NCM 109 (Sabio)

The nurse of a well-baby clinic prepares to administer an immunization to a child. The mother of the child tells the nurse that the child has had a fever and is taking antibiotics. The nurse takes the child's temperature and notes that it is 101.5° F rectally. The nurse plans to take which action?

1. Delay the immunization.

The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?

1. Fine grayish red lines

The interval when a client manifests signs and symptoms specific to a type of infection is the:

1. Illness Stage

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

1. The child is 18 months old

Which criterion should the nurse determine are characteristics of scabies? Select all that apply.

2.It appears as burrows or fine, grayish-red lines. 3.It is transmitted by close personal contact with an infected person. 4.It is endemic among schoolchildren and institutionalized populations. 6.Household members and contacts of the infected child need to be treated at the same time that the child is being treated.

A group of nursing students are reviewing the six links in the chain of infection and the nursing implications for each. The students demonstrate understanding of the information when they identify which precaution as helping to break the chain of infection to the susceptible host?

B) Maintaining skin integrity

A nurse is conducting a health history for a 1-month-old with an infectious disorder. Which segment of the health history would be most helpful for the nurse when determining if the infant developed the infection from the mother?

B) Past medical history

A client asks the nurse to explain how to perform a proper handwashing procedure. Which of these responses would be the most appropriate for the nurse to make?

B. "Be sure to wet your hands thoroughly before using soap."

What teaching would the nurse provide to a client receiving tetanus toxoid?

B. "Soreness at the injection site is a common reaction."

The current immunization for tetanus and diphtheria toxoids and pertussis, Tdap, is administered to people in which age range?

B. 11 years of age and older

In addition to standard precautions, the nurse would initiate droplet precautions for which patients?

B. A patient diagnosed with diptheria

What is the priority nursing assessment to monitor when administering vaccinations?

B. Anaphylaxis

An allergy to which substance is a contraindication to the administration of an immunizing drug?

B. Egg

A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is considered:

B. Safe for the home setting

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care?

B. The nurse works from "clean" areas to "dirty" areas during bath.

A child is diagnosed with scarlet fever. The nurse is reviewing the child's medical record, expecting which medication to be prescribed for this child?

C) Penicillin V

A school-aged child with an infectious disease is placed on transmission-based precautions. Which nursing diagnosis would most likely be a priority?

C) Social isolation related to infectivity and inability to go to the playroom

Which of these client statements is the most reliable indicator that a client has an understanding of infection prevention?

C. "My fingernails are short and well-trimmed."

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation?

C. Discard the supplies and prepare a new sterile field with another person holding the patient's hand.

What is the most effective way to control transmission of infection?

C. Hand hygiene practices

When giving a vaccine to an infant, the nurse will tell the mother to expect which adverse effect?

C. Soreness at the injection site

A 28 year old patient is in the urgent care center after stepping on a rusty tent nail. The nurse evaluates the patient's immunity status and notes that the patient thinks she had her tetanus booster about 10 years ago, just before starting college. Which immunization would be most appropriate at this time?

C. Tdap

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?

C. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene.

When the physician looks in a child's mouth during a sick-visit exam, the mother exclaims: "Her tongue is bright red! It was not like that yesterday." The physician would most likely order which medication based on the probable diagnosis of scarlet fever?

a) Penicillin to prevent acute glomerulonephritis

A nurse practitioner suspects that a child has scarlet fever based on which of the following assessment findings?

a) Red, strawberry tongue

A child is diagnosed with group A streptococcal pharyngitis. The nurse would teach the parents to be alert for signs and symptoms of which of the following?

a) Scarlet fever

The nurse is caring for a child hospitalized with pertussis. Which of the following nursing interventions would be the highest priority for this child?

a) The nurse will administer oxygen.

The nurse is caring for a 10-year-old boy with diphtheria. Which of the following would the nurse institute as a tier 2 precaution?

a) Use of a protective mask

Which of the following is usually the only symptom of pediculosis capitis (head lice)?

a. Itching

Impetigo ordinarily results in which of the following?

a. No scarring

The nurse should provide which information to parents about the prevention of parasitic infections? Select all that apply.

a. Perform good handwashing. d. Shoes should be worn outside. e. Fruits and vegetables should be washed before eating.

A 6-year-old child is brought to the clinic by his parents. The parents state, "He had a sore throat for a couple of days and now his temperature has been over 102°F. He has this rash on his face and chest that looks like sunburn but feels really rough." Which of the following would the nurse suspect?

b) Scarlet fever

A chief danger of scarlet fever is that children may develop

b) acute glomerulonephritis.

How should the nurse respond to a parent who asks, "How can I protect my baby from whooping cough?"

b. "Make sure your child gets the pertussis vaccine."

A nurse is conducting a health education class for a group of school-age children. Which statement made by the nurse is correct about the body's first line of defense against infection in the innate immune system?

b. Skin integrity

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching?

1. "I understand that I need to leave the scabicide on for 4 hours before washing it off."

A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?

1.Pastia's sign

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list? Select all that apply.

1.Siblings may also need treatment. 4.Grooming items such as combs and brushes should not be shared. 5.Launder all the bedding and clothing in hot water and dry on high heat. 6.Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching?

2. "I understand this whooping cough is viral and I have to let it run its course."

The school nurse is visiting a kindergarten classroom to teach the students the importance of hand washing. During the teaching session the nurse notes that one girl is scratching her head. On inspection, the nurse determines that the child has pediculosis capitis. When reinforcing instructions to the mother about care of this condition, which statement by the mother indicates that she needs further teaching regarding this condition?

2."I will call a carpet cleaning service to clean all my carpets in the house."

A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse reinforces instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further teaching?

2."My child will need to be treated with oral antibiotics."

The nurse reinforces instructions regarding the use of permethrin 1% to the parents of a child who has been diagnosed with pediculosis capitis. Which statements by the parents indicate they understand the instructions? Select all that apply.

2."The hair should not be shampooed for 24 hours after treatment." 3."The medication can be obtained over the counter in a local pharmacy." 5."The medication is applied to the hair after shampooing, left on for 5 to 10 minutes, and then rinsed out."

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

3. Apply an ice pack to the injection site.

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

3. Lesions most often are located on the arms and chest."

The nurse assists with providing an instructional session to parents regarding impetigo. Which statement by a parent indicates the need for further teaching?

3."Lesions are most often located on the arms and chest."

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?

3."We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."

A parent calls the clinic nurse to schedule an appointment for her child's diphtheria, tetanus, and pertussis vaccination. The parent tells the nurse that her child had a swelling at the injection site and low-grade fever after the last diphtheria, tetanus, and pertussis (DTaP) vaccination. Which instructions should the nurse give to the parent to lessen this type of reaction to the upcoming vaccination?

3.To administer an appropriate dose of Tylenol 45 minutes before the appointment

Permethrin (Elimite) is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?

4. Apply the lotion to cool, dry skin at least 30 minutes after bathing.

A 4 month old comes to clinic for shots. The child is up to date. What vaccines should the kid get at this time?

4. DTaP, hib, PCV, RV

What is the most prevalent type of helminthic infestation?

Ascariasis

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for d/c. What statement made by parent indicates a NEED for further instruction?

4. We need to maintain droplet precautions and a quiet environment for at least 2 weeks

The school nurse is conducting pediculosis capitis (head lice) assessments. Which finding indicates a child has a "positive" head check?

4. White sacs attached to the hair shafts in the occipital area

If an infectious disease can be transmitted directly from one person to another, it is:

B) A communicable disease

A child is diagnosed with a helminthic infection. Which of the following would the nurse expect to be prescribed? Select all answers that apply.

B) Albendazole C) Pyrantel pamoate

Before the nurse washes the hands when leaving an isolation room, what is the last thing that is removed?

A) Mask

The most effective way to break the chain of infection is by:

A) Practicing good hand hygiene

The nurse instructs a client in infection prevention. Which of the following statements, if made by the client, indicates that the teaching was effective?

A. "I should wash my hands before changing my wound dressing."

A student nurse recalls that the body has nonspecific defense systems to protect against infection. Which of the following is an example of this system?

A. Saliva

A nurse in the emergency room is taking care of a 4-year-old patient who has a suspected case of impetigo. The nurse knows that which of the following precautions is most important to prevent the spread of this infection?

A. contact precautions

The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching?

4."I need to shampoo my child's hair, apply the medication, leave it on for 10 minutes, and then rinse it out."

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

4.DTaP, Hib, IPV, pneumococcal vaccine (PCV)

The nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is appropriate?

4.Forty-eight hours after using the antibiotic ointment

The nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?

4.Seal non-washable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned.

The parents of a 5-year-old have just found out that their child has head lice. Which statement by the parents would support the nursing diagnosis of deficient knowledge?

A) "I can't believe it. We're not unclean, poor people."

When a nurse is performing surgical hand hygiene, the nurse must keep the hands:

A) Above the elbows

A nursing student is preparing a presentation on aseptic techniques. Which of the following statements should be included in the presentation?

A. Dirty items contain organisms that have the potential to cause infection.

A student nurse is demonstrating the proper procedure for maintaining a sterile field. Which of the following guidelines should be followed? (Select all that apply.)

A. Never reach across a sterile field. B. Objects below the waist are considered unsterile. E. One inch around the edges is considered contaminated.

The nurse is providing teaching after an adult receives a booster immunization. Which adverse reaction will the nurse immediately report to the health care provider? (select all that apply)

C. joint pain E. Rash over the arms, back and chest F. Shortness of breath

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must:

D. Consider the outer 1 inch of the sterile fielda s contaminated

Administration of which substance provides passive immunity?

D. Immunoglobulins

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?

D. all patients receiving care in hospitals

The public health nurse is discussing immunizations with a group of caregivers of infants. One of the mothers asks the nurse why the child will need immunizations. Which of the following statements would be the most appropriate statement for the nurse to make to this mother?

c) "The infant is born with immunity to some diseases, but those immunities decrease over the first year of life."

Nursing students are learning about the infectious process. They correctly identify the first stage of an infectious disease to be which of the following?

c) Incubation period

A child is brought to the emergency department by his parents. The parents report that he stepped on a rusty nail about a week and a half ago. The child is complaining of cramping in his jaw and some difficulty swallowing. The nurse suspects tetanus. When assessing the child, the nurse would be alert to which muscle groups being affected next?

c) Neck

An 11-year-old girl arrives at the doctor's office with fever, a sore throat, chills, and malaise. A throat culture indicates scarlet fever. Which other symptom should the nurse notice in this patient that clearly indicates scarlet fever?

c) The tongue has a white or red "strawberry" appearance

Which statement indicates that a father understands the treatment for his child who has scarlet fever?

c. "I will give the penicillin for the full 10 days."

Which of the following is an important nursing consideration when caring for a child with impetigo contagiosa?

c. Carefully wash hands and maintain cleanliness when caring for an infected child.

What type of micro-organism causes ascariasis, a large roundworm resembling an earthworm?

c. Parasite

Which of the following is the primary clinical manifestation of scabies?

c. Pruritus

A child steps on a nail and sustains a puncture wound of the foot. Which of the following is the most appropriate method for cleansing this wound?

c. Soak foot in warm water and soap.

A 3-week-old infant is diagnosed with pertussis. Which antimicrobial agent would the nurse expect the physician to prescribe?

d) Azithromycin

A nursing instructor is teaching the students about the standard and transmission-based precautions. What type of precautions requires placing a patient in an isolated room with limited access, wearing gloves during contact with the patient and all body fluids or contaminated items, wearing two layers of protective clothing, and avoiding sharing equipment between patients?

d) Contact precautions

Which of the following begins as an upper respiratory illness and progresses to a persistent cough characterized by an inspiratory whoop?

d) Pertussis

The nurse is talking to the parents of a child with pediculosis capitis. Which of the following should the nurse include when explaining how to manage pediculosis capitis?

d. "You will need to remove nits with an extra-fine tooth comb or tweezers."

The most common method of microorganism transfer from one person to another in a hospital is prevented by:

d. Performing hand hygiene thoroughly and frequently

What should be included in the care for a neonate who was diagnosed with pertussis?

d. Treatment of all close contacts with a prophylactic antibiotic