Ch. 31 - Infection Prevention and Management

A client with a localized inflammatory response asks the nurse why the area is reddened. Which response by the nurse would be most appropriate?

"It is the result of blood accumulating in the dilated vessels."

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

handwashing

A nurse is developing a presentation for a local community group about infections and resistance to them. When describing acquired specific defenses, what would the nurse most likely include?

humoral immunity

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

A nurse suspects that a client may be developing sepsis based on assessment findings. The practitioner orders a serum lactate level to be obtained. When reviewing the results, which serum lactate level would the nurse identify as indicative of sepsis?

4.6 mmol/L

A nurse is reviewing a client's complete white blood cell (WBC) count and differential. The nurse determines that the client is experiencing neutropenia based on which absolute neutrophil count?

800 cells/mm3 (less than 1000)

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

Greater than 40.5°C

A nurse is preparing a class for a group of new parents about infections and infants. When reviewing the development of the infant's immune system, what would the nurse be least likely to include?

Newborns have little difficulty localizing infections.

A client reports fatigue, malaise, and a low-grade fever. What phase of the infectious process does the nurse determine the client is experiencing?

Prodromal phase

The nurse administered an antipyretic drug to a client with high-grade fever of 101.4°F (38.6°C). Which intervention should the nurse perform next?

Reassess temperature after 1 hour and document results in the chart.

A client is in the fever phase. His temperature remains significantly elevated. The nurse is preparing to implement sponge bathing. Which type of water would the nurse most likely use?

Tepid water

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate?

The client will state how to safely take the prescribed antibiotic.

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

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?

Young children often have a vigorous immune response to infection and thus high fevers.

In which population should the nurse recognize an increased risk for infection? Select all that apply.

debilitated clients older adults clients with impaired skin integrity

A client presents to the clinic reporting fever and abdominal pain. Blood work shows an elevated white count. This client is:

in the acute phase.

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

A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client?

obtaining rectal temperatures

A nurse is working with a 50-year-old woman status post liver transplant. She is on multiple immunosuppressive drug therapies, is intubated, and is n.p.o. with parenteral nutrition running through a central line. What would raise the nurse's suspicions that the client is developing septicemia? Select all that apply.

temperature of 103.1°F (39.5°C) A WBC count of 15,000 with 12% bands

The nurse is caring for a client with an impaired immune system. The nurse is concerned about the client acquiring a healthcare-associated infection (HAI). What intervention would the nurse focus on to help control HAIs?

Apply principles of medical and surgical asepsis.

The physician orders a serum trough drug level for a client who is receiving antibiotic therapy. The client is receiving the drug every 6 hours: at midnight, 6 a.m., noon and 6 p.m. The nurse anticipates that the specimen would be obtained:

just before the 6 a.m. dose.

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?

"Your white blood cells have increased in the area."

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

Keep the door closed. Provide gentle oral care. Remove any fresh flowers from the client's room.

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."

The nurse is educating the client on culture and sensitivity test. The client wants know to when the nurse could get the results back. Which response should the nurse use?

"It could take 24 to 36 hours to grow cultures and about 48 hours for sensitivity."

A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area?

Area of active drainage

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?

1500

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.

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?

A= Assessment

A nurse is working with an 82-year-old man following gallbladder surgery. He is n.p.o. and has IV access in his hand. He also has a Foley catheter in place. He is able to ambulate with the aid of a walker. What does not lower this client's immunity?

Ambulation

The nurse instructor is discussing the relation of early ambulation and infection control. Which response from the student indicates the need for further explanation?

All clients must ambulate as early as possible to avoid infection.

A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply.

Basophils Neutrophils Eosinophils

The mother of a client who is acutely ill and is responding well to the antibiotic treatment states "I know this antibiotic will heal my child." The mother requires further education based on which statement? Select all that apply.

Antibiotics do not heal. Antibiotics slow the growth or kill the microorganism. Antibiotics prevent further damage to the system affected.

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.

At 8:30 a.m., the client is admitted to the floor from the clinic with an infected spider bite wound. When administering the antibiotic, choose the time that infusion should be done following the severe sepsis resuscitation protocol.

By 9 a.m. to ensure early administration of antibiotics

A nursing instructor is describing the phases of a febrile episode. What would the instructor describe as happening first?

Chill

A client has a concentration of Staphylococcus aureus located on his skin. He is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which stage?

Colonization

What would be considered a mechanical defense mechanism?

Coughing

A client in the ICU has a central venous catheter in place. The client has now become septic with no obvious cause or source of infection. Antibiotic therapy does not help resolve the sepsis. What would the nurse suspect that the client has most likely developed?

Healthcare-associated infection (HAI)

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?

Inform the physician about this finding.

Which term describes the time interval after the resolution of a primary infection when a microorganism lives within the host without producing symptoms?

Latent

During an interaction with a client who is HIV-positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period?

Prodromal period

The nurse assessing a client who had an elevated temperature 1 hour ago determines that the client is in the crisis phase of fever. What would lead the nurse to this conclusion?

Profuse diaphoresis

The nurse is assessing a client with an elevated temperature. Which of the following would lead the nurse to determine that the client is in the fever phase?

Skin warm and flushed

What are characteristics of the stage of infection known as full stage of illness? Select all that apply.

Specific signs and symptoms are present. The organisms are growing and multiplying.

A client is admitted with Clostridium difficile (C. difficile) with frequent loose stool and fever. Which action should the nurse implement for this client? Select all that apply.

Start contact precaution protocol and place a sign by the door. Allocate a vital signs machine for the client's room.

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the physician should be notified immediately?

The client's heart rate is greater than 90 bpm.

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 suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?

clear mucus

After explaining to students about the progression of infection, an instructor determines that the education was successful when the students identify which period as the time during which a disease can be passed from one person to another?

communicable period

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.

The Neutropenic Precaution sign was posted outside the client's room. Which subsequent nursing action supports this set-up?

eliminating vegetable salads from the diet.

A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

helps to determine prescribed antibiotic therapy

A client trips while ambulating and breaks open the skin on his knee. The next day the knee is red, warm to the touch, and painful at the site of the injury. The client's complete blood count (CBC) shows a high white blood cell count. What would the nurse suspect is wrong with the client?

infection of the knee

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

The nurse is providing care to a client with Lyme disease. The nurse identifies the cause of this infection as:

parasite

When developing a plan of care for a client who has developed neutropenia secondary to chemotherapy, which of the following would the nurse most likely include? Select all that apply.

placing the client in a private room having the client wear a mask when outside the room removing fresh flowers from the room

A nurse is working with a young woman, age 15, in a community health clinic. It is early October, and the young woman is worried that she will become ill and miss school, stating "I am always getting sick this time of year." What health promotion activities are appropriate to include in the nurse's teaching today? Select all that apply.

proper handwashing techniques administration of influenza immunization information on sleep hygiene

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

The nurse is creating a care plan for a client. Risk for Infection is the identified problem. Which situation supports this problem?

the client with a urinary catheter inserted at the emergency department