380 EXAM 3 ATI INFECTION STUDY GUIDE

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

McBurney's point is located by drawing a line from the navel to the right iliac crest. Divide the line into three equal lengths. McBurney's point is midway between the navel to the iliac crest. Pressure over this point will elicit pain in clients with appendicitis.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following lab findings will affect wound healing? a. Serum albumin 3.2 g/dL b. Hemoglobin 16 g/dL c. WBC count 8,000/mm3 d. PTT 1.8

a. Serum albumin 3.2 g/dL **A serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay wound healing, and lead to infection.

A nurse is providing teaching to a patient about measures to prevent UTIs. Which of the following statements indicates the need for further patient teaching? a. "I will need to wipe my perineal area from back to front after urination." b. "I will need to empty my bladder regularly and completely." c. "I will need to drink apple cider vinegar each day." d. "I need to drink 8 cups of liquid each day."

a. "I will need to wipe my perineal area from back to front after urination."

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? a. Sudden decrease in abdominal pain b. Absent Rovsing's sign c. Flaccid abdomen d. Low-grade fever

a. Sudden decrease in abdominal pain **sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.

A nurse is assessing a client who has DM and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (SATA) a. Bradycardia b. An increase in neutrophils c. An increase in RBCs d. An increase in platelets e. Localized edema

b, e *Tachycardia, not bradycardia, is an indication of infection

A nurse us reviewing the medical record of a client who has a UTI. Which of the following findings should the nurse recognize as a risk factor? a. COPD b. Diabetes mellitus c. Anemia d. Osteoporosis

b. Diabetes mellitus **Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take? a. Place the client in a room with negative airflow. b. Wear a mask when providing care to the client. c. Ensure the client's room has HEPA filtration. d. Wear a gown when providing care to the client.

b. Wear a mask when providing care to the client. **The nurse should wear a mask when within 3 feet of a client who requires droplet precautions.

A nurse is caring for a child who has influenza. The nurse should identify that which of the following statements by the parent indicates the child has an increased risk for Reye syndrome? a. "I give my child ibuprofen when his muscles are aching." b. "I am encouraging my child to drink grapefruit juice." c. "I give my child aspirin to reduce his fever." d. "I am leaving a humidifier on in my child's room when he naps."

c. "I give my child aspirin to reduce his fever." **The administration of aspirin for fever associated with a viral illness increases the child's risk for Reye syndrome. Reye syndrome is a metabolic encephalopathy with manifestations of cerebral edema and fatty changes in the liver.

A nurse is teaching a group of teenage client about the use of condoms for the prevention of sexually transmitted infections. Which of the following statements should the nurse include in the teaching? a. "Use a natural membrane condom rather than a polyurethane condom." b. "You may use a condom more than once." c. "Use an oil-based lubricant when you use a condom." d. "Female condoms can help prevent transmission of sexually transmitted viruses."

d. "Female condoms can help prevent transmission of sexually transmitted viruses." **The client who uses a female condom can prevent sexually transmitted viruses when the polyurethane or nitrile sheath is placed in the vagina.

A nurse is providing teaching to a client who has a prescription for heat therapy for Tx of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching? a. "I will sit on the side of the tub and soak my right leg two times every day." b. "I'll keep a heating pad on the calf of my right leg when I am lying down." c. "I'll place my leg under a heat lamp every 3 hours." d. "I'll wrap a warm, wet towel around my right calf every 4 hours."

d. "I'll wrap a warm, wet towel around my right calf every 4 hours." **Moist heat is more effective than dry heat in treating cellulitis. Moist heat relieves the manifestations of inflammation by increasing blood flow to the affected area. The nurse should instruct the client to elevate the right leg 8 to 15 cm (3 to 6 in) above the level of the heart and apply warm, moist heat to the site every 2 to 4 hr.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? a. Serous b. Purulent c. Sanguineous d. Serosanguineous

d. Serosanguineous

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? a. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. b. Irrigate the wound with an antiseptic prior to obtaining the specimen. c. Include intact skin at the wound edges in the culture. d. Swab an area of skin away from the wound to identify the usual flora.

a. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. **The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse is admitting a client who was prescribed antibiotic therapy and now has a C. diff infection. Which of the following actions should the nurse take? a. Disinfect equipment in the client's room daily. b. Place the client in a protective environment. c. Use alcohol hand sanitizer after completing tasks for the client. d. Have the client wear a mask when out of the room.

a. Disinfect equipment in the client's room daily. **The nurse should disinfect equipment in the client's room every day, or when visibly soiled, to minimize the C. difficile spores in the client's room. The nurse should choose a solution that is effective against spores.

A nurse is caring for a client following an abdominal surgery. The client has a Rx for dressing changes q 4 hr and PRN. Which of the following objects should the nurse use to reduce skin irritation around the incision area? a. Montgomery straps b. Enzymes c. Alcohol swabs d. A transparent dressing

a. Montgomery straps **Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips.

A nurse is assessing a client prior to administering a seasonal flu vaccine. THe client says he read about a flu vaccine thats given as a nasal spray and wants to receive it. The nurse should recognize that which of the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)? a. The client's age is 62. b. The client smokes one pack of cigarettes a day c. The client has a history of myocardial infarction. d. The client has recently traveled to Europe.

a. The client's age is 62. **Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is contraindicated for this client. Pregnancy and immunocompromised status are also contraindications.

A nurse us caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? a. To prevent fluid from accumulating in the wound b. To limit the amount of bleeding from the surgical site c. To provide a means for medication administration d. To eliminate the need for wound irrigations

a. To prevent fluid from accumulating in the wound **The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures.

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply? a. Transparent dressing b. Wet-to-dry gauze dressing c. Hydrogel dressing d. Alginate dressing

a. Transparent dressing **A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area. *Wet-to-dry gauze dressing: used to remove necrotic tissue from a wound. A stage I pressure ulcer has no necrotic tissue. *Hydrogel dressing: rehydrates the bed of a wound and promotes autolytic debridement. It is used for stage II through stage IV pressure ulcers. Alginate dressing: used for stage II through stage IV pressure ulcers that have moderate to heavy drainage.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Use a transfer device to lift the client up in bed. b. Apply cornstarch to keep sensitive skin areas dry. c. Massage the skin over the client's bony prominences. d. Elevate the head of the bed no more than 45°.

a. Use a transfer device to lift the client up in bed. **Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions. *Keeping the head of the bed no higher than 30° helps minimize shearing forces. Higher elevations can cause the skin to stick to the bed linens while deeper tissues slide downward.

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's lab values? a. WBC 17,000/mm3 b. Neutrophils 3,000/mm3 c. RBC 4.2 million/mm3 d. Lymphocytes 3,000/mm3

a. WBC 17,000/mm3 **The expected reference range for a WBC count for a child is 5,000 to 10,000/mm3. A WBC count of 17,000/mm3 is elevated. The nurse should expect to see an elevated WBC count because appendicitis is an acute bacterial infection. CHILD REFERENCES: *neutrophils: 3,000 to 5,800/mm3 *RBC: 4 to 5.5 million/ mm3 *lympohcytes: 1,000 to 4,000/mm3

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? a. Replace the catheter every 3 days. b. Check the catheter tubing for kinks or twisting. c. Irrigate the catheter once each shift. d. Clean the perineal area with an antiseptic solution daily.

b. Check the catheter tubing for kinks or twisting. **The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.

A nurse in a community health clinic is administering seasonal inactive influenza vaccine. Before admin, the nurse must confirm that the client isn't allergic to which of the following? a. Shellfish b. Eggs c. Gelatin d. Yeast

b. Eggs **The nurse should assess the client for allergies to eggs. The seasonal influenza vaccine contains small amounts of egg protein and can induce a severe allergic reaction in clients who are hypersensitive.

A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b. Metabolic alkalosis **A client who has influenza has experienced excessive vomiting leading to metabolic alkalosis. Manifestations include dizziness, Circumoral paresthesias, and numbness and tingling of the extremities. *Metabolic acidosis: a low pH level and a low bicarbonate level with manifestations such as Kussmaul's respirations, lethargy and confusion. *Respiratory acidosis: a low pH and a high bicarbonate level with manifestations such as warm, flushed skin, headache and tachycardia. *Respiratory alkalosis: high pH and a low bicarbonate level with manifestations such as tremulousness, blurred vision and difficulty concentrating.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? a. Check the client's vital signs. b. Assess the client's pain level. c. Cover the wound with a moist, sterile gauze dressing. d. Obtain a culture and sensitivity of the wound drainage.

c. Cover the wound with a moist, sterile gauze dressing. **The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? a. Enforce strict bedrest for 3 days. b. Apply fresh ice packs every 4 hr. c. Elevate the affected leg on two pillows. d. Apply antibiotic ointment to the wound with dressing changes.

c. Elevate the affected leg on two pillows. **Cellulitis is an acute inflammation of the deep connective tissue of the skin, caused by infection, The edema of the inflammatory response puts the client at risk for skin breakdown.. Elevation of the affected area and frequent repositioning reduces dependent edema and assists in the healing process.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring UTIs. Which of the following actions should the nurse include in the client's plan of care? a. Cleanse the perineum from back to front. b. Obtain a prescription for an indwelling urinary catheter. c. Encourage fluid intake at and between meals. d. Offer the client the bedpan every 2 hr.

c. Encourage fluid intake at and between meals. **Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Reposition the client every 3 hr. b. Massage bony prominences to promote circulation. c. Provide the client with a diet high in protein. d. Apply cornstarch to keep the skin dry.

c. Provide the client with a diet high in protein. **Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? a. Massage the client's red bony prominences. b. Assess the client's skin for increased coolness. c. Reposition the client every 2 hr. d. Keep the client's skin moist.

c. Reposition the client every 2 hr. **The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse is assessing a client who is 48 hr post-op following abdominal surgery. Which of the following findings should the nurse report to the provider? a. Blood pressure 102/66 mm Hg b. Straw-colored urine from an indwelling urinary catheter c. Yellow-green drainage on the surgical incision d. Respiratory rate 18/min

c. Yellow-green drainage on the surgical incision **Thick yellow-green drainage is indicative of an infection and should be reported immediately.

A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client. Which of the following results indicates exposure to and a possible infection with TB? a. 4 mm erythema b. 5 mm induration c. 10 mm wheal d. 15 mm induration

d. 15 mm induration **A positive reaction to a tuberculin skin test is an induration (a hardened area) that is 10 mm or greater in diameter. The nurse should measure the area of induration, not any accompanying erythema or swelling. *wheal is the bump after intradermal injection

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify? a. Maintain NPO status. b. Monitor oral temperature every 4 hr. c. Medicate the client for pain every 4 hr as needed. d. Administer sodium biphosphate/sodium phosphate.

d. Administer sodium biphosphate/sodium phosphate. **Enemas and laxatives are contraindicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for peritonitis.

A clinical nurse educator is preparing an educational program about transmission of MRSA. Which of the following info should the nurse include in the teaching? a. Place clients who have MRSA on airborne precautions. b. MRSA can be effectively treated with an antiviral medication. c. MRSA can live on the hands for 1 hr. d. Bathe clients with water and chlorhexidine gluconate.

d. Bathe clients with water and chlorhexidine gluconate. **Bathing hospitalized clients with premoistened cloths or warm water that is mixed with chlorhexidine gluconate significantly decreases infection with MRSA.

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? a. Serosanguineous drainage b. Mild erythema c. Warmth d. Fever

d. Fever **Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.

A charge nurse is teaching a group of healthcare workers about hand hygiene to prevent infection. Which of the following info should the charge nurse include in the teaching? a. Keep artificial nails trimmed. b. Use alcohol-based hand rubs before administering eye drops for a client. c. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile. d. Use chlorhexidine to wash hands if the client is immunosuppressed.

d. Use chlorhexidine to wash hands if the client is immunosuppressed. **The CDC recommends health care workers use chlorhexidine for hand washing when providing care to a client who is immunosuppressed.

A nurse is reviewing the lab results of a client who has a pressure ulcer. THe nurse should identify an elevation in which of the following lab values as an indication that the client has developed an infection? a. BUN b. Potassium c. RBC count d. WBC count

d. WBC count **An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.