Chapter 24 Fundamentals of Nursing / Course Point Quiz 1
An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond?
"As we age, our immune system does not function as well."
A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:
3 days.
Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?
Client receiving chemotherapy The nurse should determine that the client receiving chemotherapy is the client at greatest risk for VRE infection due to having a compromised immune system from the chemotherapy. Other risk factors for VRE include recent abdominal or chest surgery, presence of urinary or central IV catheter, prolonged antibiotic use (especially with vancomycin), and lengthy hospital stays (especially in an ICU).
A nurse is caring for a client, age 4 months, following surgical repair of a tracheoesophageal fistula. When collecting the client's vital signs, the nurse notes her rectal temperature to be 103.1°F (39.5°C). The nurse knows what to be true of fever in young children?
Correct- Young children often have a vigorous immune response to infection and thus high fevers. Children can frequently have fevers over 104°F (40°C). Young children are more prone to febrile seizures than adults. However, the overall percentage of children who have a febrile seizure is still relatively low. Young children frequently mount a high fever to an invading organism. A fever of 103.1°F (39.5°C) is not typical of a postoperative temperature elevation.
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?
Decontaminate hands using an alcohol-based hand rub.
Which statement about neonatal development is accurate?
Neonates may have an infection without fever.
A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?
WBC of 25,000 mcL Leukocytes, also called white blood cells (WBCs), and the inflammatory response make up the second line of defense to microbial invasion. A normal WBC count is 5,000 to 10,000 cells/mm3. A count above this range is indicative of infection.
Surgical asepsis is defined as:
absence of all microorganisms. Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.
The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin?
droplet
The nurse is caring for an older adult with influenza. Which precautions will the nurse begin?
droplet
A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.
increased respiratory rate lymph node enlargement fever
Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care?
skin is dry and intact
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?
surgical asepsis
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
urinary catheter
The nurse reviews principles of infection prevention during yearly safety training. Which action(s) would the nurse use as an example of safe practice? Select all that apply.
Donning gloves and gowns as a substitute for handwashing in some circumstances Sterilizing any item entering the vascular system The nurse demonstrates the principles of infection prevention by donning gloves and gowns when they can substitute for handwashing (gloves can break or some liquids can penetrate gloves) and sterilizing any item entering the vascular system. The nurse should never recap needles (recapping can cause needlestick injury and pathogen spread). The nurse should wash hands with soap and water when C. difficile is a potential pathogen (alcohol-based rubs are ineffective against C. difficile). Artificial nails are not acceptable for health care workers in most areas (microorganisms tend to adhere to separated artificial nail surfaces).
An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection?
Healthcare-associated infection (HAI) Gram-negative rods, which comprise much of the bowel's normal flora, are associated with healthcare-associated infections caused by self-contamination.
The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?
Pour the liquid into a sterile container within the sterile field. The solution container should be held outside the edge of the sterile field and poured steadily from a height of 4 to 6 inches into a sterile container previously added to the sterile field and positioned at the side of the sterile field. This assures minimal splashing, as moisture contaminates the sterile field, and maintains sterility of the bottle and solution.
A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?
T-lymphocytes T-lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.
The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection?
contact Any multidrug resistant organism requires contact precautions to help prevent the spread of the organism to others. This will include MRSA. Airborne precautions can be utilized with diseases in which the causative organism is passed through the air after the infected person has coughed, sneezed, or talked. Tuberculosis is an example. Droplet precautions are warranted when the disease is spread through large particle droplets such as rubella and mumps. Reverse isolation is used to protect the client from any new infectious organisms. This can be utilized for client's who may be immunocompromised or already have a serious infection and the nursing team is trying to prevent further infections from complicating the client's health.
A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is:
it is a vaccine given to booster antibodies towards the tetanus pathogen.
The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?
"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." By explaining that alcohol-based hand rubs are effective in preventing the spread of microbes, the nurse directly addresses the client's concern. While washing with soap and water may not be necessary, it doesn't address the client's concern. Alcohol-based hand rub is an appropriate method for hand hygiene even when you plan to touch the client.
A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful?
"I will obtain a mask from the staff and wash my hands before touching my family member." Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is elderly or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.
The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?
Correct- into a private room The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.
When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?
Discard the bottle and get a new one because the saline has expired.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract Escherichia coli residing in the intestinal tract is typical normal flora. Escherichia coli in the urinary tract is indicative of a urinary tract infection. Shigella germs are a common cause of severe diarrhea and are contagious. Shigella in the urinary tract is indicative of a urinary tract infection.
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?
Use a sterile cotton-tipped applicator to apply the prescription to the site Applying the ointment with the gloved finger contaminates the prescription ointment. Sterile cotton-tipped applicators are used to apply ointments or solutions to the wound bed to avoid contaminating the wound. A 4 × 4 gauze pad should not be applied until the wound is cleansed properly with sterile supplies. Soiled dressing supplies should be placed in a biohazardous trash bag or container.
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?
an older adult client with a history of heart failure
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
hand washing Hand washing technique is the single most important procedure in reducing the spread of microorganisms from either the client to the surroundings or the surroundings to the client. A client does not need to learn a sterile technique for the abdominal incision. Most client procedures are related to clean handing and do not need gloves to be added to a dressing change. The nurse should review signs of infection and healing of the abdominal incision.
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a nonparticulate (N-95) respirator when entering the room.
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?
Avoid touching the outer surfaces of the gown.
Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?
Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.
The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as:
parasite. Lyme disease is spread through the bite of an infected tick, an arthropod, which is classified as a parasite. The bacteria Borrelia burgdorferi causes Lyme disease in humans. Viruses cause numerous infections but are not associated with Lyme disease. Fungi also cause disease in humans but are not associated with Lyme disease.
The nurse is assisting a colleague with wound care. The colleague has established the sterile field and is pouring out normal saline into a sterile container, as seen in the picture above. What is the nurse's best action while observing the colleague perform the task?
observe the colleague and take no further action The colleague is demonstrating appropriate sterile technique. Consequently, there is no need to obtain a new dressing tray. The container cannot overlap the nonsterile edges of the field, but it does not necessarily need to be centered. The bottle should be held 4 to 6 in (10 to 15 cm) above the container, as pictured.
Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?
wearing a particulate respirator for all care and interaction with this client To prevent the transmission of TB, the National Institute for Occupational Safety and Health recommends the use of a particulate air filter respirator that fits snugly to the face for all client care and interaction. A face mask does not block small TB particles effectively. Protective eyewear is only needed if contact with bodily fluids is expected. The client would be placed in a negative pressure room to prevent the potential spread of TB.