Immunity/Infections

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistant Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply. 1. Blood urea nitrogen is 60 mg/dL 2. Creatinine is 2.1 mg/dL 3. Glucose is 140 mg/dL 4. Hemoglobin is 15 g/dL 5. Magnesium is 1.5 mEq/L 6. White blood cell count is 14,000/mm3 (14.0 × 109/L)

1, 2 Vancomycin is an antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms such as MRSA and diarrhea associated with Clostridium difficile. Kidney function needs to be monitored while on vancomycin therapy. Option 1: Normal BUN is 6-20 mg/L. Urea is a waste product of protein digestion by the liver and should be excreted in urine by the kidneys. High levels of urea in the blood indicate kidney impairment. This test is less accurate at determining kidney function than creatinine. Option 2: Normal creatinine is 0.6-1.3 mg/dL. Creatinine is a waste product of normal muscle breakdown and should be excreted in urine by the kidneys. High levels of creatinine in the blood indicate kidney impairment. This test is more accurate at determining kidney function than BUN. Option 3: Glucose of 140 (normal 70-110, <140 for ill patients, <170 for critically ill patients) is expected in an ill patient, as infection causes physiological stress and gluconeogenesis. Options 4, 5: Hgb of 15 g/dL is normal (12-16 F, 14-18 M) and magnesium of 1.5 mEq/L is normal (1.5-2.5 mEq/L) Option 6: An elevated WBC (normal 4,500-11,000 mm3) is expected in a patient with an infection.

A client allergic to bee stings was stung about 20 minutes ago at a picnic. Based on the assessment data, the nurse anticipates which immediate actions? Select all that apply. 1. Inhaled albuterol 2. Intramuscular epinephrine 3. Intravenous methylprednisolone 4. Intravenous metoprolol 5. Intravenous nitroglycerine

1, 2, 3 Anaphylactic shock has an acute onset (20-30 minutes). It results in hypotension and respiratory complications (bronchoconstriction from histamine release, laryngeal edema) and can lead to cardiac and respiratory failure. Treatment involve reducing severity of symptoms, maintaining airway, reducing inflammation, and preventing shock (elevate legs, resuscitate with fluids). Option 1: Albuterol is a fast acting bronchodilator that will improve breathing. This should be given second. Option 2: Epinephrine is a vasoconstrictor that will reduce symptoms of anaphylaxis. Repeat dose every 5-15 minutes if no response. This should be given first (after calling 911). Option 3: Methylprednisone is a corticosteroid and decreases inflammation and swelling. Option 4: Metoprolol is a beta blocker that treates hypertension and should not be given with anaphylaxis, as BP is already low due to vasodilation. Option 5: Nitroglycerine is a vasodilator and should not be given.

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply. 1.After insertion, secure the catheter with a sterile, semipermeable dressing 2.Clean ports with an alcohol swab prior to accessing the catheter system 3.Prior to insertion, apply chlorhexidine, using friction, to the venipuncture site 4.Prior to insertion, shave excess hair over the selected venipuncture site 5.Replace or remove the venous catheter every 48 hours

1, 2, 3 Option 1: Sterile tape can prevent accidental removal of the catheter, and prevent excessive back and forth motion that can introduce pathogens into the vein. Option 2: Ports should be cleansed with alcohol for 15 seconds. When not in use, ports should be capped with a sterile cap. Option 3: The venipuncture site should be cleaned for 30 seconds and allowed to air dry. Option 4: Shaving hair causes microabrasions, which are potential portals of entry for bacteria. Option 5: The IV catheter should be changed every 72 hours, or more often with signs of complications. Changing it too often for no reason puts the client at risk of infections with the extra manipulation and punctures.

A nurse is reinforcing teaching with a client newly diagnosed with human immunodeficiency virus (HIV) about actions to prevent complications. Which of the following statements indicate that teaching was effective? Select all that apply. 1. "I should ask for my steak to be cooked thoroughly with no pink." 2. "I should receive the influenza vaccine every year." 3. "I will ask my roommate to change the cat litter box for me." 4. "If I travel to a developing country, I will use bottled water when brushing my teeth." 5. "If my HIV viral load is undetectable, I do not need to wear condoms."

1, 2, 3, 4 Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive immune system impairment. Clients with HIV are susceptible to opportunistic infections that typically occur during periods of low CD4+ counts Options 1, 3: Undercooked meats and cat feces are both sources of an opportunistic parasites called Toxoplasma gondii. Option 2: Remaining up to date on vaccinations prevents chances of getting that illness. Option 4: Poorly sanitized water can contain infectious pathogens. Option 5: Clients with HIV can always transfer the virus to their partner, regardless of viral load.

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. 1. Don gown, gloves, and N95 respirator when entering the client's room 2. Ensure that pregnant staff members are not assigned to care for this client 3. Place single-use, disposable thermometer and stethoscope in the room 4. Place the client in a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted

1, 2, 3, 4, 5 Varicella (chickenpox) is a viral infection that is highly contagious when the blister-like rashes are open and weeping. It is transmitted through airborne particles or contact of the open vesicles. Option 1: Since it's an airborne virus, an N95 respiratory is necessary. Option 2: Varicella virus can cause fetal abnormalities. Option 3: Patients with isolation precautions need to have their own, dedicated equipment. Option 4: Negative pressure rooms prevent infectious airborne particles from escaping through the doorway Option 5: Once the lesions are no longer weeping, the virus is not longer transmittable.

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply. 1. Disposable gown 2. Face shield 3. Gloves 4. N95 respirator 5. Surgical mask

1, 2, 3, 5 Bacterial meningitis is an infection of the meninges around the brain or spinal cord. Patients are on droplet precautions, as it can spread through large droplets from coughing, sneezing, or talking and can travel up to 6 feet. Options 1, 2: A gown and face shield are used with patients on droplet precautions if there is a risk of splashing. Otherwise, a surgical is sufficient for routine care. Option 3: Gloves should always be worn with any contact involving bodily fluids, open wounds, or any skin conditions. Option 4: An N95 respiratory is used for airborne precautions; these particles are must smaller than droplets. Option 5: A surgical mask is appropriate for droplet precautions.

The nurse is caring for a client in the acute phase of meningococcal meningitis. Which nursing actions should be included in the client's plan of care? Select all that apply. 1. Assign client to a private room 2. Don mask before entering room 3. Elevate head of bed 10-30 degrees 4. Keep padded tongue blade at bedside 5. Maintain dimmed room lighting

1, 2, 3, 5 Meningitis is a bacterial infection that causes inflammation of the meninges, the membrane that covers the brain and spinal cord. Symptoms include N/V, fever, headache, neck stiffness, photophobia, and AMS. Option 1: Meningitis is highly infectious and requires strict droplet isolation. Option 2: Due to being transmissible via droplets, a mask, is required during contact. Option 3: Keeping the HOB slightly elevated promotes venous return from the brain and reduces intracranial pressure. Option 4: Due to increased intracranial pressure, the client is at risk for seizures, so seizure precautions should be in place (padded bed rails, O2, suction). Tongue blades are contraindicated during a seizure due to risk of injury to the patient. Option 5: Patients with meningitis experience headaches and photophobia; provide them with a low stimulus environment to reduce neuroirritability.

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply. 1.Apply color-coded, nonslip socks to the client's feet 2.Move the client to a room closer to the nurses' station 3.Place a bedside commode to the right of the client 4.Raise all bed rails before leaving the room 5.Use a bed alarm to alert staff when the client gets up

1, 2, 3, 5 Option 1: Non-slip socks can prevent falls Option 2: Moving the client to a room closer to the nurse's station will allow for more frequent observation and faster response time Option 3: Placing a commode to the right of the client (stronger side) decreases the number of steps they have to take to get to it. Option 4: Raising all bed rails is considered restraint, and clients with AMS may try to climb over them, increasing the risk of injury. Option 5: A bed alarm alerts staff when the client attempts to get out of bed, which allows for prompt response

An adult client with bacterial pneumonia becomes increasingly disoriented and somnolent. Which assessment findings indicate that the client may be in septic shock? Select all that apply. 1. Blood pressure of 80/50 mm Hg 2. Capillary refill of 5 seconds 3. Temperature of 96.4 F 4. Urine output of 125 mL/hr 5. WBC count of 26,000/mm3

1, 2, 3, 5 Sepsis is an overwhelming, full body response to infection of blood or tissues that causes impaired organ function. Septic shock occurs when sepsis causes cardiovascular collapse and/or impairs the body's ability to maintain normal metabolic and cellular processes. Option 1: Cytokines released in a large scale inflammatory response result in massive vasodilation, leading to hypotension and increased capillary permeability. Tachycardia will also occur to compensate for the low BP. Option 2: A long capillary refill time is also indicative of shock, as the decreased BP lead to inadequate tissue perfusion. Option 3: A fever or hypothermia are both signs of septic shock. A fever is due to inflammation and is the body's response to infection, and hypothermia occurs when the shock worsens due to metabolic alterations and inadequate tissue perfusion. Option 4: A urine output >30 ml/hr is considered adequate. With septic shock, output will be <30 ml/hr due to inadequate organ perfusion. Option 5: A WBC of 26,000 mm3 is very elevated (normal 4,000-11,000 mm3) and is indicative of severe infection.

The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply. 1. Chewing sugar-free gum or using artificial saliva 2. Scheduling regular dental examinations 3. Showering with lukewarm water and avoiding harsh soaps 4. Using over-the-counter decongestants to alleviate nasal symptoms 5. Using over-the-counter lubricants to ease vaginal dryness

1, 2, 3, 5 Sjögren's syndrome causes inflammation of exocrine glands, leading to dryness. Option 1: Chewing gum increases salivary secretions and prevents dry mouth. Option 2: Dry mouth increases the risk of cavities. Option 3: Sjögren's syndrome dries out the skin; cooler water, gentle soap, and lotion can prevent further dryness. Option 4: OTC decongestants cause further dryness of mouth and nasal mucosa and should be avoided. Option 5: Sjögren's syndrome causes vaginal dryness.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply. 1. 38-year-old with methicillin-resistant Staphylococcus aureus 2. 42-year-old with Clostridium difficile diarrhea 3. 69-year-old with pertussis infection 4. 72-year-old with vancomycin-resistant Enterococcus 5. 80-year-old with influenza

1, 2, 4 Contact precautions include: private room or shared with same infection, dedicated equipment, PPE (gloves and gown), and proper hand hygiene (not alcohol). Options 1, 2, 4: Infections that require contact precautions include any drug-resistant bacteria (MRSA, VRE), c. diff, and scabies. Options 3, 5: Clients with pertussis (whooping cough) or influenza will need droplet precautions.

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply. 1. Gloves when contact with body fluids is anticipated 2. Gloves when starting an intravenous line 3. Gown, gloves, face shield, and goggles for every client encounter 4. Hand hygiene before and after providing client care 5. N95 respiratory mask and face shield

1, 2, 4 HIV is a blood-borne virus that attacks the body's immune system and can lead to AIDs without antiretroviral therapy. Options 1, 2: Gloves are worn when there is any potential contact with blood or body fluids. Option 3: Gowns, face shields, and goggles are only worn when there is potential for splashing. Option 4: Hand hygiene should be performed before/after client care regardless of diagnosis. Option 5: HIV requires standard precautions only. It is not spread through droplet or airborne, so an N95 mask is not necessary.

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. 1.Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 2.Pull glove off over the soiled dressing to encase it before disposal 3.Save unused sterile 4 x 4's by taping original package shut for the next dressing change 4.Wash hands prior to putting on gloves and after removing them 5.Wrap soiled dressing in paper towels before disposing of it in the trash can

1, 2, 4 Option 3: This package of 4x4's is no longer sterile and can no longer be used for sterile dressing changes once opened. Option 5: Soiled linens need to be placed into specially marked containers indicating they are biohazard.

A parent calls the nurse telehealth triage line with concerns about an allergic reaction to something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? Select all that apply. 1. Dyspnea 2. Fever 3. Lightheadedness 4. Skin rash (hives) 5. Wheezing

1, 3, 4, 5 Anaphylaxis is a severe allergic reaction that occurs soon after exposure to an allergen. It causes vasodilation, which leads to tissue edema, hypotension, etc. Treatment includes IM epinephrine (vasoconstriction), airway management, and volume resuscitation, along with antihistamines and glucocorticoids to decrease inflammatory response. Options 1, 5: Anaphylaxis causes tissue edema, leading to a compromised airway (stridor, wheezing, bronchospasm). Option 2: Anaphylaxis does not cause a fever. Option 3: Lightheadedness is caused by hypotension, which in turn also causes tachycardia. Option 4: Hives, pruritus, and flushing also occur with anaphylaxis.

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply. 1.Cleanse periurethral area with antiseptics every shift 2.Ensure each client has a separate container to empty collection bag 3.Keep catheter bag below the level of the bladder 4.Routinely irrigate the catheter with antimicrobial solution 5.Use sterile technique when collecting a urine specimen

2, 3, 5 Option 1: Routine perineal hygiene should be completed each shift and after bowel movements with soap and water, not antiseptic. Consistent use of antiseptic may lead to development of drug-resistant bacteria. Option 2: Separate containers per patient will prevent spreading bacteria to other patients. Option 3: The catheter bag should be kept below the bladder to prevent backflow of urine. It also needs to be kept off the floor, and avoid any kinks. Option 4: Regularly irrigating the catheter may introduce bacteria into the ureters and bladder and cause an infection. Option 5: Sterile technique. Duh.

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB). Which option best describes the care the nurse provides on this program? 1. Follows the client until 3 sputum cultures are normal 2. Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits 3. Provides and watches the client swallow every prescribed medication 4. Screens all of the client's close contacts

3 Noncompliance with the treatment plan is a major problem in treating TB due to the length of time drug therapy is required (usually about 6 months) and the associated unpleasant side effects. DOT is an effective patient-centered treatment strategy developed by the World Health Organization that increases compliance with drug therapy, prevents reinfection and the development of multi-drug resistant TB strains, and controls the spread of TB disease worldwide. TB is curable if the client completes the prescribed medication regimen.

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care? 1. Assess the client's feelings about placement at a skilled nursing facility for care 2. Educate the client on the risks of tissue death if not properly cared for at home 3. Explore the client's abilities and motivation to perform care at home 4. Provide the client with the supplies needed to change dressings as recommended

3 The nurse must first identifies the barriers to self care (physical ability, knowledge, motivation) prior to any interventions.

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure. Select all that apply. 1.Discard the first 6-10 mL of blood drawn from the line 2.Flush the line with sterile normal saline before and after collection 3.Perform hand hygiene 4.Place the specimen in a biohazard bag 5.Scrub the catheter hub with antiseptic prior to use

3, 4, 5 Option 1: Wasting the first ~10 ml of blood will prevent inaccurate lab results, but it doesn't affect transmission of infections. Option 2: Flushing the line with NS assists with checking for patency prior to blood draw, and will clear the line after the draw to prevent blood from clotting in the line. It doesn't affect transmission. Option 3: Hand hygiene is the #1 way to prevent transmission of infectious diseases. Option 4: Blood and body fluids are hazardous materials. A special biohazard container alerts staff of this and ensures people take steps necessary to prevent exposure when handling these. Option 5: Scrubbing the hub will help prevent transmission of infection to the client from any pathogens on the syringes.

A female client comes to the clinic with a suspected lower urinary tract infection; urinalysis confirms a diagnosis of cystitis. Which symptoms reported by the client would be most consistent with this condition? Select all that apply. 1. Chills and vomiting 2. Flank pain 3. Painful urination 4. Urinary frequency 5. Urinary urgency

3, 4, 5 Urinary tract infections (UTIs) are bacterial infections that begin at perineal area enter the urethra, causing inflammation and infection (urethritis). The infection can that ascend into the bladder (cystitis), and eventually work its way up into the kidneys (pyelonephritis). Options 1, 2: These are symptoms of pyelonephritis and is much more serious. Symptoms can include N/V, fever, chills, and flank pain. Options 3, 4, 5: Cystitis causes inflammation of the bladder mucosa and ureters, causing painful urination, urinary frequency, urinary urgency, hematuria, and suprapubic discomfort.

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? Select all that apply. 1. Client is on a calorie-restricted diet for obesity 2. Creatinine is 1.3 mg/dL 3. History of congenital heart disease 4. International Normalized Ratio of 2.5 5. Presence of prosthetic valve

3, 5 Clients with heart defects such as congenital heart disease or a prosthetic valve are at risk for developing infective endocarditis (infection of the endothelial lining of the heart) with certain surgeries. These patients needs to be on prophylactic antibiotics prior to surgery. Option 1: A calorie-restricted diet will have no impact on oral surgery. Option 2: A creatinine of 1.3 is within normal limits (0.6-1.3 mg/dL). Options 3, 5: Heart disorders put clients at an increased risk for IE with certain oral surgeries. Option 4: Patients on anticoagulants will have an increased INR (therapeutic range for warfarin is 2-5, normal is <1). This puts them at an increased risk for bleeding, but they are still in normal therapeutic range and the risk isn't as severe as IE.

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply. 1. Applies sterile gloves before performing client care 2. Ensures surgical masks are worn by staff in the client's room 3. Requests that the client be assigned to a single-client room 4. Uses alcohol-based sanitizers for hand hygiene 5. Wears a single-use, disposable gown during client care

3, 5 Clostridium difficile is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client with C difficile, it is critical that the nurse implement contact isolation precautions to prevent transmission of microorganisms Option 1: Only clean gloves are necessary. Option 2: C. diff requires contact precautions, not droplet (droplet requires a surgical mask) Option 3: Surfaces can become contaminated with C. diff, so the client needs to be in their own room to prevent spreading it to another patient. Option 4: Soap and water is much more effective at cleaning hands, and must be used with C. diff. Option 5: With contact precautions, a gown and gloves are required. This client will also require dedicated equipment that remains in their room.

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply. 1. "I use a soft-bristle toothbrush and mild mouth rinse." 2. "I enjoy walking and wear nonskid footwear for safety." 3. "I use a safety razor and gentle shaving cream." 4. "Sometimes I get constipated, so I have been taking docusate." 5. "When I have a headache, I take over-the-counter ibuprofen."

3, 5 Immune thrombocytopenic purpura is an autoimmune condition in which antibodies destroy platelets, leading to a low platelet count (<150,000 mm3). These patients are at an increase risk for bleeding. Option 1: Soft bristle brushes and mild (non-alcoholic) mouth washes will decrease risk of gum bleeding. Option 2: Patients should avoid high activity/rough exercises that increase the risk of injury and bleeding. Option 3: Safety razors cause micro-abrasions and can still cause larger cuts. Electric razors should be used. Option 4: Taking stool softeners and laxatives can prevent straining, which can cause anorectal fissures and hemorrhoids (which cause bleeding). Option 5: NSAIDs like ibuprofen decrease platelets and increase the risk of GI bleeds. Acetaminophen and opioids are a better option for pain management.

The nurse is preparing educational materials about histoplasmosis for a group of nursing students. Which teaching point is appropriate for the nurse to include? 1. Histoplasmosis infection causes pink or purple spots to develop all over the client's skin 2. Histoplasmosis infection usually causes serious illness and often requires hospitalization 3. Histoplasmosis is a bacterial infection that is spread through the air from an infected person 4. Histoplasmosis is an opportunistic infection that occurs in clients who are immunocompromised

4 Histoplasmosis is an opportunistic fungal infection that most commonly occurs in clients with compromised immunity due to medical conditions (eg, HIV, malnutrition) or immunosuppressant medications. Option 1: Pink or purple lesions is indicative of Kaposi sarcoma; a form of cancer that affects immunocompromised clients with HIV. Option 2: Histoplasmosis is usually asymptomatic and usually does not require treatment. If symptoms do develop, they may include mild pneumonia-like symptoms (fatigue, fever, dyspnea, cough). Option 3: Histoplasmosis is a fungal infection, not bacterial. It spreads through inhalation of spores found in soil that contains bird or bat dropping. Option 4: Although usually asymptomatic or mild symptoms, repeated exposure in patients who are immunocompromised may develop chronic pulmonary infections, requiring hospitalization.

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? 1. 15-year-old student athlete in the emergency department with a fractured femur 2. 46-year-old with a large abdominal incision and 2 peripheral IV lines 3. 72-year-old who received a permanent pacemaker 24 hours ago 4. 80- year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator

4 MRSA is a bacterial infection that requires contact precautions. Clients most at risk of infection are the elderly, immunosuppressed, long history of antibiotic use, and/or LDA (lines, drains, airways). Option 1: MRSA is spready through contact, so this client could have gotten it from a locker room. In this age group, it most commonly appears as a skin infection. Option 2: This client does have 2 IV lines and a portal of entry (abdominal incision), but is not elderly. Option 3: This client is elderly and does have an incision from the pacemaker placement, but the incision is small. Option 4: This client is elderly and with a chronic illness (immunosuppressed), and is on an airway. Patients with COPD require antibiotic and corticosteroid treatments, as well.

The nurse reviews the most current laboratory results of assigned clients. Which result should the nurse report to the health care provider immediately? 1. Client who has cellulitis of the leg with a white blood cell (WBC) count of 13,000/mm3 2. Client who has chronic kidney injury with a hematocrit of 28% and hemoglobin of 9 g/dL 3. Client who has type 2 diabetes mellitus with a 2-hour postprandial serum glucose of 165 mg/dL 4. Client who is 1 month post kidney transplant with a urinalysis showing WBCs and bacteria

4 Option 1: Cellulitis is a bacterial infection of subcutaneous tissue. An elevated WBC is expected. Normal WBC count is 4,000-11,0000 mm3. Option 2: Kidneys produce erythropoietin; a hormone that stimulates bone marrow to produce erythrocytes. With kidney dysfunction, lower RBC, Hct, and Hgb are expected. Option 3: A postprandial (after meal) serum glucose of 165 mg/dL would be expected with a patient with DM. For run-of-the-mill hospital patients (i.e. not critically ill), the goal for serum glucose is <140 mg/dL. Option 4: Patients with organ transplants are placed on immunosuppressants (Prednisone, cyclosporine) to prevent organ rejection, and are at a higher risk for infection. Early recognition and prompt treatment reduces the risk of serious complications.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery? 1.Hemoglobin 15 g/dL, hematocrit 45% 2.International Normalized Ratio (INR) 1.3 3.Platelet count 295,000/mm3 4.Temperature 100.4 F (38 C) with cough

4 Option 1: Hgb and Hct are within normal limits (Hgb 14-18 M, 12-16 F; 40-50% M, Hct 35-45% F) Option 2: An normal INR is <1, and 2-3 if they are on warfarin therapy. This is only slightly above normal, so their bleed risk is only slightly elevated. Option 3: Normal platelet count is 150-400,000 mm3. Option 4: A temperature of 100.4 F with cough indicates an infection or illness. Use of anesthesia in this condition can exacerbate the unknown condition and increase the risk of post-op pneumonia.

Laboratory results: White blood cells 1,100/mm3 Absolute neutrophil count 400/mm3 Hemoglobin 8.2 g/dL Platelets 78,000/mm3 The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? 1. Administer erythropoietin injection 2. Minimize venipunctures and avoid intramuscular injections 3. Place sequential compression devices (SCDs) to the legs 4. Provide a private room and neutropenic precautions

4 Option 1: Normal hemoglobin is 14-18 male and 12-16 female. His hemoglobin level shows moderate anemia. Option 2: Venipunctures and IM injections can cause prolonged bleeding in patients with thrombocytopenia and should be avoided if platelet count falls below 50,000/mm3. Normal platelet count is 150,000-400,000 mm3. Option 3: This client would need SCDs since their platelet count is so low, they cannot be on anticoagulant therapy. However, it's not the priority intervention. Option 4: This patient's WBC count is low (normal 4,000-11,000 mm3) and neutropenic (normal 2000-8000 mm3). They are at a higher risk of infections and need to be under neutropenic precautions (no fresh produce, no flowers, private room, strict handwashing).

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection? 1. Assist the client to the shower and provide directions to use antibacterial soap 2. Delay the bath until the client has received antibiotic therapy for 24 hours 3. Use a bath basin with warm water and a new wash cloth for each body area 4. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client

4 Option 1: This client has a surgical incision that needs to remain dry; this will be difficult to do in the shower. Also, patients in the ICU tend to have lines or equipment that will prevent showering. Option 2: Bathing should only be delayed if the patient's condition is unstable. Bathing can prevent skin infections and keep the incision clean. Option 3: The water needs to contain a chlorohexidine solution when bathing a client with MRSA. Option 4: The current recommendation for clients with MRSA or other drug-resistant organisms is to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection.

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1.Isolation gown, surgical mask, goggles, and gloves 2.Isolation gown and surgical mask 3.N95 respirator mask 4.Surgical mask

4 Patients with TB are under airborne precautions and must remain in negative air pressure rooms except during transportation. The client must wear a surgical mask to prevent spreading the illness, but nothing else. Healthcare workers treating this patient must wear an isolation gown, gloves, and an N95 mask.

The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room? 1. Child with chickenpox for the past 14 days; all lesions are crusted and dried 2. Child with impetigo who has been on antibiotics for 3 days 3. Child with leg rash secondary to poison ivy exposure 4. Child with suspected pertussis who has paroxysms of coughing

4 Pertussis (whooping cough) is a bacterial infection that causes severe, rapid coughing, which leads to vomiting. Option 1: Chickenpox is no longer contagious once the lesions have crusted and dried; this can take up to 3 weeks. Option 2: Impetigo (bacterial infection of the skin that is more common in young children) is no longer contagious 24 hours after antibiotic therapy begins. Option 3: Poison ivy is not considered contagious; the pustules do not contain the urushiol oil, so the rash cannot be spread to another person. Option 4: Pertussis is highly contagious and can be deadly; it requires droplet precautions.

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action? 1. Holds the package 6" (15 cm) above the sterile field and drops the sterile gauze onto the field 2. Opens the sterile gauze package with ungloved hands 3. Places the sterile gauze dressings within 1" (2.5 cm) from the edge of the sterile drape 4. Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago

4 The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions' policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution.

The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used. 1. Remove the gown and gloves without contaminating hands 2. Exit the negative-pressure room and close the door 3. Remove the N95 respirator mask and perform hand hygiene 4. Discard the gown and gloves and perform hand hygiene 5. Place the call light within the client's reach

5, 1, 4, 2, 3 Order of PPE removal should be from most to least contaminated. The nurse also needs to take into consideration the type of precautions. Option 5: The call light is contaminated, so the nurse needs to be in full PPE when touching it. Option 1: The gown and gloves are the most contaminated PPE and should be removed first; this needs to be done in the patient's room to prevent contamination outside of the room. Option 4: Hand hygiene should be performed after removing gown and gloves, as skin exposure was possible during removal. Option 2: While keeping the N95 respiratory on, the nurse should leave the room. Option 3: Because this patient is also on airborne precautions, the N95 respirator needs to stay on until the nurse leaves the patient's room.

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply. 1.Keep dedicated equipment for client 2.Perform hand hygiene before exiting the room 3.Place a "No Visitors" sign on the client's door 4.Wear a face mask when in the room 5.Wear an isolation gown when providing direct care

1, 2, 4, 5

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used. 1. Gloves 2. Goggles or face shield 3. Gown 4. Hand hygiene 5. Mask or respirator

Hand hygiene → gown → mask → goggles → gloves

The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD). The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated. Which prescription is of concern and prompts the nurse to notify the health care provider (HCP)? 1. Lansoprazole 2. Metronidazole 3. Prednisone 4. Sulfasalazine

Option 1: Lansoprazole is a proton pump inhibitor that treats and peptic ulcers and GERD. Option 2: Metronidazole is an antibiotic that treats IBD Option 3: TB never goes away, so a patient who had active TB in the past now has latent TB. Immunosuppressing drugs like corticosteroids (Prednisone) can cause the TB to activate, in which case symptoms will present and it can be spread to others. Option 4: Sulfasalazine is a disease-modifying antirheumatic drug (DMARD) that is anti-inflammatory and used to treat IBD.

A clinic nurse examines a client with a tentative diagnosis of primary Sjögren's syndrome. Which finding observed by the nurse would most likely be associated with this syndrome? 1. Dry eyes and mouth 2. Low back stiffness 3. Multiple tender points 4. Thickening of the skin

1 Sjögren's syndrome is an autoimmune condition that causes inflammation of the exocrine glands, resulting in decreased production of tears and saliva.

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply. 1.Disinfect surfaces with diluted bleach solution 2.Hand hygiene with alcohol-based hand rub 3.Wear a face mask 4.Wear a protective gown 5.Wear nonsterile gloves

1, 4, 5 Clients with c. diff should be placed under contact precautions, which includes gloves and gown. Surfaces need to be disinfected, and alcohol-based hand hygiene is not effective at eliminating c. diff; soap and water only.

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle. The client has HIV infection. Place in order the steps the nurse should take. All options must be used. 1. Remove gloves 2. Go to employee health clinic 3. Notify the nurse's supervisor 4. Take postexposure prophylaxis 5. Wash area with soap and water

1, 5, 3, 2, 4

The nurse is caring for a 76-year-old client newly admitted with pneumonia and Clostridium difficile infection. Which of the following would be priority to report to the health care provider? 1. Blood gas results of PO2 80 mm Hg, pCO2 35 mm Hg , pH 7.38 2. BUN of 29 mg/dL, potassium of 3.3 mEq/L, sodium of 132 mEq/L 3. Coarse crackles in lung bases with moderate sputum production 4. Fever of 100.6 F and reports of chills and fatigue

2 A C. diff infection is caused by an overgrowth in the intestine when normal GI flora is destroyed (usually from antibiotic use). Symptoms are usually watery diarrhea, nausea, fever, and abdominal pain. Option 1: PO2 80 mmHg is normal (>80-100 mmHg), pCO2 of 35 mmHg is normal (35-45 mmHg), and pH 7.38 is normal (7.35-7.45) Option 2: The patient is hypokalemic (normal potassium 3.5-4.5 mEq/L), hyponatremic (normal sodium 135-145 mEq/L), and BUN is elevated (normal 6-20 mg/dL). The client is showing signs of hypovolemia and an electrolyte imbalance. Options 3, 4: Coarse crackles, sputum, fever, chills, and fatigue are all expected finding of pneumonia.

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse? 1.Applying a warm compress to the affected extremity 2.Maintaining the affected leg flat on the bed 3.Marking and dating the reddened areas 4.Wearing a gown and gloves while bathing the client

2 Cellulitis is inflammation of the subcutaneous tissues caused by bacteria. It can be caused by an insect bite, cut, abrasion, or open wound and is characterized by redness, edema, pain, and fever. Option 1: Applying a warm compress will promote circulation, alleviate discomfort, and reduce edema. Option 2: The affected leg should be raised to promote lymphatic drainage and reduce edema. Also, weeping wounds should be protected from long exposure to moist/soiled linens to promote tissue integrity. Option 3: Marking/dating the reddened areas can assist with monitoring improvement or worsening of the condition. Option 4: Standard precautions are sufficient for general care with cellulitis, but gloves and gown should always be worn if there is any potential contact with body fluids.

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? 1. Face shield/goggles 2. Gloves 3. Gown 4. Mask/respirator

2 Gloves should be removed first to prevent contamination of other items. Goggles should be removed next, followed by gown, then mask.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. 1.Ensuring the client wears an N95 respirator at all times 2.Keeping the door of the client's room closed at all times 3.Maintaining a log of everyone in and out of the client's room 4.Removing both pairs of gloves before removing gown and mask 5.Restricting visitors from entering the client's room

2, 3, 5 Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed. Option 1: Ebola requires airborne precautions. Option 2: Patients on airborne precautions will usually be in a negative air pressure room and the door needs to be kept shut. Option 3: Keeping a log is necessary for disease surveillance; all logged individuals are monitored for symptoms. Option 4: The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE and removed last. Option 5: Visitors are prohibited unless absolutely necessary for the client's well-being.

The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for further instruction? 1. "I can stop taking these HIV drugs once my viral levels are undetectable." 2. "I need to get tested regularly for sexually transmitted infections because I'm sexually active." 3. "I should use latex condoms and barriers when having anal, vaginal, or oral sex." 4. "I won't stop injecting drugs, but I will use a needle exchange program."

1 Antiretroviral therapy (ART) is a multi-drug medication regimen that prevents progression of HIV, reducing viral load and increasing CD4 (helper T cell) count. Option 1: Discontinuation, or poor adherence, to ART results in progression of HIV and may lead to AIDS. Options 2, 3, 4: Patients with HIV are immunocompromised and need to reduce exposure to pathogens whenever possible.

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? 1.Femoral line inserted in emergency department post cardiac arrest 48 hours ago 2.Internal jugular line inserted 6 days ago in operating room 3.Peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago 4.Subclavian line with slight redness at anchor suture sites inserted in intensive care unit 72 hours ago

1 Option 1: Femoral lines are not ideal, as they cannot be kept clean due to urine or feces, and they are difficult to keep an occlusive dressing over them. Options 2, 4: Upper body vessels (jugular, subclavian) are the preferred sites for CVCs because they are easier to keep clean. These lines were inserted using sterile technique in sterile environments (OR, ICU). Option 3: PICCs can be left in for up to one year. The occlusion of one lumen does not necessitate removal or increase risk of infection.

The clinic nurse performs an admission assessment on a client diagnosed with systemic lupus erythematosus (SLE). Which characteristic cutaneous manifestation of SLE would the nurse most likely assess? 1. Butterfly shape rash 2. Petechiae 3. Pruritus 4. Urticaria

1 SLE is an autoimmune disorder in which the body's immune system attacks tissues and cells. The skin is a common target organ to be attacked. Option 1: Butterfly shape rash on the face and is a characteristic manifestation of SLE. It is more pronounced during flare-ups of the disease. Option 2: Petechiae are pinpoint, round spots that appear on the skin as a result of bleeding. They are not specific to SLE. Option 3: Pruritus is itchy skin and is not specific to SLE. Option 4: Urticaria (hives) occur as the body's response to allergens. This is not specific to SLE.

The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? 1. Abrupt-onset hypertension and headache 2. Blue and cold fingertips 3. Dry cough and exertional dyspnea 4. Heartburn and difficulty swallowing

1 Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. It's progressive and there is no cure. Option 1: Narrowing of vessels is a complication of scleroderma, and can cause renal crisis if kidney vessels are constricted. Acute organ failure can occur. Option 2: Blue, cold fingertips can be caused by Raynaud's phenomenon; this can occur secondary to scleroderma and is caused by vasospasm. It requires urgent treatment to prevent (immersing hands in warm water) to prevent tissue damage, but it's not life-threatening. Option 3: Scleroderma can cause pulmonary fibrosis, which causes dry cough and dyspnea. O2 may be required for comfort, but it's not life-threatening. Option 4: Heartburn and dysphagia are common symptoms of scleroderma.

The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus. Which result is of greatest concern and prompts the nurse to notify the health care provider? 1. Creatinine of 1.8 mg/dL 2. Elevated erythrocyte sedimentation rate 3. Positive antinuclear antibody titer 4. White blood cell count of 3,600/mm3

1 Systemic lupus erythematosus (SLE) is an autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body. SLE ranges in severity from mild (eg, affecting skin, muscles, joints) to severe (eg, affecting kidneys, heart, lung, blood vessels, central nervous system) disease. Option 1: Increased creatinine (normal 0.6-1.3 mg/dL), BUN (normal 6-20 mg/dL), and an abnormal urinalysis (positive for protein, RBCs) indicate lupus nephritis. This can be life threatening and needs to be treated with aggressive immunosuppressive meds to prevent irreversible kidney damage. Option 2: An ESR (normal<30 mm/hr) is a test that measuresthe rate at which RBCs descend in a tube over a 1 hour period. It's a non-specific measure of inflammation, and an elevated ESR would be expected in SLE. Option 3: Antinuclear antibodies target a misdirected attack at your own proteins and are a sign of autoimmune disorders. A positive ANA is expected with SLE. Option 4: Mild leukopenia (<4000 mm3), anemia (<12 F, <14 M), and thrombocytopenia (<150,000 mm3) are expected findings in SLE.

The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV. Which of the following statements by the client indicates a need for further education? Select all that apply. 1. "I don't have to use protection if my sexual partner is also HIV positive." 2. "I have to make sure my family knows not to borrow my razors." 3. "I need to avoid eating raw or undercooked meats and eggs." 4. "I started to use lambskin condoms during sex, as I have a latex allergy." 5. "I won't reuse or share any needles or syringes that I use to inject heroin."

1, 4 HIV (human immunodeficiency virus) is a viral infection of the CD4+ (Helper T) cells and results in progressive immune system impairment. Option 1: HIV has multiple strains, so two HIV positive people can still infect one another. Option 2: HIV is transmissible through blood and increases risk fo HIV exposure if razors are shared. Option 3: Undercooked meats and eggs contain pathogens that can increase risk for infection. Option 4: Natural barriers like lambskin o not prevent STI transmission due to presence of small pores. Option 5: Sharing or reusing needles increases the risk of new infections or infecting others.

An elderly client has a 17-mm induration after a tuberculin skin test (TST). Based on this result, which statement is most accurate? 1. The client has a false-positive reaction due to advanced age 2. The client has a tuberculosis (TB) infection 3. The client has active TB disease 4. The client must be isolated immediately

2 Option 1: The elderly have decreased immunity, and may be unable to develop antibodies to react to the intradermal tuberculin, leading to a false-negative. Option 2: Any induration >15 mm is a positive result and the client is infected with TB. They must now follow-up with a chest x-ray to see if their TB is latent or active. Option 3: A chest x-ray is necessary to determine if the TB is active; if so, the client can develop symptoms and his disease will be contagious. Option 4: Isolation will be required only if the TB is active.

The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis? 1. A client with asthma who uses an albuterol nebulizer once a day 2. A septic client receiving intravenous broad-spectrum antibiotics daily 3. A teenage client with braces who drinks several sugary drinks daily 4. An elderly client with poor oral hygiene and inadequate nutrition

2 Oral candidiasis (also known as thrust) is a yeast infection of the mucous membranes caused by Candida albicans. It is treated with antifungal medications (Nystatin) and good oral hygiene. Option 1: Nebulizers containing a corticosteroid increase the risk of thrush; clients should rinse out their mouth after each use. However, nebulizers containing albuterol (a bronchodilator) are not at an increased risk. Option 2: A client who is immunocompromised (such as with septic, is at an increased risk of infections. Also, the use of antibiotics kills certain bacteria, allowing opportunistic infections to arise. Options 3, 4: Inadequate nutrition, poor nutrition, and poor oral hygiene are at an increase risk of oral infections, but not as much risk as someone who is immunocompromised.

The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? 1. 4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and inner elbows 2. 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash 3. 12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose 4. 14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-resistant Staphylococcus aureus

2 Patients with diseases that are the most contagious (i.e. airborne) should be placed in isolation rooms (negative air pressure, high efficiency filtration systems). Option 1: Scabies would require contact precautions. Option 2: Measles is highly contagious and requires airborne precautions. Option 3: Influenza requires droplet precautions. Option 4: MRSA requires contact precautions. This patient should also be under isolation precautions, but measles is the priority.

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? 1. A private room with contact and droplet precautions 2. A private room with negative airflow and contact and airborne precautions 3. A private room with positive airflow and airborne precautions 4. A semi-private 2-bed room with standard precautions

2 Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy), or with advanced age. When the lesions are open (disseminated), they may transmit infection via both air and contact.

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Clarify the prescription for oseltamivir with the health care provider 2. Instruct the client to cover the mouth and nose while coughing or sneezing 3. Place a mask on the client when transporting the client through the halls 4. Plan discharge teaching about the importance of annual influenza vaccination 5. Use contact precautions when providing care for the client

2, 3, 4 Influenza (flu) is a contagious viral infection that affects the respiratory tract. Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise. Option 1: Oseltamivir (Tamiflu) are given to treat clients within 48-72 hours of the onset of symptoms. They inhibit viral reproduction and can shorten the duration of illness. Options 2, 3: Flu is spread through droplets, so covering nose/mouth when coughing and wearing a mask can help prevent transmission. Option 5: Patients with the flu should be placed on droplet precautions, not contact.

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? 1.Antecubital fossa 2.Dorsal surface of hand 3.Dorsum of foot 4.Lateral surface of wrist

2 This client is at a higher risk of infection due to his compromised immunity from malnourishment and pneumonia. Option 1: The AC is commonly used in the ER due to its size and ease of cannulation, but occlusion occurs when the elbow is bent; bending the arm moves the catheter, increasing risk for infection. Option 2: The hand is the most dorsal site, allowing for future sites up the arm as needed for future IVs. Option 3: Veins in the lower extremities may have decreased venous return. Option 4: The radial vein is close to many nerves; nerve damage may occur.

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply. 1. Avoid annual influenza vaccination 2. Avoid situations that cause physical and emotional stress 3. Avoid sun exposure and ultraviolet light when possible 4. Notify the health care provider if you have fever 5. Use antibiotic soap to cleanse skin rashes

2, 3, 4 Systemic lupus erythematosus (SLE) is an autoimmune disorder that results in inflammation and damage to many body parts. Symptoms can include painful /swollen joints, extreme fatigue, skin rashes, and kidney problems. The symptoms typically appear for periods of time (called flares) alternating with periods of remission. Option 1: People with SLE are more susceptible to infections, so it's recommended they are vaccinated to prevent further illnesses. Option 2: Physical and emotional stress can exacerbate SLE, so exercise, adequate rest, and abstaining from smoking can help prevent flare-ups. Option 3: Sunlight can worsen rashes caused by SLE. Option 4: Fever is often the first sign of an infection. Option 5: Harsh soaps and chemicals should be avoided when cleaning SLE rashes.

The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client's WBC count has increased from 11,200/mm3 to 14,600/mm3 over the last 24 hours. The nurse understands that which of the following assessment findings indicate potential infection? Select all that apply. 1. Client rating left shoulder pain as 4 on a scale of 0-10 2. Greenish-gray drainage noted on surgical dressing 3. Productive cough with thick, green sputum 4. Stiff abdomen with rebound tenderness on palpation 5. Warm, reddened area around the incision site

2, 3, 4, 5 Cholecystectomy (removal of the gallbladder) is performed through laparoscopic or open surgery. Signs of postoperative infection typically appear 3-7 days after surgery. Systemic signs may include fever, elevated WBC count, and fatigue. Option 1: Referred left shoulder pain can occur post-op after a cholecystectomy due to diaphragmatic nerve irritation caused by the CO2 used to inflate the abdomen. Options 2, 5: Purulent drainage, edema, and redness, and warmth are all signs of a surgical site infection. Option 3: Productive cough with non-clear sputum may indicate pneumonia. This can occur due to decreased lung expansion post-op due to pain, opioids, anesthesia, and immobilization. Decreased lung expansion will lead to collapsed alveoli (atelectasis), which causes secretions to build up in lungs, which causes pneumonia. Option 4: Stiff abdomen with rebound tenderness indicate peritonitis, an infection of the peritoneal cavity around organs. This can cause sepsis and death if not treated.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? 1.Get the client out of bed and away from the radiation source 2.Manually reinsert the implant and notify the health care provider 3.Use long-handled forceps to secure the implant in a lead container 4.Wrap the implant in the linens and place it in a biohazard bag

3 An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies. Option 1: The client is already being emitted with radiation, so it's not an extra danger to them if it becomes dislodged. It's only dangerous to staff and visitors going into the room. Option 2: The nurse should not handle the radiation implant without forceps. Option 3: The nurse should secure the implant in a lead container using forceps (don't touch it), then contact the HCP to get it re-implanted. Option 4: Linens will not protect people from radiation.

A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash. What is the priority question for the nurse to ask the client? 1."Did the rash start after taking a new medication?" 2."Have you been keeping the rash covered?" 3."Have you ever had chickenpox?" 4."What have you tried to help the pain?"

3 Herpes zoster (Shingles) has a characteristic unilateral pattern of fluid-filled blisters. It occurs due to reactivation of the chickenpox virus, varicella-zoster. The chickenpox virus remains dormant in sensory nerves until immune compromise reactivates it. Before asking how the client has been treating the rash, the nurse needs to identify it. The fact that the rash is unilateral identifies it as Shingles, and not due to a new medication.

A nurse is discharging a client who has been hospitalized with streptococcal infective endocarditis (IE). Which statement by the client would indicate a need for further teaching? 1. "I may need prophylactic antibiotics before dental work." 2. "I should call my health care provider (HCP) or 911 right away if I notice my speech is slurred." 3. "I shouldn't be concerned if I continue to have a fever at home." 4. "I will expect a home health nurse to give me IV antibiotics for several more weeks."

3 Infective endocarditis is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel. Option 1: A client who has had IE is at risk for reoccurrence, and prophylactic antibiotics should be given for high risk procedures. Option 2: IE causes vegetation to form in valves of the heart, leading to embolization. Slurred speech indicates a stroke. Option 3: Reoccurring fever may indicate the antibiotic therapy was ineffective. Option 4: Antibiotic therapy for IE should last for 4-6 weeks. The client will be placed on a PICC line and antibiotic therapy can continue at home through a home health nurse.

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 1. 51 y.o. client who received a permanent pacemaker 48 hours ago 2. 60 y.o. client who had a myocardial infarction 24 hours ago 3. 74 y.o. client with stroke and an indwelling urinary catheter for 3 days 4. 75 y.o. client with dementia and dehydration who is on IV fluids

3 Option 1: This client is not elderly, and the incision to place the pacemaker was small. Option 2: If this client did not have surgery following MI, then he has no open wounds and is low risk. Option 3: This client is elderly and has a port of entry for bacteria (foley catheter). Option 4: This client is elderly and has a port of entry for bacteria (IV line), but the foley is a larger risk factor than an IV.

The client with suspected active pulmonary tuberculosis (TB) has a positive tuberculin skin test (TST). Which prescription from the health care provider does the nurse anticipate will confirm the diagnosis in this client? 1. Collect 2 blood cultures from different intravenous sites after cleansing with a chlorhexidine swab 2. Collect 2 early morning nose specimens (swabs) from each nare using sterile culturettes 3. Collect an early morning sterile sputum specimen on 3 consecutive days 4. Collect blood for the QuantiFERON-TB test after cleansing the site with a chlorhexidine swab

3 Options 1, 4: Both a TST and a QuantiFERON-TB test can detect tuberculosis antibodies, but it won't confirm if it's latent or active. Option 2: Nose cultures can detect MRSA, but not TB. Option 3: If TB is active, it will be in the lungs. Another method to determine if TB is active is a chest X-ray.

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF). Which question is most important for the nurse to ask to establish a diagnosis? 1. "Do you typically take all your antibiotics when they are prescribed?" 2. "Has anyone in your family had rheumatic fever?" 3. "Have you recently had a streptococcal throat infection?" 4. "What has your temperature been over the past several days?"

3 RF is an acute inflammatory disease of the heart and can occur 2-3 weeks after a strep throat infection. It can also affect the CNS, skin, and joints. Option 1: Failing to complete antibiotic therapy can lead to reoccurrence of illness, but it would not establish a diagnosis. Option 2: Rheumatic fever is not contagious. Option 3: RF is an autoimmune reaction caused from anti-streptococcal antibodies, developed during a strep infection. Option 4: Fever is a symptom of many illnesses and does not indicate RF.

The nurse assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration. The client has no symptoms. Which action will the nurse take next? 1. Document the negative response in the client's medical record 2. Have the client return in a week to receive a second injection 3. Obtain a prescription for the client to have a chest x-ray 4. Place the client in an airborne-infection isolation room

3 The PPD (Mantoux) test screens for tuberculosis by injecting tuberculin intradermally. If there is induration (raised area) of >15 mm 24-48 hours later, then the result is positive. Option 1: A 16 mm induration is a positive result, indicating the client has been exposed to TB and has developed an immune response. It does not be the client has active TB, however. Option 2: A second injection is only given if the results were negative and is done to double check the results. Option 3: The next step after a positive PPD is to have a chest X-ray completed to confirm if the client has active TB. Option 4: The client would be placed in an airborne infection room only if the chest x-ray shows active TB.

The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine. What information will the nurse include in the teaching plan? 1.Adhesive bandaging should remain on the lesions to prevent virus shedding 2.Blood tests will be drawn to ensure the virus is eradicated 3.Condoms should be used during intercourse until the lesions are healed 4.Gloves should be used to apply the medication to the lesions

4 Acylclovir is a drug that shortens the duration and severity of active herpes lesions; Genital herpes is a sexually transmitted infection and is highly contagious, especially when the lesions are active. Option 1: The lesions need to be kept clean and dry. They can be cleansed with warm water and soap, but not bandaged. Option 2: The herpes virus cannot be eradicated. Option 3: Abstinence is indicated when the lesions are active. When dormant, condom use is indicated. Option 4: Even if the patient is applying topical creams to their own lesions, they should wear gloves, as the fluid from the lesions can spread the infection.

The nurse teaches a group of homeless community clients preventive measures related to transmission of hepatitis A. Which of these measures would the nurse teach as the priority precaution to prevent transmission? 1. Do not share needles when injecting drugs 2 Practice safe sex by using condoms 3. Receive the hepatitis A vaccine 4. Wash hands after bowel movements and before eating

4 Hepatitis A is a viral infection that most commonly occurs through the fecal-oral route. The virus reproduces in the liver and is in bile. Options 1, 2: Hep A is rarely transmitted through blood or sexual contact; this would be the likely transmission route of Hep B. It is not the best method to prevent transmission. Option 3: The Hep A vaccine is recommended for everything >1 year old and adult at risk (healthcare workers, homosexual men, drug users, travelers to Hep A prevalent areas, people with liver diseases). Option 4: Hygienic measures and proper food preparation are the most effective ways at preventing Hep A transmission.

The nurse should consider which of the following client reports as an indication of an allergic reaction? 1. "I can't eat broccoli or cabbage when I take my warfarin." 2. "I get a headache when using my nitroglycerine patch." 3. "My feet swell when I take felodipine." 4. "My lips swell when I eat bananas or avocados."

4 Option 1: Warfarin inhibits vitamin K-dependent clotting factors, making blood clot less. Vitamin K-rich foods (broccoli, cabbage) will reduce the effects of warfarin. Option 2: Nitro is a vasodilator. Dilation of cerebral vessels can cause headaches. Acetaminophen (Tylenol) can be used to treat this side effect. Option 3: Felodipine is a calcium channel blocker that causes vasodilation. Peripheral edema is an expected side effects. The client should elevate the legs and use compression stockings. Option 4: Swelling lips is a sign of an allergic reaction. Bananas and avocados share a protein found in latex; it's possible that an allergic reaction to these foods indicates an allergy to latex.

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? 1. Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C 2. Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection 3. Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis 4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

4 Options 1, 3: Hepatis C and HIV infection are both standard precautions. Osteomyelitis and DKA are not infectious diseases and do require any special precautions. Option 2: COPD is not an infectious disease and does not require special precautions. Latent TB is also not infectious (however, if this were active TB, then this patient would require airborne precautions). Option 4: MRSA requires contact precautions, as this can be transmitted to others. Pneumonia can be contagious depending on its cause.

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? Select all that apply. 1. Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss

4, 5, 6 TB is an airborne bacterial infection that is usually pulmonary, but can be extrapulmonary (meninges, GU, GI, bone/joints). General symptoms (regardless of location) of TB are fever, night sweats, anorexia, and fatigue. Option 1: Dysuria (painful urinary) is a symptom of GU tuberculosis Option 2: Jaundice can be a symptom of TB affecting the liver, or it can be a side effect of TB drugs. Option 3: Back pain is a symptom of spinal TB. Options 4, 6: Night sweats and weight loss are general symptoms of any tuberculosis infection Option 5: Hemoptysis is a sign of late stage TB. Other pulmonary symptoms include cough, SOB, and dyspnea.