Quiz 1

Vancomycin-resistant Enterococcus

Patients on an infectious disease unit have each of the infections listed. Which is/are health care-associated infection(s)? (Select all that apply.)

Document normal findings

The first time that a client voids after cystoscopy, the nurse observes pink-tinged urine. What is the appropriate nursing response?

5 mL

The maximum amount of fluid that can be used to irrigate a nephrostomy tube is ___________ mL.

Administer opioid analgesics as ordered.

Mr. C has been admitted through the Emergency Department with a diagnosis of renal calculi. While awaiting several diagnostic tests, Mr. C. cries out and asks for "something for pain." Which nursing action is appropriate?

Emphasize the need for proper hand washing by patients, visitors, and staff.

Nursing care of the immunosuppressed patient should include which of the following?

"Patients with impaired bed mobility have an increased risk for pressure ulcers."

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement?

Protein in the urine during a random urinalysis

The nurse associates which assessment finding in the diabetic patient with decreasing renal function?

Primary immunodeficiency

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition?

Incomplete bladder emptying Reflux of urine into the ureters

An 86-year-old woman was seen by her primary care provider four times last year for kidney infections. Which age-related factors does the nurse identify that may contribute to these frequent infections? (Select all that apply.)

A strong, abrupt urge to urinate occurs shortly before involuntary urine loss. Urge incontinence is commonly the result of an overactive bladder muscle. Medications are often effective in reducing bladder overactivity.

An older adult patient has been diagnosed with urge urinary incontinence. Her husband asks what this means. Which statements accurately describe this diagnosis? (Select all that apply.)

Increased confusion

An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient?

Fluid volume excess related to fluid overload

An older patient is receiving intravenous fluids to treat dehydration. When she complains of shortness of breath, your assessment reveals a 20-point increase in her systolic blood pressure and a heart rate of 100 beats per minute. The most likely cause of these findings is:

5 mL

An order is written to irrigate a ureteral catheter. The nurse knows that the maximum amount of irrigating fluid is:

HEPA filter respirators protect the caregiver by filtering inspired air

The advantage of using HEPA filter respirators rather than surgical masks is that:

Lithotripsy

The client tells the nurse that the health care provider is going to "take care of my kidney stones by doing something with sound, laser, or dry shock wave energy." How does the nurse document this planned procedure?

Vulnerable population

The nurse in a newly opened community health clinic is developing a program for the individuals considered at greatest risk for poor health outcomes. How should the nurse consider this group?

Heat Redness Swelling

The nurse inspects for inflammation at an intravenous infusion site. Which of the following are classic signs of local inflammation? (Select all that apply.)

Establish a bowel and bladder program for the patient

The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action?

Basic infection control techniques

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning?

Anaphylactic reaction

The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition?

Use of personal protective equipment Patient teaching on methods to inhibit transmission Administration of intravenous fluids Strict monitoring of intake and output

The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.)

His immune system is functioning properly.

The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12-24 hours post operation dependent on which condition?

The infected person is often very contagious.

Characteristics of the incubation period of the infectious process include which of the following?

Increase fiber intake Increase water consumption.

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.)

Breathing exercises

Following a nephrectomy, which of the following patient needs takes priority?

Immunologic processes

Glomerulonephritis is caused by which of the following?

Check the patient for wetness every 2 hours and ask the patient to state whether he or she is wet or dry. Have the patient practice pelvic muscle exercises by contracting perineal muscles as if holding back gas.

Habit training is being used to treat a patient with urinary incontinence. What should the nurse instruct the nursing assistant to do? (Select all that apply.)

The specific type of pathogen that is causing an infection

In order to provide an intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide?

Allows monocytes and neutrophils to pass into the inflamed tissue.

In the first phase of the inflammatory process, capillary permeability increases. What purpose does this increase serve?

Uninsured or underinsured status High cost of medications Inadequate nutrition

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.)

Acute illness overwhelmed his already limited cardiac and renal function.

Mr. J. had been a healthy 90-year-old man until he developed pneumonia. While acutely ill with pneumonia, he showed signs of early heart and renal failure. He became weak and his tolerance for physical activity declined. Even though the pneumonia resolved, several months passed before he returned to his previous level of functioning. How would you explain this delay?

Prompt treatment of UTIs helps to prevent progressive kidney damage.

Ms. P, 25 years of age, has been recently diagnosed with polycystic kidney disease. She reports that her mother died of kidney disease, but she does not know much about it. What information should be included in the teaching plan?

Notify the registered nurse that Ms. P. may have fluid overload.

Ms. P, 85 years of age, is hospitalized with pyelonephritis. She is receiving intravenous fluids because she is unable to take adequate fluids orally. About an hour after the intravenous fluids are initiated, she complains of feeling short of breath. Her pulse is 90 beats per minute and bounding. What action should the nurse take?

Antimicrobial selection is based on the results of culture and sensitivity tests. Antimicrobials are prescribed only for serious infections. Vaccinations for infectious diseases are encouraged.

Nurses on an infectious disease unit want to implement measures to reduce bacterial resistance to antimicrobials. Which measure(s) will help to prevent the development of bacterial resistance? (Select all that apply.)

Contains the materials used by the body in the initial inflammatory response

On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes what information about this fluid?

overflow

Autonomic dysreflexia is a very serious complication of which type of incontinence?

Disease prevention

A public health nurse is caring for a patient in the community who has been exposed to tuberculosis. What aspect of care is the public nurse providing?

Oliguric renal disease

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium?

Acute renal failure

A patient presents to the clinic complaining of nausea, vomiting, and fatigue. Lab results reveal elevated BUN and creatinine levels. Which acute condition is this patient at most risk for developing?

Last formed bowel movement

A bedridden patient with no history of bowel incontinence has been involuntarily passing liquid stools for 2 days. What additional data should the nurse collect?

Dysuria

A client reports a painful, burning sensation during urination. Which term should the nurse use to document this symptom?

Hyperkalemia

A client with chronic kidney disease becomes confused and reports nausea, abdominal cramps, and lack of sensation in the legs. Upon assessment, the heart rate is found to be irregular. Which condition does the nurse anticipate?

Documentation of pessary placement so it will not be forgotten

A clinic patient has had a pessary inserted because of urinary incontinence. Care of this patient includes:

ANF

A hormone with physiologic effects that decrease blood pressure is:

Once the dehydration is corrected, the patient's confusion should improve."

A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct?

"The patient is losing sphincter control due to the dementia."

A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response?

Fatigue

A patient with chronic kidney disease is most likely to complain of which symptom?

The patient's immune system is attacking his own tissues.

A physician has just told a patient that he has an autoimmune condition. What is the correct term for this type of condition?

Enteric-coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue."

A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric-coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following?

Offer information related to smoking cessation

A nurse is reviewing factors that lead to prevention of non-communicable diseases. Which intervention would be most effective for the nurse to implement for a group of patients?

Cardiac disease Diabetes End stage renal disease Stroke Chronic lower respiratory disease

A nurse is reviewing health promotion strategies with regard to population health. Which non-communicable disease processes linked to high morbidity and mortality can be addressed through health promotion? (Select all that apply.

"If I don't feel sick, then I don't have to worry about transmitted diseases."

A nurse is teaching a group of business people about disease transmission. The nurse knows that additional teaching is needed when one of the participants states which of the following?

"The term applies to individuals who have decided not to immunize but instead use isolation practices to maintain health."

A parent asks the nurse to explain the term "herd immunity". How should the nurse respond?

"It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

A patient asks the nurse what the purpose of the Wood light is. Which response by the nurse is accurate?

"Avoid sharing razors and other personal items."

A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient?

Staphylococcus aureus

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism?

Circulatory overload

A patient in shock has been given blood, crystalloids, and osmotic fluids. The nurse's assessment reveals: pulse rate 80 bpm, bounding, regular; respiratory rate 30 breaths per minute; blood pressure 140/86 mm Hg; dyspnea and crackles throughout lung fields. Which complication should the nurse suspect?

Alcohol

A patient in the independent living unit of a retirement home reports that she has had several incidents of bowel incontinence. The nurse's assessment reveals that the patient consumes all of the items listed subsequently. Which one might be related to the patient's fecal incontinence?

Decreasing pruritus

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on?

"An antibiotic helps to kill the infection causing the inflammation."

A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication?

"Ice should be applied for 15-20 minutes every 2-3 hours over the next 1-2 days."

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse's best response?

two (2) liters

A patient is receiving diuretics to eliminate excess fluid that has been retained in body tissues. In 2 days, the patient lost 4.4 lb (2 kg) in body weight. This represents how many liters of fluid loss? ________.

"The medications that I take will help prevent my body from attacking my new kidney."

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement?

Notify the health care provider that the client's urine output is too low

After a nephrectomy, the nurse assesses that a client has eliminated 25 mL in the past hour. Which nursing action is appropriate?

Active acquired immunity

After vaccination for measles, a person will not become ill if exposed to the measles virus. The patient's ability to resist the measles virus is called:

Primary prevention

At the well-child clinic, how does the nurse correctly teach a mother about health promotion activities and describe immunizations?

Sedentary lifestyle Inadequate fluid intake Family history of calculi Excessive vitamin D supplements

Which of the following contribute to the development of renal calculi? (Select all that apply.)

BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?

"Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel."

The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3-4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response?

Urine output is very small today.

The nurse is making a home visit to a child who has a chronic disease. Which finding has the most implication for acid-base aspects of this patient's care?

Control inflammation

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient?

Clean technique may be used at home but not in a hospital.

The nurse is preparing to discharge a patient who will be doing self-catheterization at home. How does intermittent self-catheterization in the home setting differ from that in an institution?

Avoid caffeine Drink a glass of water before and after intercourse Cleanse the perineum from front to back after elimination

The nurse is preparing to teach a group of women about reducing the risk of cystitis. Which teaching will the nurse include? (Select all that apply.)

Urine output 8 mL/hr

The nurse is reviewing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician?

An elevation of the total white cell count indicates generalized inflammation

The nurse is reviewing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange?

Strengthening perineal muscles can improve urinary control. You will need to continue the exercises indefinitely to maintain control.

The nurse is teaching a patient to perform pelvic muscle exercises. Instructions should include which of the following? (Select all that apply.)

Portal of entry

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element?

Oral temperature 38.6° C/101.5° F WBC 20 cells/McL × 109/L

The nurse reviews the patient and notes all of the following. Which of the findings indicates systemic manifestations of inflammation? (Select all that apply.)

Early stage acute

The nurse reviews the patient's complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response?

Are part of primary prevention for system disorders Help protect individuals and communities Are recommended by the Centers for Disease Control and Prevention (CDC)

The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)

Standard Precautions are required when caring for any patient in any setting.

Which statement is true regarding the need to use Standard Precautions?

It is usually caused by relaxation of the pelvic floor muscles.

Which statement should be included when teaching a woman about stress urinary incontinence?

Make a substantial difference in morbidity and mortality.

The primary healthcare nurse would recommend screening based on known risk factors, because of which action?

Soiled caregiver hands

The primary mode of transmission of health care-associated infections is:

Catheterization

The procedure that causes most health care-associated infections is:

Small intestine

The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body?

Occult blood testing

What is a primary prevention tool used for colon cancer screening?

Pooling of urine in the urinary system

What is the effect of immobility on the urinary tract?

Rectal thermometer

What is the most appropriate measure for a nurse to use in reviewing core body temperature when there are suspected problems with thermoregulation?

Recent changes in elimination patterns Changes in color, consistency, or odor of stool or urine Discomfort or pain with elimination List of medications taken by patient

When a nurse is conducting a health history assessment, which information would be viewed as most important as related to the patient's elimination status? (Select all that apply.)

Hydronephrosis

When a ureter is obstructed by a renal calculus, which complication may occur?

Prevention of pneumonia in patients with chronic lung disease

Which clinical management prevention concept would the nurse identify as representative of secondary prevention?

Advise patient to avoid exposure to sunlight. Encourage at least 1.5 quarts (1500 mL) of fluids daily. Inspect the skin for lesions.

Which interventions are appropriate when a patient is taking a sulfonamide for a UTI? (Select all that apply).

Parasitic

While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection?

The virus lives inside the host cell and drugs that harm viruses often harm host cells as well.

Why have numerous antibacterial drugs but relatively few antiviral drugs been developed?