Infection Quiz

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration

An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC?

A client who is being treated for septic shock

The nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort?

Assume a left side-lying position while in bed

Regarding pneumonia, the most common bacterial causative agent (which happens to also be in the pneumonia vaccine) is:

Streptococcus pneumonia

In a diagnosis of a lower urinary tract infection, which structures could be affected? Select all that apply.

bladder urethra

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)?

Ensure that the catheter is removed as soon as possible.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

Fever and change in urine clarity

A client with suspected sepsis has come into the Emergency Department. What are signs of sepsis? Select all that apply.

Increased Heart rate Decreased bloop pressure Increased insipirations

Your client with suspected sepsis has had labs drawn. Which lab shows us poor tissue perfusion?

Increased lactic acid

Sepsis can cause massive vasodilation. Fluid leaves the vasculature and goes into the interstitial space (third space). Since fluid is sitting in the interstitial space instead of the vessels, the tissues have poor perfusion. So, we give the patient rather a large amount of isotonic IV fluid such as:

Normal saline

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

PaCO2

What intervention should be specified in the client's plan of care while a client is ventilated, since there is a high incidence of ventilator-associated pneumonia (VAP)?

Performing frequent oral care

The nurse is caring for a client who has been admitted for the treatment of AIDS. In the morning, the client tells the nurse that he experienced night sweats and recently "coughed up some blood." What is the nurse's most appropriate action?

Place the client on respiratory isolation and inform the physician.

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next?

Provide oxygen for consistent hypoxia

A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply.

Temperature of 102.5F Heart rate of 130 beats/minute Respiratory rate of 28 breaths/minute

The nurse is caring for a client who has ventilator associated pneumonia. The spouse asks the nurse how their spouse developed this type of pneumonia. The response that is most accurate is:

Ventilator associated pneumonia develops due to artificial airways and being on a ventilator.

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult?

acute confusion

Which of the following treatments are necessary for a client that has pneumonia? Select all that apply.

antibiotics. oxygen therapy to keep sats at 92 and above. gradual increase of activity.

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply.

atelectasis hemorrhage pneumonia

Common symptoms of pneumonia include which of the following? Select all that apply.

fever productive cough with yellow/green sputum gradual onset of shortness of breath

A client with pneumonia has a CBC drawn. Which result is most indicative of infection?

increased WBC