Infection
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. Auditing staff members' hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods
ANS: A All methods will help prevent infection; however, health care workers' lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.
An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? A. Check the resident's oxygen saturation. B. Do a complete neurologic assessment. C. Give the prescribed PRN lorazepam (Ativan). D. Notify the resident's primary care provider.
A A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation; this will take several minutes to complete. Administering lorazepam may make the client more confused and agitated because antianxiety drugs may cause a paradoxical reaction, or opposite effect, in some older clients. Depending on the results of the client's pulse oximetry and neurologic examination, notifying the primary care provider may be an appropriate next step.
A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? The client will be treated for 5 to 7 days. The client will require IV antibiotics for 7 to 10 days. The client will complete 6 days of therapy. The client must be afebrile for 24 hours.
A Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised client or one with hospital-acquired pneumonia. A client may become afebrile early in the course of treatment with anti-infective medications; this may cause many clients to fail to complete their course of treatment.
The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? A. Arrange for a health care worker to watch the client take the medication. B. Give the client written instructions about how to take prescribed medications. C. Have the client repeat medication names and side effects. D. Instruct the client about the possible consequences of nonadherence.
A Because this client is unlikely to adhere to long-term treatment unless directly supervised while taking medications, the best option is to arrange for directly observed therapy. Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Also, the question does not indicate whether the client can read. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless may be more concerned with obtaining shelter and food than with properly taking his or her medication.
A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease? "I am here to receive the yearly pneumonia shot again." "I am here to get my yearly flu shot again." "I should avoid large gatherings during cold and flu season." "I should cough into my upper sleeve instead of my hand."
A Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once. Older clients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.
A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? Ethambutol Isoniazid Pyrazinamide Rifampin
A Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless. Contact lenses will also be stained and oral contraceptives will be less effective.
A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? A. Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) B. Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C. Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) D. Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)
A The combination of isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat TB. Metronidazole is used to treat anaerobic bacteria and some parasites, but is not effective against TB. Acyclovir is used to treat viral infection. Flunisolide is a corticosteroid that is useful in asthma or other airway disease to prevent wheezing. Prednisone is a steroid. Guaifenesin is a mucolytic. Ketorolac is a nonsteroidal anti-inflammatory drug that is used for short-term pain relief. Salmeterol and cromolyn sodium would most likely be given to clients with respiratory difficulties such as poorly controlled asthma from allergic sources. Dexamethasone is a steroid.
A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? (Select all that apply.) A. Combination drug therapy is effective in preventing transmission. B. Combination drug therapy is the most effective method of treating TB. C. Combination drug therapy will decrease the length of required treatment to 2 months. D. Multiple drug regimens destroy organisms as quickly as possible. E. The use of multiple drugs reduces the emergence of drug-resistant organisms.
ABDE Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Although combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.
The 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Elevated mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate
A. An abnormally large number of mononuclear leukocytes will confirm a diagnosis of mononucleosis.
Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is true? A. Antibiotics have been given to clients for conditions that do not require antibiotics. B. Microorganisms are more susceptible to antibiotics today than when they were given years ago. C. Additional precautions are taken, along with Standard Precautions, to prevent infection. D. Certain antibiotics are effective for specific infections only.
A. Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics.
Which of the following strategies by the nurse would be most helpful in treating a patient who is experiencing chills because of an infection? A. Provide a light blanket. B. Encourage a hot shower. C. Monitor temperature every hour. D. Turn up the thermostat in the patient's room.
A. Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.
A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? (Select all that apply.) A. Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B. The medications may cause nausea. The client should take them at bedtime. C. The client is generally not contagious after 2 to 3 consecutive weeks of treatment. D. These medications must be taken for 2 years. E. These medications may cause kidney failure.
AB Not taking the medication as prescribed could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea and are best taken at bedtime to prevent this. The client is generally not contagious after 2 to 3 weeks of consecutive treatment and improvement in the condition has been observed. The combination regimen for treatment of TB has decreased treatment time from 6 to 12 months to 6 months. TB medications may cause liver failure, not kidney failure.
A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Elevate the arm above the level of the heart. b. Order a fan to help cool the client if feverish. c. Place cool, wet cloths on top of the wound. d. Take the client's temperature every 4 hours.
ANS: A Elevating the extremity above the level of the heart will help with swelling and pain. Fans are not recommended as they can disperse microbes. Having a cool, wet cloth on the wound may macerate the broken skin. Taking the client's temperature provides data but does not increase comfort.
A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best? a. Assess the client frequently for worsening of his or her condition. b. Delegate comfort measures to unlicensed assistive personnel. c. Ensure the client is placed on Contact Precautions. d. Restrict visitors to the immediate family only.
ANS: A Meningitis is a disease caused by endotoxins, which are released with cell lysis. Antibiotics often work by lysing cell membranes, which would increase the amount of endotoxin present in the client's body. The nurse should carefully monitor this client for a worsening of his or her condition. Delegating comfort measures is appropriate for any client. Clients with meningitis are placed on Droplet Precautions, and initiating isolation should have been done on admission. The client does not need to have visitors restricted.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin (Vancocin). b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.
ANS: A Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.
The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) a. Appropriate drug b. Proper route of administration c. Standardized peak levels d. Sufficient dose e. Sufficient length of treatment
ANS: A, B, D, E In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.
A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet from the client at all times. c. Order specialized masks/respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care.
ANS: A, C A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot distance is required for Droplet Precautions. Chlorhexidine is used for clients with a high risk of infection.
A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. b. Notify the provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation.
ANS: B A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.
A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.) a. Administer antipyretics around the clock. b. Change the client's gown and linens when damp. c. Offer cool fluids to the client frequently. d. Place ice bags in the armpits and groin. e. Provide a fan to help cool the client.
ANS: B, C Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.
The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) a. Colonization b. Host c. Mode of transmission d. Portal of entry e. Reservoir
ANS: B, C, D, E Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.
A hospital unit is participating in a bioterrorism drill. A "client" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "client"? a. Airborne Precautions b. Contact Precautions c. Droplet Precautions d. Standard Precautions
ANS: D Only Standard Precautions are needed. No other special precautions are required for the "client" because inhalation anthrax is not spread person to person.
A client is admitted with possible sepsis. Which action should the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.
ANS: D Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.
Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching client excretions or secretions.
ANS: D, E Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you should also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet away from clients is also not part of Standard Precautions.
An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A. It would not be beneficial for this client. B. It would help decrease the bronchospasm. C. It would clear up the density in the bases of the client's lungs. D. It would decrease the client's pain on inspiration.
B A bronchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client. It would decrease dyspnea and feelings of shortness of breath. A bronchodilator would not be able to clear up the density in the bases of the client's lung. The cause of the density is unknown; however, an infection such as pneumonia is likely, which bronchodilators do not treat. Although a bronchodilator would help a client breathe easier, it does not have any analgesic properties.
Which symptom of pneumonia may present differently in the older adult than in the younger adult? Crackles on auscultation Fever Headache Wheezing
B Older adults may not have fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups.
A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? "You are not contagious unless you stop taking your medication." "You will not be contagious to the people you have been living with." "You will have to take these medications for at least 1 year." "Your sputum may turn a rust color as your condition gets better."
B The people the client has been living with have already been exposed and need to be tested. They cannot be re-exposed simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.
Which method is the best way to prevent outbreaks of pandemic influenza? Avoiding public gatherings at all times Early recognition and quarantine Vaccinating everyone with pneumonia vaccine Widespread distribution of antiviral drugs
B The recommended approach to disease prevention consists of early recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. Public gatherings should be avoided only if a widespread outbreak has occurred in a community. No vaccine is available for pandemic influenza. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.
Which actions aid in the prevention and early detection of infection in the client at risk? Select all that apply. A. Inspect the skin for coolness and pallor. B. Promote sufficient nutritional intake. C. Encourage fluid intake, as appropriate. D. Monitor the red blood cell (RBC) count. E. Obtain cultures as needed. F. Remove unnecessary medical devices.
B, E, F. Nutrition has a direct correlation to improvement of general health; having balanced, appropriate nutrition is one way to prevent infection. Blood cultures would be used to detect a possible system infection
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which of the following parameters would the nurse monitor, other than temperature, if the patient requires this medication? A. Pain level B. Intake and output C. Oxygen saturation D. Level of consciousness
B. Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance.
Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B. Client with pulmonary tuberculosis who is receiving multiple medications C. Client with sinusitis who has just arrived after having endoscopic sinus surgery D. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing
B. Client with pulmonary tuberculosis who is receiving multiple medications
A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? A. Administer levofloxacin (Levaquin) 500 mg IV. B. Draw aerobic and anaerobic blood cultures. C. Give lorazepam (Ativan) as needed for agitation. D. Refer to social worker for alcohol counseling.
B. Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile client for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action; the question indicates that the client is agitated but does not indicate whether other attempts to control agitation have been tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge; this client is febrile and agitated, and a referral is not the immediate concern.
The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible pulmonary tuberculosis who currently has hemoptysis D. Client with right empyema who has a chest tube and a fever of 103.2° F
C A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.
The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? A. Completing the antibiotic medication regimen B. Taking pain medications every 4 to 6 hours C. Contacting the provider if the throat feels more swollen D. Using warm saline gargles and irrigations
C Clients with peritonsillar abscess are at risk for airway obstruction due to swelling and should notify the provider if signs of obstruction occur, such as stridor or drooling. It is important to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but none of these is the most important thing to teach the client.
A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? A. Ensure that ED staff members receive oseltamivir (Tamiflu). B. Obtain specimens for the H5 polymerase chain reaction test. C. Place the client in a negative air pressure room. D. Start an IV line and administer rehydration therapy.
C If a client is exhibiting symptoms of avian flu or any other pandemic influenza, he or she is assumed to be contagious until proven otherwise. Preventing the spread of disease to the community is the top priority, so placing the client in a negative air pressure room is the nurse's first action. If avian influenza is diagnosed, it is important that those exposed receive oseltamivir or zanamivir (Relenza) within 48 hours of contact with the client. Obtaining specimens will be important to determine whether the client has avian influenza; this test takes approximately 40 minutes to complete. A client with avian flu will become dehydrated because of diarrhea, so starting an IV to administer rehydration fluid is important, but is not the first priority.
A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order? A. Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours B. Ceftriaxone (Rocephin) 2 g IV every 8 hours C. Ciprofloxacin (Cipro) 400 mg IV every 12 hours D. Pyrazinamide (Zinamide) 1000 to 2000 mg orally every day
C Intravenous ciprofloxacin (Cipro) is a first-line drug for treatment of inhaled anthrax. A dose of 400 mg IV every 12 hours is typically used for treatment of anthrax, while a dose of 500 mg orally twice daily is usually prescribed for anthrax prophylaxis. Oral doses of amoxicillin are used only as prophylaxis, not as treatment, for inhaled anthrax. Cephalosporins such as ceftriaxone are not used for treatment of anthrax. Pyrazinamide (Zinamide) is used for treatment of tuberculosis.
A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? Contact the health care provider for tuberculosis (TB) medications. Perform a TB skin test. Place a respiratory mask on the client. Test all family members for TB.
C The concern is that this client has TB. A respiratory mask should be placed on the client immediately. Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. It is important to remember to let the client know that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.
The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A. Evaluating each other's handwashing technique B. Deciding which brand of handwashing soap to use C. Reinforcing the need for handwashing after caring for clients D. Determining which clients are most likely to infect other residents
C. All health care providers have a responsibility to reinforce education on basic handwashing, including that provided for nursing assistants.
A 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Decreased mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate
C. Decreased neutrophil count In a client with mononucleosis, a white blood cell count would show a decrease in neutrophils.An abnormally large not decreased number of mononuclear leukocytes would be seen with mononucleosis. In most active infections, especially those caused by bacteria, the total leukocyte count is elevated, not decreased. An elevated erythrocyte sedimentation rate indicates infection, but does not specifically indicate mononucleosis.
Which statement about the transmission of hepatitis C is true? A. Feces are a likely body fluid by which to transmit the disease. B. Airborne Precautions are used for the prevention of hepatitis C. C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D. No precautions are necessary with the use of nail clippers or scissors.
C. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection.
Which client is at greatest risk for developing an infection? A. 54-year-old man with hypertension B. 17-year-old woman with a fractured tibia in a cast C. 65-year-old woman who had coronary bypass surgery 4 days ago D. 71-year-old man in a nursing home
C. Older clients with decreased vascularity to the integumentary system are at risk for infection.
Which of these nurses would be assigned to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A. An experienced LPN/LVN who has worked on the medical unit for 10 years B. An RN with experience in the operating room who transferred a month ago to the medical unit C. A float RN with 7 years of experience on the inpatient oncology unit D. An RN who has worked mostly on the same-day surgery unit since graduating a year ago
C. This RN would be familiar with complications and assessment for IV fluids and pneumonia.
When assessing a patient who is receiving cefazolin (Ancef) for treatment of a bacterial infection, the nurse would conclude that treatment has been effective based upon which of the following data? A. White blood cell (WBC) count 16,500/μl, temperature 98.8○ F B. White blood cell (WBC) count 8000/μl, temperature 101○ F C. White blood cell (WBC) count 8500/μl, temperature 98.4○ F D. White blood cell (WBC) count 4000/μl, temperature 100○ F
C. This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/μl. An elevated WBC count is an indicator of infection.
A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? Chest x-ray Complete blood count (CBC) Tuberculosis (TB) skin test Throat culture
D A throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. A chest x-ray or TB skin test is not indicated by the symptoms given. A CBC might be indicated to evaluate infection and dehydration, but would not be the first action.
The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? A. Ensures that the client is wearing a mask B. Tells the visitor that the client cannot receive visitors at this time C. Provides a particulate air respirator to the visitor D. Provides a mask to the visitor
D Because the visitor is entering the client's isolation environment, the visitor must wear a mask. The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator.
The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client? "Whooping" after a cough Hemoptysis Mild cold-like symptoms Post-cough emesis
D Clients with pertussis will have paroxysms of coughing often followed by changes in color and/or vomiting. Adults do not usually have the characteristic whooping sound associated with coughing that children with pertussis exhibit. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.
Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? Homeless people Hospital staff Politicians Prison staff and inmates
D High-risk groups for respiratory infection include those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities. Although homeless people are a high priority, they are not the group at greatest risk of those listed. Education could be provided in shelters or during outreach activities. Hospital staff are at risk owing to their contact with ill clients and family members; however, they are already aware of how to prevent respiratory infection. Politicians are not at higher risk for respiratory infection than any other group with public exposure.
The nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? A. "Handwashing is the best way to prevent transmission." B. "I should avoid kissing and shaking hands." C. "It is best to cough and sneeze into my upper sleeve." D. "The intranasal vaccine can be given to everybody in the family."
D The intranasal flu vaccine is approved for healthy clients ages 2 to 49 who are not pregnant. Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A new recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.
The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? A. Keeping the head of the bed elevated 30 to 45 degrees B. Performing oral care after suctioning the oropharynx C. Washing hands and donning gloves prior to the procedure D. Wearing a disposable particulate mask respirator and protective eyewear
D To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. Keeping the head of the bed elevated 30 to 45 degrees is not the most important precaution. Performing oral care is a comfort measure. Washing hands and donning gloves is necessary, but not the most important measure.
Which is a common clinical manifestation of infectious disease? A. Dry and pink skin B. Hypothermia C. Decreased respiratory rate D. Decreased level of consciousness
D. Hyperpyrexia, which usually accompanies infection, is a cause of a decreased level of consciousness.
Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A. Carefully washes hands that are visibly soiled B. Wears a mask and gloves when the client's body secretions or body fluids are likely to be handled C. Wears a mask with eye protection and performs proper handwashing D. Wears gloves when contact with body secretions or body fluids is expected
D. The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids.
Which intervention is the most appropriate to address the priority problem of feelings of isolation when caring for a client who is placed on Transmission-Based Precautions? A. Encourage family and friends to call the client. B. Provide education on the mode of transmission. C. Encourage the client to watch television. D. Ask a certified hospital chaplain to visit the client. Provide education on the mode of transmission.
Provide education on the mode of transmission.
A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first? a. Obtain cultures of the lesions. b. Place the client on Airborne Precautions. c. Prepare to administer antibiotics. d. Provide comfort measures for the rash
This client has manifestations of smallpox, a public health emergency, and should be placed on Airborne Precautions first before other care measures are implemented.