Test 3 Practice Questions
How many SIRs criteria are needed to start thinking an infection may be sepsis?
2+
how long does it take to heal from a superficial partial-thickness burn?
21 days
how long does it take for a superficial burn to heal
3-6 days
What is ideal MAP?
70-100
how long does it take for a deep partial thickness burn to heal
>21 days
A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment
A
A nurse is caring for a client who has C. diff infection and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown B. Use alcohol-based sanitizer to cleanse the hands C. Wear a mask when assisting the client with his meal tray D. Place the client on complete bed rest
A
A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters."
A
A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? A. "May I go with my family to the visitor's lounge?" B. "I'll see my friends when I get home." C. "My dad is coming to visit. Can you fix my hair for me?" D. "I told my cousins I'm in protective isolation."
A
A nurse is planning care for a client who deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of the burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises B. Use clean technique to provide wound care C. Place the client on the low-protein diet D. Maintain the client on bed rest
A
A patient receiving chemotherapy is an example of A. Susceptible host B. Causative agent C. Portal of entry D. Mode of transmission
A
The nurse has just received report on four clients. Which client should the nurse see first? A. A 2 month old infant with Temperature of 102.1 F B. A 16 year old complaining of pain to the right leg C. A 41 year old client waiting for suture removal D. A 90 year old client with a blood glucose of 263
A
A charge nurse finds an increased incidence of health-care-associated infections (HAIs) on a long-term care unit. Which priority action should the charge nurse take to address the problem? A. Monitor the staff's hand hygiene techniques B. Hold a mandatory in-service training session about hand hygiene and infection rates C. Require nurses to take an online course on HAIs D. Conduct a chart review to gather data about clients who develop HAIs
D
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30mL/hr D. Temperature of 102.4F
D
A nurse is caring for a client who has a new prescription for amphotericin B. The nurse should plan to monitor the client for which of the following adverse effects? A. Hyperkalemia B. Hypertension C. Constipation D. Nephrotoxicity
D
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding s which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous D. Purulent exudate
D
A nurse is receiving report on a client who C. diff and is being transferred from another unit. Which of the following precautions should the nurse take? A. Place the client in a negative-airflow room B. Clean the client's room with antibacterial disinfectant C. Wear a mask when entering the client's room D. Perform hand hygiene with nonantimicrobial soap and water after client care
D
A nurse on a pediatric unit has just received reports for 4 newly admitted clients. For which of the following children should the nurse plan to initiate droplet precautions? A. A child who has Rocky Mountain spotted fever B. A child who has roseola C. A child who has Molluscum contagiosum D. A child who has pertussis
D
Airborne (such as coughing or sneezing) is an example of A. Causative agent B. Portal of exit C. Portal of entry D. Mode of transmission
D
Handling food with unwashed hands is an example of A. Portal of entry B. Causative agent C. Susceptible host D. Mode of transmission
D
Which of the following medications requires patient to use a back up method of birth control? A. Azithromycin B. Ceftriaxone C. Cefepime D. Penicillin
D
Which of the following should be avoided by a client with a UTI? A. Cranberry juice B. Bananas C. Carbohydrates D. Caffeine
D
Which statement should be included in education for a patient taking antibiotics? A. Make sure you store the leftover medication away from children B. You should take your leftover antibiotic to the medication disposal site C. As long as the rash you develop is small you shouldn't worry D. Ensure you take all of this medication, even if your symptoms improve
D
_______describes the use of medication to reat infections due to bacteria, viruses, or fungi A. culture B. Sensitivity C. Chemotherapy D. Antimicrobial therapy
D
What range is the SBP indicating organ dysfunction?
SBP <90 or MAP <70
acute treatment of burns in ED
fluid resuscitation ventilatory management
epidermis, dermis and underlying tissues affected
full-thickness burns
effects of severe burns: GI system
hyperacidity ileus melena hematemesis increased abdominal girth
effects of severe burns: respiratory system
hypoxia increased respirations rhonchi decreased ciliary movement airway obstruction
The patient is ordered IV antibiotics. What is important to check before hanging the antibiotic?
if cultures were ordered or completed
effects of severe burns: metabolism
increased catabolism increased anabolism weight loss acidosis hyperglycemia
what fluid do we usually give to patients with severe burns?
lactated ringer or NS (isotonic)
clinical manifestations of deep partial-thickness burns
pale, waxy, moist or dry blisters decreased capillary refill decreased pain sensation contractures possible
clinical manifestations of full-thickness burns
pale, waxy, yellow, brown, mottle, charred, nonblanching red skin dry and leathery surface no sense of pain or light touch skin grafting required
effects of severe burns: integumentary system
skin loss sensory loss decreased temperature
only effects epidermis
superficial burn
both epidermis and dermis (papillary layer) are affected
superficial partial-thickness burns
effects of severe burns: cardiovascular system
third spacing decreased BP increased pulse decreased RBCs decreased CO decreased tissue perfusion
T/F it is possible to overdose on antibiotics
true
What is the name of the criteria used to determine if an infection has turned to sepsis?
SIRS criteria
What is MAP equation?
(SBP + 2 (DBP))/3
The nurse is providing education to the parents of a newborn. Included in the information is to take the infant to see a healthcare provider if they experience a fever above 100.5 F before 3 months of age. The father of the newborn asks why this is such a concern for the baby. Which of the following is the best response for the nurse to provide? A. "Newborns do not have a developed immune system and a fever could indicate an infection which would need to be treated promptly to prevent further complications" B. "You would need to see your provider for them to be able to give the appropriate dose of medication." C. "A fever may just mean the baby is teething but the doctor would need to confirm this." D. "A fever can make the baby very irritable which can be overwhelming for new parents. The physician would want to go over some different approaches to caring for a sick newborn at home."
A
The respiratory tract is an example of A. Portal of entry B. Reservoir C. Causative agent D. Mode of transmission
A
Which of the following is the most reliable method of determining the appropriate antibiotic to treat an infection? A. Sputum culture & sensitivity B. WBC C. Physical assessment findings D. CBC with differential
A
Which of the following statements are true about the medication acyclovir? A. It can be used to treat viral conditions such as shingles B. You do not need to take all of the medication to feel better C. You should limit how much water you drink while taking this medication D. It is safe to drink alcohol while taking this medication
A
which of the following can be a sign of increased ICP in a 2 month old infant? A. Focal seizures B. Nystagmus C. HR of 135 D. Loud cry
A
The charge nurse is helping the RN review her patient assessment for indicators of sepsis. Which of the following assessment findings could indicate sepsis in the patient? (Select all that apply) A. WBC 2,000 B. Temperature 96.4 F C. WBC 6,500 D. Temperature 98.9 F E. Respirations 24/min F. Temperature 102.2 F
A B E F
A nurse is educating peers on ways to prevent sepsis. Which of the following should be included in the education provided? A. Following sterile procedure when inserting a foley catheter B. Wearing PPE when entering every patient room C. Asking for all patients to be placed on an antibiotic upon admission to the hospital D. Placing clients with infections in negative pressure rooms
A.
A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I feel like I cannot breathe when I walk up the stairs."
B
A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates that the client is developing an infection? A. Temperature 100F B. Erythema at the incision site C. WBC count 9000 D. Pain reported as 6 on a scale of 0-10
B
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest B. Monitor the child for increased temperature C. Administer oxygen to the child D. Monitor the child for bleeding
B
A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as part of an effective conference? A. The planning process for the conference is centered on the nursing staff B. Other health care professionals are in attendance at the conference C. Controversial opinions regarding the plan of care are not tolerated during the conference D. The conference is focused on a discussion of the client's health care issues with minimal attention to resolving them
B
A school-age client is brought to the ED with complaints of lethargy, an oral fever of 101.2F, and feeling "weaker than usual." The client has a history of leukemia that has been treated with oral chemotherapy. Which physician's order would receive the highest priority by the nurse? A. Administer an antipyretic B. Initiative IV therapy C. Administer IV antibiotics D. Obtain a CBC with differential
B
Bacteria are an example of A. Susceptible host B. Causative agent C. Reservoir D. Mode of transmission
B
Blood of bodily fluids are an example of A. Portal of exit B. Reservoir C. Mode of transmission D. Causative agen
B
Fungi is an example of A. Portal of entry B. Causative agent C. Mode of transmission D. Portal of exit
B
What is the priority when preventing infection? A. Wearing gloves with patient care B. Frequent handwashing C. Observing isolation precautions D. Limiting visitors
B
When preparing an educational presentation for hospital staff on the topic of sepsis, the nurse should include which of the following in the presentation? A. Systemic inflammatory response syndrome (SIRS) only occurs in patients with sepsis B. Sepsis can result in a series of adverse events including vasodilation and hypercoagulability C. Sepsis is usually not as severe in pediatric patients D. Sepsis is not a concern for breastfeeding babies since they will receive immunity from the mother
B
Which of the following is an early sign of hypoxia? A. O2 saturation reading below 92% B. Confusion C. Blue tint to the nailbeds D. Cyanosis around the mouth
B
Which of the following is not usually considered a sign of an allergic reaction? A. Rash B. Dry mouth C. Itching D. Swelling of the lips
B
Which patient is at the highest risk of infection? A. A patient receiving oxygen B. A patient recovering from a total knee replacement C. A patient with nausea and vomiting D. A patient with chest pain
B
Which of the following labs should be monitored for a patient receiving IV gentamicin? SATA A. Magnesium Level B. WBC C. BUN D. Peak & Trough
B C D
A nurse is assessing for DIC in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? SATA A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension
B C E
A nurse is assessing the abdominal incision of a client who is 3 days postoperative. The incision is slightly edematous and pink with crusting on the edges and is draining serosanguineous fluid. Which of the following assessments describes the incision? A. The incision is showing early signs of infection B. The incision is showing early signs of dehiscence C. The incision is showing signs of healing without complications D. The incision is showing signs of developing a fistula
C
A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? A. Monitor intake and output B. Administer antibiotics C. Monitor respiratory status D. Encourage fluid and food intake
C
A nurse is following standard policy and procedure for reporting a client who has a communicable disease. Which of the following infections should the nurse plan to report to the CDC? A. C. diff B. Candidiasis C. VRSA D. Trichomoniasis
C
A nurse is teaching a client with SLE who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A. Hypoglycemia B. Tendinitis C. Infection D. Weight loss
C
An N95 should be used with which type of precautions? A. Standard B. Contact C. Airborne D. Droplet
C
Food is an example of A. Portal of entry B. Mode of transmission C. Reservoir D. Causative agen
C
How would the nurse best explain a blood glucose level of 250mg/mL to the family of a nondiabetic client in septic shock? A. The value reflects the dextrose in the IV infusion B. The value reflects the body's inability to metabolize glucose C. The value reflects the body's attempt to respond to stress D. The value reflects a new diagnosis of diabetes mellitus
C
The nurse is assessing a client who has been taking linezolid to treat a staph A infection. Which of the following findings should the nurse report to the provider? A. Nausea B. Headaches C. Paresthesias D. Insomnia
C
The nurse would determine that a client being treated for sepsis is improving when the following are found with the client assessment. Which of the following would the nurse expect to find first? A. BP stabilizes within normal limits B. Urine output increases to 30mL/hr C. Fluid resuscitation requirements diminish D. Blood culture results are normal
C
Which of the following are not considered when selecting an antibiotic? A. Patient allergies B. Sensitivity of the infecting organism to an antimicrobial C. Home environment of the patient D. Location of the infection
C
Which of the following conditions can most increase the risk of developing meningitis? A. Arthritis B. Hypertension C. Otitis media D. Gout
C
Which of the following is a common presenting symptom for older adults with an infection? A. Fever B. Fatigue C. Confusion D. Pain
C
Which of the following medications can be ototoxic? A. Amoxicillin B. Acyclovir C. Gentamicin D. Cefepime
C
__________ is the body's first line of defense against infection A. Inflammatory response B. Mucous membranes C. Intact skin D. Acidity of the stomach
C
T/F Antibiotics can be used to treat bacterial and viral illnesses
False
T/F The common cold can be treated with appropriate antibiotics
False
T/F The flu can be treated with antibiotics
False
T/F a patient with the flu should be placed on airborne precautions
False
T/F airborne precautions requires the use of a surgical mask at all times
False
T/F gentamicin can be used to treat RSV
False
If sepsis is suspected, what labs would you anticipate being ordered?
Lactate CBC CMP ABG Blood cultures
Sepsis criteria includes increased HR, increased RR, low or high temperature. What is the other SIRS criteria?
Low or high WBC
T/F A patient with HIV/AIDS should be treated with standard precautions
True
T/F A patient with tuberculosis should be placed on airborne precautions
True
T/F Broadspectrum antibiotics can be used to treat a wide variety of infectious organisms
True
T/F Older adults may present with a lower than normal body temperature as a sign of infection
True
A common clinical complaint of sepsis is
altered mental status
clinical manifestations of superficial partial-thickness burns
bright red, moist skin blisters blanches upon pressure
acute treatment of burns in ICU/burn team
fluid management ventilation surgery hydrotherapy nutrition PT wound care medications psychosocial support
effects of severe burns: urinary system
decreased GFR increased creatinine increased BUN increased USG increased uric acid myoglobinuria
effects of severe burns: immune system
decreased T cells decreased B cell increased WBCs decreased proteins phagocytosis
both epidermis and dermis (papillary and reticular layers) affected
deep partial-thickness burns
clinical manifestations of superficial burns
dry, pink to bright red skin slight edema chills headache N&V
prehospital patient management: burns
eliminate burn source stabilize patient removed restrictive jewelry, clothing
T/F A patient should increase their fluid intake to 1500mL per day to help thin and expel respiratory secretions
false
T/F It is best to treat all infections with broad spectrum antibiotics
false
T/F antipyretics are used to treat viral infections
false