1012 Infection
The mother of a 3-year-old child with rubeola states that she once heard that it was called by another name. The nurse tells the mother that rubeola commonly is known as: Measles Chickenpox German measles Whooping cough
Measles Measles is another name for rubeola. Chickenpox is also known as varicella. German measles is also known as rubella. Whooping cough is also known as pertussis.
A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with patient care, remove the gown first and then remove the gloves.
Don an N95 respirator mask before entering the room. A N95 respirator mask is unique to airborne precautions. It is unique for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be non-permeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.
A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. The nurse teaches the client that the purpose of the antibiotics is to help: Prevent incisional infection Avoid postoperative pneumonia Limit the risk of a urinary tract infection Eliminate bacteria from the gastrointestinal (GI) tract
Eliminate bacteria from the gastrointestinal (GI) tract The GI tract contains numerous bacteria; antibiotics are given to decrease the number of microorganisms in the bowel before surgery. Preventing incisional infection is a potential complication prevented by the use of sterile technique when changing the dressing. Avoiding postoperative pneumonia is a potential complication prevented by coughing, deep breathing, and early ambulation postoperatively. Limiting the risk of a urinary tract infection is a potential complication prevented by hygiene, meatal care, and increased hydration postoperatively.
What nursing intervention should be implemented routinely after a client has a vacuum aspiration abortion? Giving the client the prescribed oxytocic medication Preparing the client for discharge within 30 minutes Teaching the client about the various methods of birth control Encouraging the client to take the prescribed antibiotic medication
Encouraging the client to take the prescribed antibiotic medication Prophylactic antibiotics after a decrease the incidence of infection. Oxytocics are not used routinely after an abortion unless there is excessive vaginal bleeding. The client is usually observed for 1 to 3 hours before being discharged. Birth control instructions should be given before the abortion; a client is not receptive to teaching immediately after the procedure.
Nitrofurantoin (Macrobid) 0.1 gm is prescribed for a client with a urinary tract infection. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number.
First convert 0.1 g to its equivalent in mg by multiplying by 1000 (move the decimal 3 places to the right). Use the "Desire over Have" formula of ratio and proportion to solve the problem. Desire 100 mg x tablets ---------------- = --------- Have 50 mg 1 tablet 50x = 100 x = 100 ÷ 50 x = 2 tablets
A client who has recently been found to be infected with HIV comments to the nurse, "There are so many terrible people around. Why couldn't one of them get HIV instead of me?" What is the best response by the nurse? "It seems unfair that you should have this disease." "I'm sure you really don't wish this on someone else." "It might be good for you to speak with your religious leader." "I'm sure you know that HIV infection is now considered a chronic illness."
"It seems unfair that you should have this disease." The client is in the anger or "why me" stage of grieving; encouraging the client to express feelings will help the client resolve them while moving toward acceptance. "I'm sure you really don't wish this on someone else" is a judgmental response that may create a rift in the nurse-client relationship. Suggesting that the client speak with a religious leader may precipitate guilt feelings and ignores the current concern. "I'm sure you know that HIV infection is now considered a chronic illness" does not reflect what the client said; people with newly diagnosed chronic illnesses grieve for their loss of health.
A client with tuberculosis is to begin Rifater (combination of isoniazid [INH], rifampin [RIF], and pyrazinamide [PZA]), and streptomycin sulfate (streptomycin) therapy. The client says, "I've never had to take so much medication for an infection before." The nurse should explain: "This type of organism is difficult to destroy." "Streptomycin prevents side effects of Rifater." "You'll only need to take the medications for a couple of weeks." "Aggressive therapy is needed because the infection is well advanced."
"This type of organism is difficult to destroy." Multiple drugs are administered because of the concern regarding drug resistance. Streptomycin sulfate is an antibiotic; it does not prevent the side effects of Rifater therapy. Multiple antitubercular drugs are necessary for an extended period, approximately six to eight months depending on the individual. Aggressive therapy may increase anxiety and may not be needed even when the infection is well advanced.
Tuberculosis is confirmed and isoniazid (INH), rifampin (Rifadin), and pyridoxine (vitamin B6) are prescribed for a client. The client says, "I've never had to take so many medicines for an infection before." What is the nurse's best reply? "Rifampin prevents side effects from INH." "This type of organism is difficult to destroy." "You'll need only one medication in a couple of months." "Aggressive therapy is needed because your infection is so advanced."
"This type of organism is difficult to destroy." Organism mutation commonly results in drug resistance when treatment is inadequate. Rifampin decreases the replication of the tubercle bacillus ; pyridoxine is used to prevent neuropathy associated with INH. The response "You'll need only one medication in a couple of months" is an inaccurate statement. High concentrations of at least two antitubercular drugs are necessary for an extended period. The response "Aggressive therapy is needed because your infection is so advanced" may raise anxiety and may not be true; aggressive combination drug therapy always is used for tuberculosis.
A newly hired nurse, during orientation, is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? "Let me get my preceptor." "Wash your hands before and after any client care." "Clean all instruments and work surfaces with an approved disinfectant." "Ensure proper disposal of all items contaminated with blood or body fluids."
"Wash your hands before and after any client care." The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of handwashing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.
A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? "Wear sterile gloves when doing the procedure." "Wash your hands before performing the procedure." "Perform the self-catheterization every 12 hours." "Dispose of the catheter after you have catheterized yourself."
"Wash your hands before performing the procedure." To avoid transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2 to 3 hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.
A nurse is changing the dressing of a sixth-grader with severe burns. What basic principles of surgical asepsis must the nurse consider? A paper field must remain dry to be considered sterile. Sterile items held below the waist are considered sterile. A 1-inch border around a sterile field is considered contaminated. Sterile objects in contact with clean objects are considered contaminated. A fenestrated drape is not considered sterile.
#1, 3 and 4 Once a sterile paper field becomes wet it allows microorganisms on the surface of the table to contaminate the field. A 1-inch border around the outer edge of a sterile field is considered contaminated because the edges touch the table. Once a sterile object comes into contact with any object that is not sterile, it is no longer considered sterile. Sterile objects below the waist are considered contaminated. A fenestrated drape may be considered sterile as long as it has not been contaminated.
During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. What information in the client's history supports the health care provider's diagnosis of pulmonary tuberculosis? (Multiple) Fever Dry cough Night sweats Frothy sputum Engorged neck veins Blood-tinged sputum
#1, 3 and 6 Tuberculosis is an infectious disease in which recurrent fevers are present, usually in the late afternoon. Profuse diaphoresis at night (night sweats) is a classical sign of tuberculosis. Blood-tinged sputum (hemoptysis) results from pathophysiological trauma to mucous membranes. The cough is productive, not dry, because the inflammatory process causes purulent mucus. Frothy sputum is present with pulmonary edema, not tuberculosis. Engorged neck veins are symptomatic of heart failure.
A nurse is teaching a client about drug therapy for gonorrhea. Which fact about drug therapy should the nurse emphasize? Cures the infection Prevents complications Controls its transmission Reverses pathological changes
Cures the infection Ceftriaxone (Rocephin), followed by doxycycline (Vibramycin), is specific for Neisseria gonorrhoeae and eradicates the microorganism; other treatment regimens are available for resistant strains. If the disease progresses before the diagnosis is made, complications such as sterility, heart valve damage, or joint degeneration may occur. Transmission is not controlled; the organism is eliminated. If tubal structures, heart valves, or joints degenerate, the pathological changes will not be reversed by antibiotic therapy.
What clinical signs should lead a nurse to suspect that a 1-year-old child has rubella (German measles)? Bulging fontanel and nuchal rigidity Conjunctivitis and sensitivity to light Koplik spots on the soft palate and buccal mucosa Enlarged posterior cervical and postauricular nodes
Enlarged posterior cervical and postauricular nodes Lymphadenopathy and the development of a rash after a day of fever, sneezing, and coughing are characteristics of rubella (German measles). A bulging fontanel and nuchal rigidity are associated with meningitis and encephalitis, not rubella. Conjunctivitis and light sensitivity are associated with rubeola (measles), not rubella. Koplik spots are present with rubeola, not rubella.
The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? Soap Time Water Friction
Friction Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.
A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug? Administer the medication with meals or a snack. Provide orange or other citrus fruit juice with the medication. Give the medication an hour before milk products are ingested. Offer antacids 30 minutes after administration if gastrointestinal side effects occur.
Give the medication an hour before milk products are ingested. Any product containing aluminum, magnesium, or calcium ions should not be taken in the hour before or after an oral dose, because it decreases absorption by as much as 25% to 50%. Food interferes with absorption; it should be given one hour before or two hours after meals. Citrus juice has no influence on this drug. Antacids will interfere with absorption.
A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease? Handling a cat litter box Drinking contaminated water Having sex with many partners Eating inadequately cooked meat
Having sex with many partners Cytomegalovirus has been recovered from semen, vaginal secretions, urine, feces, and blood; it is commonly found in clients who are HIV positive. Drug use can decrease sexual inhibitions and judgment. Toxoplasmosis can be contracted from contaminated cat litter. Contaminated water is associated with hepatitis type A. Toxoplasmosis can be contracted from inadequately cooked meat.
When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take? Giving the infant to the mother Having the visitor step outside the room Verifying the infant's and mother's identification bands Asking the visitor whether the coughing and sneezing are caused by a cold
Having the visitor step outside the room Protection of newborns from unnecessary exposure to microorganisms is the priority. Giving the infant to the mother should not be done until the mother and newborn's identification bands have been verified. Verifying the infant's and the mother's identification bands should be done after the visitor leaves the room. Asking the visitor whether the coughing and sneezing are caused by a cold is a discussion that should take place outside the room. The visitor should be asked to leave if indications of an infection are present.
A nurse is caring for a client with glomerulonephritis. What should the nurse instruct the client to do to prevent recurrent attacks? Take showers instead of tub baths. Continue the same restrictions on fluid intake. Avoid situations that involve physical activity. Seek early treatment for respiratory tract infections.
Seek early treatment for respiratory tract infections. Hemolytic streptococci, common in throat infections, can initiate an immune reaction that damages the glomeruli. Baths may be linked to urethritis, not glomerulonephritis. Fluid restriction is moderated as the client improves; fluid helps prevent urinary stasis. Activity helps prevent urinary stasis.
The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? All nursing functions will be completed by discharge. All invasive intravenous lines will remain patent. The client will remain awake, alert, and oriented at all times. The client will be free of signs and symptoms of infection by discharge.
The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.
When taking the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS), the nurse must: Don clean gloves Use barrier techniques Put on a mask and gown Wash the hands thoroughly
Wash the hands thoroughly Because this procedure does not involve contact with blood or secretions, additional protection to washing the hands thoroughly is not indicated. Donning clean gloves and using barrier techniques are necessary only when there is risk of contact with blood or body fluid. A mask and gown are indicated only if there is a danger of secretions or blood splattering on the nurse (for example, during suctioning).
A nurse explains to the mother of a 1-year-old with a history of frequent ear infections that the primary cause of otitis media in young children is: Sinusitis Recurrent tonsillitis An inflamed mastoid process An obstructed eustachian tube
An obstructed eustachian tube A blocked eustachian tube impairs drainage and creates negative pressure; when the tube opens, bacteria are pulled into the middle ear. Sinusitis is not related to otitis media. Recurrent tonsillitis is not the direct cause of otitis media. Mastoiditis is a complication, not a cause, of otitis media.
A client who is in labor is admitted 30 hours after her membranes ruptured. For what condition does the nurse anticipate that the client is most at risk? Cord prolapse Placenta previa Chorioamnionitis Abruptio placentae
Chorioamnionitis The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection. A prolapsed cord usually occurs shortly after the membranes rupture, not 1½ days later. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Premature separation of the placenta is unrelated to ruptured membranes.
When planning nursing care for a 5-year-old child with acute poststreptococcal glomerulonephritis, what should the nurse emphasize that the child and family must maintain? A bland diet high in protein Bedrest lasting at least 4 weeks Isolation from children with infections A daily intramuscular dose of penicillin
Isolation from children with infections During the acute stage, anorexia and general malaise lower the child's resistance to infection. A bland diet is not necessary, but high protein and high-sodium foods should be avoided. Bedrest is not a necessary restriction. It is encouraged when the child is easily fatigued. Antibiotics are not necessary for all children with acute glomerulonephritis, only those with persistent streptococcal infections. The intramuscular route is not used.