infection
The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial
Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between caring for different clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.
Which infection requires airborne precautions? Select all that apply. One, some, or all responses may be correct. 1 Measles 2 Influenza 3 Clostridium difficile 4 Bacterial meningitis 5 Methicillin-resistant Staphylococcus aureus (MRSA)
measles Varicella, measles, and tuberculosis require airborne precautions because these infections spread through small particles in the air. Droplet precautions are implemented to prevent the spread of influenza and bacterial meningitis. C. difficile and MRSA require the use of contact precautions.
Which information about infection prevention would the nurse include when planning discharge teaching for a client being treated with chemotherapy for leukemia? Select all that apply. One, some, or all responses may be correct. 1 "Wash hands before eating and after using the toilet." 2 "Take your temperature daily and report elevations of 1 °F (0.5 °C)." 3 "Avoid use of antimicrobial soaps when showering or bathing." 4 "Increase your daily intake of fresh fruits and vegetables." 5 "Clean your toothbrush daily by running it through the dishwasher." 6 "Read food labels to avoid added sodium in your diet."
"Wash hands before eating and after using the toilet." "Read food labels to avoid added sodium in your diet." Hand washing is essential to infection prevention and will be performed by the client and all caregivers and visitors. Even mild temperature elevation may indicate severe infection in the immunocompromised client and should be reported by the client to the health care provider. Toothbrushes should be cleaned daily in the dishwasher or with a bleach solution to reduce risk for infection. Antimicrobial soaps are recommended for immunocompromised clients, especially when cleaning the axillary and genital areas. Fresh fruits and vegetables carry bacteria; cooked fruits and vegetables generally are recommended for immunocompromised individuals. No salt or sodium restriction is needed for these clients.Test-Taking Tip: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment.
A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection. Which rationale explains the nurse's comment? 1 Poor personal hygiene is the cause. 2 Inadequate dietary intake is the cause. 3 The client's developmental level is the cause. 4 A procedure performed at the hospital is the cause.
A procedure performed at the hospital is the cause. An iatrogenic infection is one caused by health care providers or therapy. Poor personal hygiene, inadequate dietary intake, and the client's developmental level are not the causes of an iatrogenic infection.Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.
Which nursing action would increase the risk of infection for a client who has a wound? 1 Applying a wet dressing 2 Exposing the external surface of the dressing to air 3 Using absorbent dressing materials 4 Administering an enzyme preparation
Applying a wet dressing Wet dressings may promote the growth of organisms, leading to infection. The external surface of dressings is always exposed to the air; only the internal surface is facing the wound. Using absorbent dressing materials collects any drainage to be removed with future dressing changes. Enzyme preparations help promote dead tissue removal and should not cause infection.Test-Taking Tip: Be alert with the stem of the question. Recollect the concepts and apply the appropriate ones; reread the options until you are certain enough to conclude which option is the suitable one.
Which actions by a client who lives with family and has an upper respiratory infection indicate that the home health nurse's teaching about infection control has been effective? Select all that apply. One, some, or all responses may be correct. 1 Covering mouth with a forearm when coughing or sneezing 2 Putting tissues in a plastic bag after using them to cough 3 Avoiding talking or spending time with family members 4 Asking the health care provider for an antibiotic prescription 5 Using an alcohol-based hand sanitizer to wash the hands
Correct1 Covering mouth with a forearm when coughing or sneezing Correct2 Putting tissues in a plastic bag after using them to cough Correct5 Using an alcohol-based hand sanitizer to wash the hands Covering the mouth with a forearm when coughing or sneezing limits the spread of respiratory droplets that may be inhaled by others. Placing used tissues in a bag will prevent spread of microorganisms to environmental surfaces. Alcohol-based hand sanitizers help decrease spread of microorganisms to household contacts or environmental surfaces. Isolation of the client from other family members is unnecessary when other ways to limit the spread of microorganisms are used. Most upper respiratory infections are viral and the use of antibiotics should be avoided.
Which criteria would the nurse consider when determining if an infection is a health care-associated infection? 1 Originated primarily from an exogenous source 2 Is associated with a medication-resistant microorganism 3 Occurred in conjunction with treatment for an illness 4 Still has the infection despite completing the prescribed therapy
Occurred in conjunction with treatment for an illness Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a medication-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a medication-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.
When the nurse is caring for a diabetic client with a bacterial infection of the foot, which assessment finding indicates a need to activate the rapid response team? 1 Hypertonic bowel sounds in all 4 quadrants 2 Blood glucose level 145 mg/dL (8.1 mmol/L) 3 Client report of level 9 pain of the foot (0 to 10 scale) 4 Systolic blood pressure persistently 85 to 90 mm Hg
Systolic blood pressure persistently 85 to 90 mm Hg A systolic blood pressure less than 90 in a client who is at risk for sepsis (such as this client with a bacterial infection and diabetes) indicates possible sepsis and systemic inflammatory response syndrome (SIRS). The nurse would immediately activate the rapid response team and anticipate collaborative actions such as further diagnostic testing, massive fluid infusion, and administration of vasoconstrictive medications. Hypotonic bowel sounds may indicate sepsis or SIRS. Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or SIRS in a nondiabetic client, but would not be unusual in a client with diabetes. Level 9 out of 10 pain would require administration of analgesics, but is not as concerning as hypotension and does not require activation of the rapid response team.
The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client? 1 All nursing functions will be completed by discharge. 2 All invasive intravenous lines will remain patent. 3 The client will remain awake, alert, and oriented at all times. 4 The client will be free of signs and symptoms of infection by discharge.
The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.
