over a surgical incision
Answer: A, B, F Rationale: A. This is an action designed to interrupt the portal of entry link in the chain of infection. By keeping the collection bag below the level of the client's pelvis, backflow is prevented, which reduces the risk of introducing pathogens into the bladder. B. Using sterile technique when administering medication parenterally helps to reduce the risk of introducing a pathogen into the body. C. Using a biohazardous transport bag is an example of controlling the mode of transmission link in the chain of infection. D. Wearing clean gloves is an example of controlling the mode of transmission link in the chain of infection. E. Hand washing is an example of controlling the mode of transmission link in the chain of infection. F. A dressing over a surgical incision provides a barrier between the healing incision and the environment. The dressing protects the client from potential invading microorganisms at the portal of entry portion of the chain of infection.
A nurse is caring for clients with a variety of wounds. Which wound will likely heal by primary intention? Select all that apply. A. Cut in the skin from a kitchen knife B. Excoriated perianal area C. Abrasion of the skin D. Surgical incision E. Pressure ulcer
Answer: A, D Rationale: A. A cut in the skin caused by a sharp instrument with minimal tissue loss can heal by primary intention when the wound edges are lightly pulled together (approximated). B. Excoriation heals by secondary, not primary, intention. Excoriation is an injury to the surface of the skin. It can be caused by friction, scratching, and chemical or thermal burns. C. An abrasion heals by secondary, not primary, intention. With an abrasion, frictions scrapes away the epithelial layer, exposing the underlying tissue. D. A surgical incision is caused by a scalpel, which is a sharp instrument. This type of wound an heal by primary intention when the wound edges are lightly pulled together (approximated) with sutures, staples, or adhesive. E. A pressure ulcer heals by secondary, not primary, intention. Secondary intention healing occurs when wound edges are not approximated because of full-thickness tissue loss; the wound is left open until it fills with new tissue.
A client has a wound that is healing by secondary intention. Which solution to cleanse the wound and dressing should the nurse expect will be prescribed to support wound healing? A. Normal saline and a gauze dressing B. Normal saline and a wet-to-damp dressing C. Povidone-iodine and a dry sterile dressing D. Half peroxide and half normal saline and a wet-to-dry dressing
Answer: B Rationale: A. Although normal saline is appropriate for cleansing a wound, removal of a gauze dressing that is dry will pull recently granulated tissue off of the wound bed, impeding wound healing. B. Cleaning with normal saline will not damage fibroblasts. Wet-to-damp dressings allow epidermal cells to migrate more rapidly across the wound surface than dry dressings, thereby facilitating wound healing. C. Povidone-iodine is cytotoxic and should not be used on clean granulating wounds. Removal of a dressing that is dry will pull recently granulated tissue off of the wound bed, impeding wound healing. D. Hydrogen peroxide is cytotoxic and should not be used on clean granulating wounds. Removal of a dressing that has dried on a wound will pull recently granulated tissue off of the wound bed.
Which condition places a client at the highest risk for developing an infection? A. Implantation of a prosthetic device B. Burns over more than 20% of the body C. Presence of an indwelling urinary catheter D. More than 2 puncture sites from laparoscopic surgery
Answer: B Rationale: A. Although wound infections can occur when prosthetic devices are implanted, they are surgically implanted under sterile conditions to minimize this risk. B. Burns on more than 20% of a person's total body surface generally are considered major burn injuries. When the skin is damaged by a burn, the underlying tissue is left unprotected, and the individual is at risk for infection. The greater the extent and the deeper the depth of the burn, the higher the risk for infection is. C. Although urinary tract infections can occur with an indwelling urinary catheter, these catheters are closed systems in which sterile technique is maintained; this minimizes the risk for infection. D. Laparoscopic surgery is performed using sterile technique to minimize the risk of infection.
A client's stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this client? A. Droplet B. Contact C. Reverse D. Airborne
Answer: B Rationale: A. Droplet precautions are used for clients who have an illness transmitted by particle droplets larger than 5 mcm, such as mumps, rubella, pharyngeal diphtheria, Mycoplasma pneumonia, pertussis, streptococcal pharyngitis, and pneumonic plague. B. Contact precautions are used for clients who have an illness transmitted by direct contact or with items contaminated by the client. Examples include gastrointestinal, respiratory, skin, or wound infections or colonization with drug-resistant bacteria (including Clostridium difficile, Escherichia coli, and Shigella). Contact precautions also are used for other infections/infestations, such as hepatitis A, herpes simplex virus, syncytial virus, and parainfluenza. C. Reverse precautions, also known as neutropenic precautions or protective isolation, are used for clients who are immunocompromised. Isolation practices are employed, and personal protective equipment is worn by the caregiver to protect the client from the caregiver. D. Airborne precautions are used for clients who have an illness transmitted by airborne droplet nuclei smaller than 5 mcm, such as varicella, rubeola, and tuberculosis.
Which client statement indicates that further teaching by the nurse is necessary regarding how to ensure protection from food contamination? Select all that apply. A. "I should stuff a turkey immediately before putting it in the oven." B. "I love juicy, rare hamburgers with onion and tomato." C. "I prefer chicken salad sandwiches with mayonnaise." D. "I know to spit out food that does not taste good." E. "I should defrost frozen food in the refrigerator."
Answer: B Rationale: A. Inserting stuffing immediately before putting the turkey in the oven is safe practice. Letting a stuffed turkey stand at room temperature is not advisable because it promotes the multiplication of microorganisms. B. Hamburger meat should be thoroughly cooked so that disease-producing microorganisms within the meat are destroyed. C. This statement is about the client's preference about food. The statement does not indicate a lack of knowledge about the use or storage of mayonnaise. D. This statement does not indicate a lack of knowledge about what to do when it is determined that something does not taste right. E. This is the correct way to defrost frozen food. Food should not be defrosted in an environment between 45F and 140F because bacteria will rapidly grow in this temperature range.
A nurse working in a clinic is assessing clients of a variety of ages. Which age group should the nurse particularly assess for subtle clinical manifestations of subclinical infections? A. Children of school age B. Older adults C. Adolescents D. Infants
Answer: B Rationale: A. School-age children generally respond to infections with acute clinical manifestations that are identified easier and earlier than in an age group in another option. B. Infections are more difficult to identify in the older adult because the clinical manifestations are not as acute and obvious as in other age groups. This outcome occurs as a result of the decline in all body systems related to aging. C. Adolescents generally respond to infections with acute clinical manifestations that are identified more easily and earlier than in an age group in another option. D. Infants generally respond to infections with acute clinical manifestations that are identified more easily and earlier than in an age group in another option.
A client tells the nurse, "I think I have an ear infection." For which objective human response to an ear infection should the nurse assess this client? Select all that apply. A. Throbbing pain B. Purulent drainage C. Feeling of pressure D. Dizziness when moving E. Hearing a buzzing sound
Answer: B Rationale: A. Throbbing pain is subjective, not objective, information because pain cannot be observed; it is felt and described only by the client. B. Purulent drainage from the ear is objective information because it can be observed and measured. C. Feeling of pressure is a response to inflammation that causes displacement of tissue. This is subjective information because it cannot be measured or verified other than that which is reported by the client. D. Dizziness is subjective, not objective, information because it cannot be measured; dizziness is experienced and described only by the client. E. Hearing a buzzing sound (tinnitus) is subjective, not objective, information because it cannot be observed; a buzzing sound is perceived and described only by the client.
A nurse identifies that a client has an inflammatory response. Which localized client response supports this conclusion? Select all that apply. A. Fever B. Swelling C. Erythema D. Bradypnea E. Tachycardia
Answer: B, C Rationale: A. A fever is a systemic, not local, response to inflammation. B. Chemical mediators released at the site of an injury increase capillary permeability, causing excessive interstitial fluid that results in swelling (edema). C. Local trauma or infection stimulates the release of kinins, which increase capillary permeability and blood flow to the local area. The increase of blood flow to the area causes erythema (redness) D. Bradypnea is a regular but excessively slow rate of breathing (less than 12 breaths per minute) and is not a response associated with the local adaptation syndrome. E. Tachycardia is an elevated heart rate of more than 100 beats per minute and is unrelated to the local adaptation syndrome.
Which is an example of a primary defense that protects the body from infection? Select all that apply. A. Antibiotic therapy B. Lysozymes in saliva C. The low pH of the skin D. The acidic environment of the vagina E. Production of mucus by cells in the genitourinary tract
Answer: B, C, D, E Rationale: A. Antibiotic therapy is the use of chemotherapeutic agents to control or eliminate bacterial infections. It is not a primary defense that protects the body from infection. The inappropriate use of antibiotics destroys the usual flora of the body and can predispose an individual to additional infections. B. Lysozymes in saliva help wash microorganisms from the teeth and gums. C. The low pH of the skin is caused by phospholipids that help prevent the development of bacterial infections. D. The acidic environment of the vagina protects it from the growth of pathogens. E. Mucus produced by epithelial cells in the genitourinary tract adheres to pathogens to facilitate their elimination through urination.
Which nursing action protects clients as susceptible hosts in the chain of infection? Select all that apply. A. Wearing personal protective equipment B. Administering childhood immunizations C. Recapping a used needle before discarding D. Instituting prescribed immunoglobulin therapy E. Disposing of soiled gloves in a waste container
Answer: B, D Rationale: A. This is an example of controlling the mode of transmission, not the susceptible host, link in the chain of infection. B. This is an example of an action designed to interrupt the susceptible host link in the chain of infection by increasing the resistance of the host to an infectious agent. C. Discarding uncapped, used syringes in a sharps container disrupts the chain of infection at the transmission link in the chain of infection. the nurse should never recap a used needle because of the risk of a needle-stick injury. D. Immunoglobulins are a group of related proteins able to act as antibodies. Immunoglobulin therapy helps defend a susceptible host against infection. E. This is an example of controlling the mode of transmission, not the susceptible host, link in the chain of infection.
The nurse is reviewing the clinical record of a newly admitted older adult male client. Which piece of information should cause the most concern? CLIENT'S CLINICAL RECORD Laboratory Results - WBC: 30,000 cells/mcL - Hct: 52% - Hb: 13 g/dL Emergency Department Nurse's Admission Note - Client reports feeling overwhelming fatigue, anorexia, "high" fevers, burning on urination, "frequently urinating small amounts," and abdominal cramping. States that these signs and symptoms have progressively worsened over the last few days. Vital Signs - Pulse: 100 beats per minute, regular - Temperature (oral): 103F - Respirations: 24 breaths per minute - Blood pressure: 110/86 mm Hg A. Temperature 103F B. Abdominal cramping C. WBC 30,000 cells/mcL D. Blood pressure 110/86 mm Hg
Answer: C Rationale: A. Although a temperature of 103F is higher than the expected range of 97.5F to 99.5F, it is not as critical as data in another option. B. Although abdominal cramping is an important piece of data, it is not as critical as data in another option. C. A white blood cell count of 30,000 cells/mcL or higher is a critical finding indicating a potential life-threatening health situation. The clinical indicators support a medical diagnosis of urosepsis--septicemia from bacteria entering the bloodstream from a urinary cause. D. A blood pressure of 110/86 mm Hg is low for an older adult man and probably is low because of dehydration associated with "high" fevers for a few days' duration. Although the blood pressure indicates a need for fluid replacement, it is not as critical as data in another option.
Which is the primary reason why the nurse should avoid glued-on artificial nails? A. They interfere with dexterity of the fingers. B. They could fall off in a client's bed. C. They harbor microorganisms. D. They can scratch a client.
Answer: C Rationale: A. Artificial nails do not interfere with finger dexterity if kept at a reasonable length (not longer than 1/4 inch beyond the end of the finger). B. Although an artificial nail falling off in a client's bed is a concern, it is not the main reason why artificial nails should be avoided. C. Studies have demonstrated that artificial nails, especially when cracked, broken, or split, provide crevices in which microorganisms can grow and multiply and therefore should be avoided by direct care providers. D. When artificial nails are cared for so that they remain intact and free of cracks or breaks, they should not scratch the skin.
A nurse is concerned about a client's ability to withstand exposure to pathogens. Which blood component should the nurse monitor? A. Platelets B. Hemoglobin C. Neutrophils D. Erythrocytes
Answer: C Rationale: A. Platelets are essential for blood clotting and are unrelated to an individual's ability to withstand exposure to pathogens. B. Hemoglobin is the part of the red blood cell that carriers oxygen from the lungs to the tissues and is unrelated to the assessment of an individual's ability to withstand exposure to pathogens. C. Neutrophils, the most numerous leukocytes (white blood cells), are a primary defense against infection because they ingest and destroy microorganisms (phagocytosis). When the leukocyte count is low, it indicates a compromised ability to fight infection. D. Red blood cells (erythrocytes) do not reflect an individual's ability to withstand exposure to pathogens. Erythrocytes transport oxygen via hemoglobin molecules.
A nurse is caring for a client with a high fever secondary to septicemia. The primary health-care provider prescribes a cooling blanket (hypothermia blanket). Through which mechanism does the hypothermia blanket achieve heat loss? A. Radiation B. Convection C. Conduction D. Evaporation
Answer: C Rationale: A. Radiation is not related to heat loss via a cooling (hypothermia) blanket. Radiation is heat loss from one surface to another surface without direct contact. B. Convection is not related to heat loss via a cooling (hypothermia) blanket. Convection is the loss of heat as a result of the motion of cool air flowing over a warm body. The heat is carried away by air currents that are cooler than the warm body. C. Conduction is the transfer of heat from a warm object (skin) to a cooler object (hypothermia blanket) during direct contact. D. Evaporation is unrelated to heat loss via a cooling (hypothermia) blanket. Evaporation is the conversion of a liquid to a vapor, which occurs when perspiration on the skin is vaporized. For each gram of water that evaporates from the skin, approximately 0.6 of a calorie of heat is lost.
A nurse is caring for a group of clients experiencing various medical conditions. Which condition places the client at the highest risk for a wound infection? A. Surgical creation of a colostomy B. First-degree burn on the back C. Puncture of the foot by a nail D. Paper cut on the finger
Answer: C Rationale: A. Surgery is conducted using sterile technique. In addition, preoperative preparation of the bowel helps to reduce the presence of organisms that have the potential to cause infection. B. There is no break in the skin in a first degree burn; therefore, there is less of a risk for a wound infection than an example in another option. C. Of all the options presented, puncture of the foot by a nail has the greatest risk for a wound infection. A nail is a soiled object that has the potential of introducing pathogens into a deep wound that can trap them under the surface of the skin, a favorable environment for multiplication. D. Paper generally is not heavily soiled, and the wound edges are approximated. This is less of a risk than an example in another option.
A client has a wound infection. Which local human response should the nurse expect to identify? Select all that apply. A. Leukocytosis B. Malaise C. Edema D. Fever E. Pain
Answer: C, E Rationale: A. An increase in white blood cells (leukocytosis) is a systemic, not local, response to an infection. B. Discomfort, uneasiness, or indisposition (malaise) is a systemic, not local, response to infection. C. Chemical mediators increase the permeability of small blood vessels, thereby causing fluid to move into the interstitial compartment, with resulting local edema. D. Fever is a systemic, not local, response to a wound infection. Microorganisms, or endotoxins, stimulate phagocytic cells that release pyrogens, which stimulate the hypothalamic thermoregulatory center to produce an increased temperature (fever, pyrexia). E. Pain is caused by localized edema that puts pressure on the surrounding nerves; this is associated with the local adaptation syndrome.
A nurse is caring for a group of clients with infections. Which infection is classified as a health-care-associated infection? A. Respiratory infection contracted from a visitor B. Vaginal infection in a postmenopausal woman C. Urinary tract infection in a client who is sedentary D. Would infection caused by unwashed hands of a caregiver
Answer: D Rationale: A. A respiratory infection contracted from a visitor is not an example of an infection that directly resulted from a diagnostic or therapeutic procedure. B. A vaginal infection in a postmenopausal woman is not an example of an infection that directly resulted from a diagnostic or therapeutic procedure. C. A urinary tract infection in a client who is sedentary is not an example of an infection that directly resulted from a diagnostic or therapeutic procedure. D. A health-care-associated infection (iatrogenic) directly results from a diagnostic or therapeutic procedure. When a caregiver does not wash his/her hands, thereby transmitting a pathogen that causes a wound infection, the result is an iatrogenic infection.
A nurse is caring for a group of hospitalized clients. Which should the nurse do first to prevent client infections? A. Provide small bedside bags to dispose of used tissues. B. Encourage staff to avoid coughing near clients. C. Administer antibiotics as prescribed. D. Identify clients at risk.
Answer: D Rationale: A. Although this is something the nurse may provide to contain soiled tissues, it is not the first action the nurse should implement to prevent infection. B. Although this is something the nurse may do to limit airborne or droplet transmission of microorganisms, it is not the first action the nurse should implement to prevent infection. C. Antibiotics generally are prescribed for clients who have infections. However, antibiotics occasionally are prescribed prophylactically. D. This is the most important first step in the prevention of infection. A client who is at risk to transmit an infection or at risk to be physiologically unable to protect the self from infection may require the institution of special precautions (e.g., transmission-based precautions, protective isolation).
Which client condition identified by a nurse is unrelated to infection? A. Catabolism B. Hyperglycemia C. Ketones in the urine D. Decreased metabolic activity
Answer: D Rationale: A. Catabolism, the destructive phase of metabolism with its resultant release of energy, is related to infection. B. Serum glucose is increased (hyperglycemia) in the presence of an infection because of the release of glucocorticoids associated with the general adaptation syndrome. C. The presence of ketones in the urine, a sign that the body is using fat as a source of energy, is related to infection because of the associated increased need for calories for fighting the infection. D. Metabolic activity increases, not decreases, with an infection as the body mounts a defense to fight invading pathogenic microorganisms.
Which does the nurse determine is a specific line of defense against infection? A. Mucous membrane of the respiratory tract B. Urinary tract environment C. Integumentary system D. Immune response
Answer: D Rationale: A. Protective mechanisms in the respiratory tract provide a nonspecific defense against pathogenic microorganisms. Primary defenses are nonspecific immune defenses that are anatomical, mechanical, or chemical barriers. In the respiratory tract, they include intact mucous membranes, mucus, bactericidal enzymes, cilia, sneezing, and coughing. B. Protective mechanisms in the urinary tract environment provide a nonspecific line of defense against pathogenic microorganisms. These defenses include intact mucous membranes, urine flowing out of the body, and urine acidity. C. Skin provides a nonspecific defense against pathogenic microorganisms. These defenses include intact skin, surface acidity, and the usual flora that is found on the skin. D. The immune response is a specific defense against pathogenic microorganisms. The production of antibodies to neutralize and eliminate pathogens and their toxins (immune response) is activated when phagocytes fail to completely destroy invading microorganisms. The nonspecific defenses (anatomical and physiological barriers, inflammatory response, and vascular and cellular responses) work in harmony with the specific immune response to defend the body from pathogenic microorganisms.