PrepU: Ch.24 aspectic & infection control

A client who thinks he has an infection has come to the clinic. During the assessment, which question would the nurse most likely ask first?

"How long have you had the infection?"

A nurse is caring for a client who reports a severe throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

Illness

Recurrent infections the client has experienced. Priority intervention can the nurse include in the first line of defense?

Intact skin and mucous membranes

A client diagnosed with methicillin-resistant (MRSA). He wants to know when he will be cleared?what is the nurses bets response.

Two separate negative test results will clear you of the infection

Which nursing actions will be performed to assist in the prevention of health care-associated infections (HAIs)?

Wash hands between caring for clients Recommend vaccinations to clients Educate clients regarding why antibiotics are not used for viral illnesses

A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing hand washing?

Wash the hands with soap & water for at least 15 seconds Use a clean paper towel to turn off hand faucets

Place a mask on the client to limit the spread of micro-organisms into the surgical wound.

When entering a clients room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field?

Older client sharing a room with a roommate, clients roommate developed C-diff. 2 days later the client develops the same symptoms.

Exogenous (HAI- relating to or developing from external factors)

Discontinuing use of a gown. How does the nurse dispose of PPE?

Fold soiled side to the inside and roll with inner surface exposed.

The nurse is assigned to four clients who report elevated temperature. Based on their admitting diagnoses, the clients are at risk for developing infection. Which client should the nurse see first?

cancer client undergoing chemotherapy (Drug therapy can cause defects in the host's response to infection)

Standard precautions include?

Mucous membranes Non intact skin Body fluid secretions Blood

A nurse is preparing to obtain an aerobic wound culture from a client's surgical site. What would be most important for the nurse to do to ensure that the results are accurate?

Clear exudate from around the wound.

What precautions is used for VRE (vancomycin-resistant enterococcus)

Contact precautions

A nurse is assessing a client with an infection and suspects that the client may be developing systemic inflammatory response syndrome. What would support the nurse's suspicions? Select all that apply.

Heart rate 110 beats/minute Chills Respiratory rate of 26/minute

Neutrophils help with?

Help fight infection and important link in generating fever to combat infection

Following stages of infection after inhaled droplets.

Incubation period Prodromal stage Illness Convalescent period

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

Bacterial resistance to antibiotics is an example of?

Survival adaptation

Most appropriate action Doffing (taking off)

Teach the colleague to let the gown fall away rather than pulling on the sleeves

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?

The client's immune system became further weakened

The nurse is caring for a postpartum mother who delivered her second child yesterday. The mother states that her older child has just been diagnosed with chickenpox. She is concerned that her newborn will develop the disease. What is the best response by the nurse?

"Have you had chickenpox?"

Airborne precautions for transporting a patient

Mask covers the nose and mouth Tie upper strings of mask Replace mask after 20-30 min. Cover client with clean sheet Prepare the stretcher with clean sheet

Airborne precautions diseases include?

Measles Varicella Pulmonary Laryngeal Tuberculosis

After assessing a client's temperature, the nurse documents that the client has a fever that is categorized as being high-grade. Which reading would the nurse most likely have obtained in this client?

39.2 degrees C

A client is being admitted to the hospital for elevated temperature for the past 24 hours. He had his right knee replaced 4 days ago in the same facility. Which assessmment is a priority for now?

Auscultate lung sounds. ( by the 5th day postoperative most likely results from pneumonia)

After finishing providing care for a client who is on contact precautions. What should the nurse try to prevent?

Avoid touching the outer surfaces of the gown.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

The flap farthest from the body

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field?

The nurse moistens a cotton ball with sterile NORMAL saline and places it on the sterile field The procedure is delayed by 1 hr because the provider receives an emergency call The nurse turns to speak to someone who enters through the door behind the nurse

How should the nurse remove PPE(personal protective equipment)

To remove a gown, nurses should unfasten ties, fall away from shoulders Nurses should remove PPE at the doorway. Except for for the respirator Nurses may need to change gloves more than once

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?

Tuberculosis

Chain of infection in order

infectious agent reservoir portal of exit mode of transmission portal of entry susceptible host

There have been an increase of needlestick injuries in the intensive care unit. When preparing to address this occurrence in a staff meeting, what should the nurse manager include in an education presentation to prevent needlestick injuries?

using self-retracting safety needles Using needleless adapters for medication administration disposing of used needles in sharps container

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting?

Planning and evaluating control Determine public health priorities Ensuring proper medical treatment Identifying endemic disease Monitoring for common-source outbreaks

Droplet precautions diseases include?

Strep Pharyngitis Pneumonia Scarlet fever Rubella Pertussis Mumps

Building blocks of the immune system

T-lymphocytes

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection?

Fever Malaise Increase in pulse and respiratory rate

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

- wear a mask when providing care within 3 ft of the client - place a surgical mask on the client if transportation to another department is unavoidable - wear a gown when performing care that might result in contamination from secretions