Med surg: Immune and Hematologic Disorders ?s
The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? A. Sterile objects are held above the waist of the technician. B. Sterile packages are opened with the first edge away from the technician. C. The outer inch of the sterile towel hangs over the side of the table. D. Wetness in the sterile cloth on top of the nonsterile table has been noted.
Correct response: Wetness in the sterile cloth on top of the nonsterile table has been noted. Explanation: Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated.
A client with AIDS develops a fever, severe headache, and stiff neck and begins to vomit. Family members state they have noticed that the client does not seem to be as alert and oriented as before. What is the nurse's priority intervention? administering an antibiotic preparing the client for a lumbar puncture starting an I.V. protecting the client's airway
Correct response: protecting the client's airway Explanation: Cryptococcus neoformans is a common opportunistic infection among clients with AIDS, and it causes neurologic disease. It is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures. The priority intervention is to make sure the client's airway is protected prior to any other interventions.
Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? A. a core body temperature of 97.9° F (36.6° C) B. confusion when listening to explanations of procedures C. polydipsia D. urine output of 90 mL over the past 6 hours
Correct response: urine output of 90 mL over the past 6 hours Explanation: Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension. Confusion with explanations of procedures does not mean that the client has a cerebral impairment. Further assessment is warranted. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decreased sensation from the hypothalamus. Polydipsia is reflective of diabetes.
Cryptococcosis
-Systemic noncontagious fungal infection classified as yeast that is inhaled and deposited in the lungs and then spreads through the lymphatic system -Usually begins as asymptomatic pulmonary infection in patients who present with meningoencephalitis Is one of the most common fungal infections of the nervous system -Rarely causes disease in people with normal immune function but can remain dormant and cause life-threatening disease if the immune system weakens or in people with alterations in normal body flora -Also known as torulosis and European blastomycosis -Keep in mind that although the organism is inhaled, the central nervous system (CNS) is the primary site for symptomatic cryptococcosis infection. In most cases of cryptococcal pneumonia, the patient is asymptomatic or experiences only mild symptoms and doesn't seek medical evaluation. In contrast, CNS cryptococcosis affects the brain and meninges, causing a variety of signs and symptoms. Be alert for other areas of involvement as well, including the skin, bone, eyes, and prostate.
A college student comes to the campus health care center with reports of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6° F (39.2° C) and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveal a leukocyte count of 20,000/mm3, antibodies to Epstein-Barr virus, and abnormal liver function tests. What are the nurse's priority action(s)? Administer antibiotics orally. Transfer student to acute care setting. Treat headache and hold food. Encourage fluids and treat fever.
Correct response: Encourage fluids and treat fever. Explanation: The client's clinical manifestations and laboratory test results suggest infectious mononucleosis. Although the WBC's are elevated, a virus is present so antibiotics would be ineffective. The client requires rest, fluids, and fever treatment. The client is not sick enough to require hospitalization.
A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity? swimming in rivers or lakes hiking in a forested area going horseback riding playing recreational softball
Correct response: swimming in rivers or lakes Explanation: When a client with HIV has moved into the AIDS phase of the infection, the client has a very low CD4 count (<200) and is at high risk for opportunistic infections. One such infection is cryptosporidia, which is caused by protozoan parasites that are often found in water. Swimming in a river or lake greatly increases the risk of this exposure. While the client should take protection to avoid pathogens or injury during the other activities listed, none are known to carry a specific risk for the client that the nurse would need to emphasize compared to the risk of cryptosporidia infection from swimming in lakes or rivers.
