VNSG 1400: Chapter 12 (Med-Surg) Prep U Questions

A client is alarmed that she has tested positive for MRSA following culture testing during her admission to the hospital. What should the nurse teach the client about this diagnostic finding?

"This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces." Explanation: This client's testing results are indicative of colonization, which is not synonymous with infection. The test results are considered reliable, and would not be characterized as "preliminary." Treatment is not normally prescribed for colonizations

A public health nurse is teaching a mother about vaccinations prior to obtaining informed consent for her child's vaccination. What should the nurse cite as the most common adverse effect of vaccinations?

Allergic reactions to the antigen or carrier solution Explanation: The most common adverse effects are an allergic reaction to the antigen or carrier solution and the occurrence of the actual disease (often in modified form) when live vaccine is used. Reactions to vaccines do not typically include sensitivity to the sun, nausea and vomiting, or joint pain.

Which of the following terms describes foreign particles that enter a host and stimulate the body's immune response?

Antigen Explanation: Antigens are foreign particles, such as microbes, that enter a host

A client's diagnostic testing revealed that he is colonized with vancomycin-resistant enterococcus (VRE). What change in the client's health status could precipitate an infection?

Development of a skin break Explanation: Colonization can progress to infection if there is a portal of entry by which bacteria can invade body tissues. The use of vancomycin, or any other antibiotic, would not necessarily precipitate a VRE infection. Prolonged skin contact is similarly unlikely to cause infection, provided the skin remains intact.

The nurse is caring for a hospitalized client with an upper respiratory infection. Which nursing actions are critical to proper management of this client?

Dispose of soiled substances in a waterproof container. Explanation: One nursing action when caring for a client with an infection is to dispose of soiled substances in waterproof containers. It is important for the nurse to assist in the regulation of blood sugar within normal limits when caring for clients with infections because sugar supports the growth of microorganisms. The nurse should promote urination to avoid catheterization, which might cause skin to break down. Nurses should encourage coughing and deep breathing to clear secretions from the airways.

The nurse is caring for a patient with a meningococcus infection. What type of precautions should be used for this patient?

Droplet Explanation: Droplet precautions are used for organisms such as influenza or meningococcus that can be transmitted by close contact with respiratory or pharyngeal secretions.

A client is admitted from the ED diagnosed with Neisseria meningitides. What type of isolation precautions should the nurse institute?

Droplet Precautions Explanation: This client requires droplet precautions because the organism can be transmitted through large airborne droplets when the patient coughs, sneezes, or fails to cover the mouth. Smaller droplets can be addressed by airborne precautions, but this is insufficient for this microorganism.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

Measles Explanation: Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.

The nurse places a client in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection?

Mode of transmission Explanation: Isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques do not directly affect the agent, host, or portal of entry.

A nurse is participating in a vaccination clinic at the local public health clinic. The nurse is describing the public health benefits of vaccinations to participants. Vaccine programs addressing which of the following diseases have been deemed successful? Select all that apply.

Polio Diphtheria Mumps Explanation: The most successful vaccine programs have been ones for the prevention of smallpox, measles, mumps, rubella, polio, diphtheria, pertussis, and tetanus. There is no vaccine for chlamydial infections. Hepatitis is not counted as one of the most successful vaccination programs, because vaccination rates for hepatitis leave room for improvement

When a hospitalized client requires contact precautions, which responses is necessary?

The client should be placed in a private room when possible. Explanation: When possible, the client requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed, doors do not need to be closed, and a room with negative air pressure is not required.

An adult client in the ICU has a central venous catheter in place. Over the past 24 hours, the client has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the client's care may have increased susceptibility to CLABSI?

The client's central line was placed in the femoral vein. Explanation: In adult clients, the femoral site should be avoided in order to reduce the risk of CLABSI. Drawing blood cultures, receiving treatment for VRE, and receiving fluids and drugs through the same line are not known to increase the risk for CLABSI.

An older adult client has been diagnosed with Legionella infection. When planning this client's care, the nurse should prioritize which of the following nursing actions?

Vigilant monitoring of respiratory status Explanation: The lungs are the principal organs of Legionella infection. The client develops increasing pulmonary symptoms, including productive cough, dyspnea, and chest pain. Consequently, respiratory support is vital. Hemorrhage and skin breakdown are not central manifestations of the disease. Preservation of the client's airway is a priority over emotional support, even though this aspect of care is important.

A nurse is informing a nursing student about the Centers for Disease Control and Prevention (CDC). Which guideline is in compliance with the CDC guidelines for handwashing?

When hands are visibly soiled Explanation: The Centers for Disease Control and Prevention (CDC) recommends handwashing when hands are visibly soiled, before and after contacts with all clients, after contact with any source of microorganisms, before and after performing invasive procedures, and before and after removing gloves. The CDC does not recommend handwashing only after removing gloves, but rather both before and after removing gloves. The nurse needs to always wear gloves if he or she has any breaks in the skin of the hands. The CDC does not recommend handwashing when the nurse's hand skin has any breaks.

A client with a history of candidiasis is being closely monitored for signs of superinfection. Which signs or symptoms can indicate that superinfection has occurred? Select all that apply.

diarrhea inflammation of oral mucous membranes vaginal discharge Explanation:Signs of superinfection, also called opportunistic infection, include diarrhea, vaginal discharge, and inflammation of oral mucous membranes. These occur when nonpathogenic or remotely pathogenic microorganisms take advantage of favorable situations and overwhelm the host.

During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply.

infectious agent portal of entry susceptible host Explanation: The six components involved in the transmission of microorganisms are described as the chain of infection. All components in the chain of infection must be present to transmit an infectious disease from one human or animal to a susceptible host: an infectious agent, an appropriate reservoir, exit route, means of transmission, portal of entry, and susceptible host.