PrepU chapter 24

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? a. "This antibiotic is the best choice since the causative organism is not known." b. "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." c. "Drug resistance can develop when the wrong antibiotic is used for pneumonia." d. "Pneumonia is usually caused by multiple organisms."

a. "This antibiotic is the best choice since the causative organism is not known."

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? a. Avoid touching the outer surfaces of the gown. b. Remove the gown before removing gloves. c. Remove the gown immediately after exiting the room. d. Perform hand hygiene before removing the gown.

a. Avoid touching the outer surfaces of the gown.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? a. Perform hand hygiene b. Don a new pair of gloves to dispose of materials c. Wrap all used materials together and discard in biohazard container d. Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

a. Perform hand hygiene

The nurse is preparing to enter a client's room who is on airborne precautions. Which technique should the nurse use when wearing a nonparticulate respirator (N-95) mask? Select all that apply. a. The mask covers the nose and mouth. b. Replace the mask after 20-30 minutes. c. Remove the mask by grasping the front of mask. d. Tie the upper strings of mask snugly against back head. e. Discard the mask in a paper lined wastebasket.

a. The mask covers the nose and mouth. b. Replace the mask after 20-30 minutes. d. Tie the upper strings of mask snugly against back head.

A nurse is caring for four clients. Which client has the highest risk of infection? a. older male with an enlarged prostate b. toddler with a benign heart murmur c. woman in second trimester of pregnancy d. young woman with a history of scoliosis

a. older male with an enlarged prostate

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? a. "Stress causes body fluids to accumulate, which leads to bacterial growth." b. "Stress leads to increased secretion of cortisol, which suppresses your immune response." c. "Stress causes the body's normal immune response to turn on itself." d. "Stress leads to a deterioration in the skin's barrier line of defense."

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

The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response? a. "Until you leave the hospital." b. "When your sputum culture is negative." c. "For 2 days as you get settled onto the unit." d. "Only until you begin to feel better."

b. "When your sputum culture is negative."

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? a. No action is needed. b. Don another pair of sterile gloves. c. Complete a sentinel event report. d. Notify the primary care provider.

b. Don another pair of sterile gloves.

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply. a. Nurses need only apply clean gloves when performing or assisting with invasive client procedures. b. During some care activities for an individual client, nurses may need to change gloves more than once. c. Nurses may use a waterproof gown more than one time. d. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. e. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. f. Nurses may lower a mask around the neck when not being worn and bring it back over the mouth and nose for reuse.

b. During some care activities for an individual client, nurses may need to change gloves more than once. d. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. e. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.

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: a. increased humoral immunity response. b. decreased cellular immunity. c. increased effectiveness of phagocytosis. d. decreased susceptibility to infection.

b. decreased cellular immunity

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter? a. Use an alcohol-based hand rub to decontaminate the hands. b. Remove all jewelry, including wedding bands, before hand washing. c. Keep hands lower than elbows to allow water to flow toward fingertips. d. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips.

c. Keep hands lower than elbows to allow water to flow toward fingertips.

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? a. standard precautions b. droplet precautions c. contact precautions d. airborne precautions

c. contact precautions

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: a. decreased b. elevated c. within normal limits d. stable

c. within normal limits

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? a. permits selection of antibiotic concentration b. helps in reducing proliferation of multidrug-resistant organisms c. narrows the therapeutic range to avoid prolonged use d. helps to determine prescribed antibiotic therapy

d. helps to determine prescribed antibiotic therapy

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? a. wear gloves when touching the client b. wear a mask and gown in the client's room c. avoid direct contact with the client d. perform hand hygiene before and after entering the client's room

d. perform hand hygiene before and after entering the client's room

The Neutropenic Precaution sign was posted outside the client's room. Which subsequent nursing action supports this set-up? a. placing a "No visitor" sign by the door b. eliminating vegetable salads from the diet. c. encouraging early ambulation in the hallways d. removing razors for shaving from the room

eliminating vegetables from the diet

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply. a. decreased pulse rate b. increased respiratory rate c. absence of pain d. lymph node enlargement e. fever

increased respiratory rate lymph node enlargement fever