2090 Prepu Chapter 2 & 27: Infection Prevention and Management

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

"It could take 24 to 36 hours to grow cultures & about 48 hours for sensitivity." Results of Gram stains can be obtained in less than 30 minutes. 24 to 36 hours is required to grow good cultures, and 48 hours is needed to obtain growth & sensitivity results.

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how she could help her family avoid community-acquired infections. What would be the nurse's best response to help prevent & control community-acquired infections?

"Make sure your family has all of their childhood immunizations."

A client the nurse is caring for has developed a bladder infection in the hospital. The client has had a Foley catheter for 2 weeks. The client's family asks the nurse how the client got this infection. What would be the nurse's best response?

"People in hospitals are often more susceptible to infections because they are already ill & they are exposed to germs while they are in the hospital."

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?

"Stress leads to increased secretion of cortisol, which suppresses your immune response."

The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?

"Your baby's resistance comes from the antibodies you passed on to him before birth & now with breast feeding." The infant's resistance to infection comes from the antibodies passed by the placenta & breast milk. The immune system does not become fully operational until 6 months of age.

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." Purulence or pus results from migration of white blood cells to the area of infection. Purulent drainage is thicker than normal & foul smelling because it has cellular debris from the inflammatory response.

A nurse is assessing a client for signs & symptoms of infection. What would the nurse expect to asses? Select all that apply.

- increased respiratory rate - lymph node enlargement - fever Findings associated with an infection include fever, increased heart rate, pain, increased respiratory rate, & lymph node enlargement.

A nurse in an oncology care unit is reviewing the laboratory test results of several clients scheduled to receive chemotherapy. The nurse determines that the client with which leukocyte count will most likely have the chemotherapy withheld?

2,500 cells/mm3 Explanation: The leukocyte count of 2,500 cells/mm3 is below normal and suggests a significant increase in the risk for infection. Thus, receiving chemotherapy could possibly cause the count to decrease even more, necessitating the withholding of chemotherapy at this time. Counts of 8,000 cells/mm3, 5,000 cells/mm3, and 9,800 cells/mm3 would be considered normal.

A client is being screened for a parasitic infection & 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. When a client is screened for a parasitic infection, stool specimens are collected daily for 3 days. Parasites lay eggs in the GI tract that can be detected on examination. Moving organisms can easily be detected in fresh specimens.

A nurse is reviewing the laboratory test results of a client who is at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis?

3.2 mmol/L Lactic acid, present in blood as lactate, is a byproduct of metabolism that is usually metabolized in the liver. Normal levels are 0.3 to 2.6 mmol/L. In sepsis, lactate levels increase secondary to anaerobic metabolism due to hypoperfusion.

A nursing instructor is describing humoral immunity & the complement system. What would the instructor include as a function of this system? Select all that apply. Make bacteria more susceptible to phagocytosis. Aid in the lysis of the bacterial cell wall. Neutralize the underlying causative virus. Enhance phagocytosis of the microbes. Encourage the inflammatory response.

Aid in the lysis of the bacterial cell wall. Enhance phagocytosis of the microbes. Encourage the inflammatory response. Explanation: The complement system enhances phagocytosis of microbes, helps in the lysis of bacterial cell walls, & encourages the inflammatory response. Antibodies act to make bacteria more susceptible to phagocytosis and, when a virus is the cause, help to neutralize the virus.

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

Apply principles of medical & surgical asepsis.

The postoperative client refuses to do deep breathing, & 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. Explanation: Encouraging clients to cough, breathe deeply, blow the nose, and move the body promotes clearance of respiratory secretions, which may become infected if allowed to pool in the lower respiratory tract. Retained secretions prevent adequate gas exchange at the alveolar level and reduce oxygen available to the tissues to combat infection, heal injured tissues, and meet metabolic needs. Secondary infections are commonly associated with impaired respiratory tract function. Timing is an important consideration when administering analgesics. To time analgesics appropriately, know the average duration of action for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense. For example, an analgesic would be offered before ambulating a client postoperatively.

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 Explanation: From the time of admission, broad-spectrum antibiotics should be administered within 3 hours for emergency department admissions, and within 1 hour for non-emergency department ICU admissions. Evidence suggests that early administration of appropriate antibiotics reduces mortality in clients with gram-positive and gram-negative bacteremia.

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

Clear mucus Assessment findings associated with a respiratory infection include productive cough, dyspnea, & abnormal breath sounds. Sputum changes in color from clear to possibly yellow, brown, or green.

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 Colonization refers to the presence of microorganisms without host interference or interaction. Infection is a condition in which the host interacts physiologically & immunologically with a microorganism. Disease is the decline in wellness of a host due to infection. Bacteremia is a condition of bacteria in the blood.

Evidence suggests that poor __________ contributes to approximately 66% of healthcare errors.

Communication

What would be considered a mechanical defense mechanism?

Coughing Explanation: Mechanical defense mechanisms are physical barriers that prevent microorganisms from gaining entry, or physical barriers that expel microorganisms before they multiply. Examples are the skin and mucous membranes, physiologic reflexes (e.g., sneezing, coughing, vomiting), and macrophages. Casts, clothing, and sunscreen do not keep microorganisms from gaining entry to the body.

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?

Early infection treatment is needed to prevent the spread of infection. Prevention of infections in early childhood requires good hygienic care of children & food, adequate vaccinations, early infection treatment to prevent spread or complications & isolation of both healthy & from infected people.

After teaching a group of nursing students about the function of the various white blood cells, the instructor determines that the teaching was successful when the students identify which cell as being involved with allergic reactions?

Eosinophils Explanation: Eosinophils are involved in allergic reactions. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. The action of basophils is unknown but they may be involved in preventing blood clotting during an inflammatory response. Monocytes are scavenger cells that dispose of cellular debris.

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/104.9F Hyperpyrexia: temperature greater than 40.5°C

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. Explanation: The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, & when they are intact, infection is rare. Chemical composition aids these physical barriers further. For example, the acidic nature of the skin & vagina helps to kill potential invaders before they enter the body. Certain illness or treatments can interfere with the body's delicate balance, causing overgrowth of Candida fungus

A nurse is developing a plan of care for a client admitted to the unit. The nurse is focusing on preventing urinary infection in the client. Which measure should the nurse use to prevent urinary tract infection?

Instructing the client to wipe front to back after using the restroom

A client is scheduled to receive an immune globulin. When explaining this to the client, the nurse integrates knowledge that this action results in which type of immunity?

Passive Explanation: Passive immunity is given in the form of immune globulins & provides only temporary protection. Cellular immunity consists principally of T-lymphocyte activity; humoral immunity involves B lymphocytes that produce antibodies conveying specific resistance to many bacterial and viral infections. Active immunity is produced when the immune system is stimulated, naturally or artificially to produce antibodies.

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy & not well." Which phase of the fever does the nurse identify the child may be experiencing?

Prodromal Children may experience symptoms prior to the fever, called the prodromal phase with non-specific symptoms before the body temperature rises.

A 20-year-old man is seen in a clinic for purulent penile discharge. He discloses that he has had five sexual partners in the past month. The client states that he always uses a condom. Which is the most appropriate NANDA-I diagnosis for the client?

Risk for Infection related to increased exposure to pathogens

_________events are safety events that can result in death or serious injury.

Sentinel

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 Explanation: During the fever phase, the skin is warm and flushed, and the client has general malaise. The client will have profuse diaphoresis and reduced shivering during the crisis phase of fever. Gooseflesh is evident during the chill phase.

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

T-lymphocytes Explanation: T-lymphocytes are important in synthesizing immunoglobulins. Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.

Care Bundles are a combination of patient care elements that are meant to be consistently used as a whole.

TRUE

Checking labeling on a unit of blood by two nurses prior to administration is the safety mechanism of redundancy.

TRUE

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. Explanation: The client's knowledge deficit is related to antibiotic therapy. Therefore, the most appropriate outcome would be that the client states how to take the prescribed antibiotic.

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 & that the physician should be notified immediately?

The client's heart rate is greater than 90 bpm. A heart rate greater than 90 beats per minute or a respiratory rate greater than 20 breaths per minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.

The nurse works on a long-term care unit. In the last 2 weeks more than half the clients on the unit have been diagnosed with gastroenteritis. What is the most likely reason?

The infection is being transmitted by health care personnel. Health care personnel are in frequent & direct contact with many clients who harbor various microorganisms; the risk for transmitting pathogenic microorganisms between clients is high.

What type of pathogen uses the cell's metabolism, & replicates itself while destroying the cell or changing the cell's genetic makeup?

Virus A virus invades a living cell many times its size, uses the cell's metabolism, & replicates itself while destroying the cell or changing the cell's genetic makeup.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection & is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

WBC of 25,000 mcL A normal WBC count is 5,000 to 10,000 cells/mm3. A count above this range is indicative of infection.

Microorganisms that are present on the human body without host interference or interaction refers to:

colonization. The term "colonization" is used to describe microorganisms present without host interference or interaction.

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 Explanation: The communicable period refers to the time during which a disease can be passed from one person to another. The incubation period refers to the time between the pathogen's entrance into the host and the appearance of symptoms. The prodromal period is characterized by nonspecific symptoms. The acute phase occurs when specific symptoms and often laboratory analysis can identify the disease.

The nurse has admitted a new client to the unit. This client has an open draining sore on the leg. Which diagnostic test would the nurse anticipate being ordered?

culture & sensitivity A culture identifies bacteria in a specimen taken from a person with symptoms of an infection. The source of the specimen may be body fluids or wastes, such as blood, sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound.

After educating students about changes in the immune system & risk for infection as people age, the instructor determines that the education was successful when the students identify?

decreased cellular immunity. As a person ages, there is a decline in cellular & humoral immunity, decreased effectiveness of phagocytosis, & an increased susceptibility to infection.

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

handwashing A person's defenses may be compromised. Healthcare-associated infections often result from poor hand hygiene & invasive procedures occurring within the health care system. HAIs occur frequently in skilled nursing facilities, jails, & other residential facilities.

A physician performs lumbar puncture & 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 Gram staining helps to order the selection of antibiotic concentration, helps in reducing proliferation of multidrug-resistant organisms, narrows the therapeutic range, & avoids prolonged use.

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 Explanation: Acquired specific defenses include cellular & humoral immunity. Gastric acid secretion, phagocytosis, & intact skin are nonspecific natural defenses.

Nursing students are reviewing information about immunizations & their role in preventing infection. Which client(s) should the students point out are not candidates for vaccinations?

immunodeficiency allergy to eggs febrile status Live vaccinations should not be given during pregnancy, acute debilitating disease, or periods of severe malnutrition. Gluten intolerance and vitamin K deficiency are not recognized as contraindications for vaccines.

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 Clinical evidence of redness, heat, and pain, & laboratory evidence of white blood cells on the wound specimen smear, suggest infection.

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. Explanation: Serum trough levels (or lowest drug level) should be obtained just before a dose is due to be administered, which would be just before any of the doses, or in this case just before the 6 a.m. dose. Peak levels or the highest level of drug concentration are obtained shortly after the drug is given.

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 Explanation: Rectal temperatures should be avoided to prevent trauma and subsequent infection. The nurse should encourage the client to wear a mask to prevent airborne infection. Providing gentle oral care & avoiding razors helps to keep the membranes intact and prevent infection

A nurse is working with a young woman, age 15, in a community health clinic. It is early October, & the young woman is worried that she will become ill & 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?

proper handwashing techniques administration of influenza immunization information on sleep hygiene It is not necessary for the client to shower with harsh soaps. This may actually lead to drying of the skin & decreased skin integrity.

Nursing students are reviewing the different types of bacteria. The students demonstrate understanding of the information when they identify which of the following as Gram-positive bacteria? Select all that apply. streptococci E. coli Klebsiella pneumoniae staphylococci trichomoniasis

streptococci staphylococci Explanation: Examples of Gram-positive bacteria include streptococci and staphylococci. E. coli and Klebsiella are examples of Gram-negative bacteria. Trichomoniasis is an example of a protozoa.

The nurse is teaching a health class in the local public health center about precautions to prevent the spread of influenza. What instructions should the nurse provide as the most important measure to prevent the spread of influenza?

thorough handwashing Hand hygiene remains the single most important measure to prevent the spread of infection, including the flu.

Nursing students are reviewing information about healthcare-associated infections. What would the students expect to find as a possible risk factor?

use of antibiotic therapy use of steroid therapy insertion of invasive devices multiple wounds