Chapter 24 questions PrepU

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?

"Help me understand your thoughts about vaccinations."

A client who has had repeated infections asks the nurse what he can do to improve his ability to resist infection. Which suggestion would be least appropriate for the nurse to give?

"Limit your intake of water each day to about 4 to 5 glasses."

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?

"Stress leads to increased secretion of cortisol, which suppresses your immune response."

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

"These barriers help prevent the transmission of infection to you or other people."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

"This antibiotic is the best choice since the causative organism is not known."

The nurse is educating a client with human immunodeficiency virus (HIV) on a new antiviral medication. Which client statement indicates a need for further teaching?

"This medication will cure the virus from my body."

A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse?

"We are giving you broad spectrum antibiotics because they are active for many types of bacteria."

A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection?

18,000 cells/mm

After assessing a client's temperature, the nurse documents that the client has a fever that is categorized as being high-grade. Which reading would the nurse most likely have obtained in this client?

39.2 degrees C

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A commercially packaged surgical item is not considered sterile if past expiration date.

asepsis

Absence of all microorganisms

An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate?

Airborne

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

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

Antigen

The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?

Assess client's pain level and manage pain accordingly.

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

Carefully open package, use thumb and forefinger to grasp folded cuff, gloved fingers under cuff of remaining glove, adjust gloves if necessary

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

Client receiving chemotherapy

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

Create an area for sterile field and opening packages

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.

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

Which mask should the nurse don when caring for a client with tuberculosis?

Filtered respirator

What is the second line of defense in microbial invasion?

Inflammation

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.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from the room.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

Surgical asepsis technique

The student nurse observes another nurse wash her hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium Difficile (C diff). Why is this behavior incorrect?

The bathroom is highly contaminated with the Clostridium difficile bacteria.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles?

The nurse removes her gown and then removes her gloves.

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection?

Urine culture is positive for vancomycin-resistant enterococci (VRE).

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?

Virus

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

When hands are visibly soiled

Surgical asepsis is defined as:

absence of all microorganisms.

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:

an older adult can have an infection without a fever.

Nursing students are reviewing information about healthcare-associated infections (HAI). What would the students expect to find as a possible risk factor? Select all that apply.

antibiotics, steroid, invasive devices, multiple wounds

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?

be sure that there are gloves of various sizes and gowns for use

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?

change to airborne precautions

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?

changing the soiled dressing

medical asepsis

clean technique

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?

contact

What is the primary purpose for the demonstrated glove application?

cover exposed wrist skin

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

decreased cellular immunity.

Exudate

drainage, fluid such as pus

Personal protective equipment for use with standard precautions includes which items? Select all that apply.

face mask, disposable gloves, eye protection, fluid-repellent gown

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?

handwashing

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

handwashing before leaving the client's room

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

into a private room

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?

intravenous antibiotic administration

A client is placed on neutropenic precautions. What would be appropriate for the nurse to do? Select all that apply.

keep door closed, gentle oral care, remove flowers

The most common infection in children is:

respiratory

Surgical asepsis

sterile technique

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

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

"All visitors who enter the room must wear N95/surgical masks."