Pass Point: Immunity / Infection

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A school aged client has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents

Has your child had strep throat recently Rationale: Asking if the client had strep throat recently is appropriate because group A streptococcal infection typically precedes rheumatic fever

A 3 month old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?

Instituting droplet precautions:

A nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action completed by the surgical technician, indicates to the nurse that the sterile field has been contaminated?

Wetness in the sterile cloth on top of the nonsterile table has been noted

When assessing a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). Which laboratory value makes this client more susceptible to such infections

3+ Urine glucose

A client was diagnosed with AIDS several years ago. He now has a CD4 T-Lymphocyte count of 110 units/L Which of the following is an appropriate outcome for this client?

No development of opportunistic infections

A client has sever cellulits of the perineum. Orders are entered by the healthcare provider. Which of the following orders should take priority?

Obtain a baseline CBC and renal and liver function test

A staff nurse on the oncology unit must teach the new unit assistant about infection control practices. The nurse should explain that which measure is most important for preventing the spread of infection?

Performing proper hand hygiene

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan?

The use of a condom is advised for sexual intercourse Rationale: Hepatitis B is spread through exposure to blood or blood products and through high risk sexual activity


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