Fundamentals Chapters 20,25,27
The proper use of the principles of body mechanics:
Acts to prevent injury to the client and/or nurse
Which term describes foreign particles that enter a host and stimulate the body's immune response
Antigen
When the client restricts use of the dominant arm because of pain and the nurse notes that the measurement of the circumference of the client's nondominant arm is greater than the dominant arm, the nurse determines that the lack of use has resulted in the dominant arm's:
Atrophy
A community health nurse is providing care for several older adults. Which factor increases these clients' susceptibility to infections?
Atrophy of the thymus gland
When the muscle contracts, which element is released into the sarcoplasmic reticulum?
Calcium
The nurse is assigned to four clients who are complaining of elevated temperature. Based on their admitting diagnoses, the clients are at risk for developing infection. Which client should the nurse see first?
Client with cancer undergoing chemotherapy
A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply.
Clostridium difficile Norovirus
A nurse is implementing aseptic practices on the medical-surgical unit to prevent infection transmission. Which route would the nurse most likely address first because it is the most common route of transmission?
Contact
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?
Contact
The nurse is caring for a client who had surgery 2 days ago. The nurse correctly recognizes which of the following as having the greatest ability to reduce the incidence of deep vein thrombosis (DVT)?
Early ambulation
A flexion contracture usually occurs because of inactivity and:
Extensor muscles being stronger that flexors.
A client with cancer has developed a metastatic bone tumor in the right hip. What complication is the client at risk for?
Fracture
An older adult who is hospitalized develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection?
Healthcare-associated infection (HAI)
Viruses invade living cells. Which disease is caused by a virus?
Hepatitis B
To eliminate needlesticks as potential hazards to nurses, the nurse should:
Immediately deposit uncapped needles into puncture-proof plastic container.
A client who is immobile reports severe pain in the right flank. The physician diagnoses the client with renal calculi. This condition often results from:
Increased serum calcium
Most healthcare-associated infections (HAI) involve which system?
Intravascular line
A client is being admitted to the hospital for elevated temperature for the past 24 hours. The client had the right knee replaced 4 days ago in the same facility. Which assessment is a priority for now?
Lung sounds
The nurse of a local university is examining a student who has swollen glands and small painful lesions of the mouth. The nurse expects to palpate swelling in the neck area because:
Lymphocytes and macrophages invade the lymph nodes
Which nursing strategy will prevent the dislocation of the hip prosthesis?
Maintaining abduction
The nurse is caring for a client receiving continuous enteral feeding. Which nursing intervention is most important to prevent infection?
Monitor temperature elevation
The nurse is caring for a client who is on strict bed rest. The medical history includes partial paralysis from a stroke suffered several years ago. There is also evidence of early dementia. The nurse correctly recognizes the client is at an increased risk for which complication?
Muscle atrophy
Which statement about neonatal development is accurate?
Neonates may have an infection without fever.
A young adult client has had orthopedic surgery on the right knee. The first time out of bed, the client describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which condition is likely affecting the client?
Orthostatic hypotension
A client has had a stem cell transplant and is receiving immunosuppressive agents. Which type of isolation would the nurse use?
Protective isolation
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection at the surgical site. What is the most important factor to prevent this infection?
Surgical asepsis
Which of the following are considered the building blocks of the immune system?
T lymphocytes
The student nurse observes another nurse wash the hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium difficile (C. diff). Why is this behavior incorrect?
The bathroom is highly contaminated with the Clostridium difficile bacteria.
Disinfectants are used:
To clean rooms between clients
Gram-negative organisms are the most common cause of:
Urinary infections
After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply.
Used syringe with attached needle Used fingerstick lancet
A nurse instructs a new mother on immunizations. An immunization produces:
active immunity
A client with asthma tries to jog a mile but cannot finish and reports fatigue. An appropriate nursing diagnosis would be:
activity intolerance related to fatigue.
The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid:
adduction of the affected leg.
A nursing student presents to the university health center reporting a sore throat, malaise, and loss of appetite. The nurse assesses the student and determines he or she has large, white-yellow exudates in the back of the throat and a fever. The student is presenting with:
an infectious disease
When an 86-year-old client reports inability to concentrate, uneasiness, light- headedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:
an older adult can have an infection without a fever.
The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes that the client has impaired muscle coordination. The nurse correctly documents the presence of:
ataxia
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria
The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:
bacterial infection
When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be:
balanced over the center of gravity.
A client with HIV is the:
carrier
Hepatitis is classified as a virus that:
causes tissue damage
A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control?
contact precautions
When a home care nurse notes that a widow of 3 months is not sleeping well, has no appetite, and does not attend activities outside the home, the nurse suspects the client is experiencing:
depression
The process of phagocytosis involves:
digestion of microbes by white blood cells.
Otitis media occurs in children because the:
eustachian tube is shorter and straighter
To compensate for the shift in the center of gravity, an older adult tends to:
flex the knees for support.
A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from:
footdrop
An 82-year-old client is taking medication for blood pressure and is suffering from syncope. The client is at risk for:
fractures
Which gait is characterized by one leg being dragged and swung forward by hip motion?
hemiplegic
An infant develops one extremity that is shorter than the other. This occurs with:
hip dislocation
A client is discharged to the daughter's home. The client weighs 250 lbs and is immobile. The nurse should instruct the daughter on the use of a:
hydraulic lift.
What is the most common reason people contact healthcare providers?
infectious disease
What is the second line of defense in microbial invasion?
inflammation
When the client has been diagnosed as having an infection in the semicircular canals in the vestibular apparatus of the ear, the nurse should assess the client for:
instability when walking, because the semicircular canals maintain equilibrium.
The nurse explains to the client that the first line of defense against infection is:
intact skin and mucous membranes.
When an older adult client walks with the knees slightly flexed and body leaning, the nurse determines that the client:
is demonstrating a common gait for the older adult.
An orthopedic client is instructed to tighten the gluteus muscles and relax. This is an example of an:
isometric exercise
A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is:
it is a vaccine given to booster antibodies toward the tetanus pathogen.
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
maintain the natural alignment of the client's body.
Any microorganism capable of disrupting normal physiologic body processes is a:
pathogen
An older adult client who suffered a hip fracture and 1 day postoperative is to receive heparin 5,000 units subcutaneous daily. This is administered to:
prevent deep vein thrombosis.
A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the:
prodromal period
The nurse is caring for a client who has a lower body injury and who is able to partially assist with transfers. The nurse should:
provide the client with an overhead trapeze.
The most common infection in children is:
respiratory
A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is:
semen
A client has a systemic infection that resulted from an untreated urinary tract infection. The client has malaise and is confused. The client is:
septic
An infection or the products of infection carried throughout the body by the blood is called:
septicemia
A home care nurse is assessing a client in the home. The client had a cerebrovascular accident and has right side paralysis. After 6 weeks of rehabilitation, the client has increasing mobility when:
she can lift the right arm ½ inch.
When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is:
standard precautions
A 70-year-old client with chronic obstructive pulmonary disease (COPD) has a respiratory infection being treated with antibiotics. The client is also taking oral corticosteroids to assist in decreasing the inflammation in the lungs. The client is prone to:
superinfection
To assess a potential injury to a client's wrist, the nurse asks the client to turn the hand and forearm upward. This movement is referred to as:
supination
A client suffered a spinal cord injury resulting in the loss of function to the arms and legs. This client would be diagnosed as having:
tetraplegia
The nurse performs hand hygiene with soap and water before caring for a client. What is the primary rationale for this action?
to eliminate disease-producing organisms from the nurse's skin
The most lethal infection in an older adult client is:
urinary
What is the most common client site for development of healthcare-associated infections (HAI)?
urinary tract
Which factor has contributed to resistant microbial strains?
use of antibiotics in clients with viral infections
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
vehicle
Before and after doing aseptic techniques with a client, the nurse should:
wash hands
A client is discharged from the hospital and will need to change the left leg dressing using sterile technique twice per day. To prevent the development of further infection, the client will need to:
wash hands for 1 minute, apply nonsterile gloves, remove the dressing, apply antibacterial waterless soap, and sterile gloves.
