Pearson Infection

A client who is coughing has blood in the sputum. In which phase of the nursing process should the nurse document these​ findings? A. Evaluation B. Implementation C. Diagnosis D. Assessment

Answer: D ​Rationale: Gathering data about the​ client's symptoms is part of the assessment. Data are analyzed during the diagnostic phase. Response to treatment is the evaluation phase. Actions to address the symptoms are performed during the implementation phase.

The nurse is completing a plan of care for a patient being treated for cellulitis. Which patient outcome has the highest priority to prevent development of septicemia? A. The patient will demonstrate understanding of proper wound care and infection control procedures. B. The patient will report a pain level of 2 or lower on a scale of 1-10. C. The patient will monitor temperature twice a day and report any elevations to the provider. D. The patient will report drinking at least 8 glasses of water daily.

Answer: A A high-priority patient outcome would be for the patient to demonstrate understanding of proper wound care and infection control procedures. A pain level of 3, not 2, is generally considered acceptable and would not have the highest priority. Fluid intake and temperature monitoring may be helpful but are not the highest priority outcomes.

The nurse is administering a urinary analgesic for pain associated with a UTI. The patient asks the nurse, "How will this help my pain?" Which response by the nurse is accurate? A. "The medication will decrease the inflammation and reduce the irritation you are feeling." B. "The medication will decrease the pain in your kidneys." C. "The medication will cause numbness in the bladder so you will not feel pain." D. "The medication will help flush out the bacteria causing the infection."

Answer: A A urinary analgesic will help decrease inflammation and irritation associated with a UTI. Urinary analgesics are not used to flush out bacteria, numb the bladder, or specifically decrease pain in the kidneys. It is important to relieve the patient's pain when possible because pain can stimulate a stress response and delay healing.

The nurse is caring for a 20-year-old who has had several recent urinary tract infections (UTIs). The patient states, "I would like to talk about nutritional options to help prevent urinary tract infections." Which statement by the nurse provides the patient with evidence-based information? A. "You should avoid alcoholic beverages, because its consumption has been linked to increased risk for UTIs." B. "Research does not support the restriction of food related to the decreased incidence of UTIs." C. "Cranberry juice should be avoided, because it has not been proven to reduce UTIs." D. "You should avoid foods high in sugar; they are a causative factor for UTIs."

Answer: A Alcohol consumption has been linked to increased risk for UTIs. The consumption of 2 glasses of low-sugar cranberry juice daily decreases the risk of UTIs. Artificial sweeteners are linked to UTIs. There are several dietary modifications that decrease the risk for UTIs.

A patient presents to the clinic stating, "This morning I noticed that I have blood in my urine." Which question by the nurse during the focused assessment for a urinary tract infection (UTI) is the priority? A. "Are you experiencing any pain when you urinate?" B. "How many times do you void per night?" C. "Do you have lower back pain?" D. "Have you tried to treat your symptoms?"

Answer: A Asking about pain is should be a priority during a focused assessment for a patient suspected of having a UTI. The question directly addresses a common symptom associated with hematuria. Asking if the patient has tried to treat the symptoms, how many times the patient voids each night, and about the presence of lower back pain are important, but may be related to other clinical diagnoses.

The nurse is teaching a patient about a newly prescribed antibiotic. Which patient statement demonstrates the teaching has been effective? A. "I should take the pills until they are gone." B. "I can stop taking the medication once I stop coughing." C. "I can only take my medication in the morning." D. "I should take my medication with milk."

Answer: A Nurses should encourage patients to take the full regimen of antibiotics as prescribed. Bacterial resistance often results from incomplete antibiotic therapy, which can lead to more serious and resistant infections in the future. Lack of adherence to the antibiotic regimen may also increase the risk of recurrent infections, producing further complications. In addition, patients who have leftover antibiotics from one infection may tend to self-medicate, using those antibiotics for another infection, even if the infection is caused by a different organism. Using antibiotics for nonsusceptible organisms is another major cause of bacterial resistance.

The nurse is meeting with a patient who reports feeling fatigued and is coughing yellow sputum. The patient is confused about what led to the sickness because no one in their home has been ill. Which response from the nurse would provide the patient an adequate explanation? A. "If you were in public and someone coughed, you could breathe in the droplets that cause infection." B. "You do not need to be exposed to microorganisms to get sick." C. "You must have picked it up from some allergens in your home left over from the fall season and the falling leaves." D. "You may be having a reaction to your medication."

Answer: A Before an individual can become infected, microorganisms must enter the body. The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry. Often, microorganisms enter the body of a host by the same route they used to leave the source. For example, an airborne infection escapes its host, or carrier, via sneezing or coughing and is transmitted to a new host who inhales the microorganism through the nose or mouth. The mouth, throat, nose, ears, eyes, and genitalia are open to outside exposure and thus are the most frequent portals of entry for microorganisms. There are many kinds of reservoirs (sources of microorganisms). Common sources are other humans, the patient's own microorganisms, plants, animals, and the general environment. Patients with allergen contact and medication reactions do not present with the manifestations identified.

A veterinary technician presents with a high fever, tachycardia, chills, and an inflamed region on her arm. She states that her arm became inflamed after she received a dog bite at the veterinary clinic a few days ago. The healthcare provider suspects cellulitis. Which sample does the nurse anticipate collecting to determine if the patient's cellulitis has progressed to septicemia? A. Blood B. Wound scrapings C. Wound drainage D. Urine

Answer: A Blood cultures are used to determine if patients with cellulitis have septicemia. Wound drainage is cultured to identify the causative organism. Wound scrapings and urine are not collected to determine if a patient's cellulitis has progressed to septicemia.

The nurse is providing a community-based parenting class to mothers of infants and toddlers. Which instruction should the nurse include in the session to prevent development of or provide early identification of cellulitis in children? A. "If your child has an insect bite, watch it closely for inflammation and drainage." B. "If a wound or irritated insect bite is present, make sure to keep the wound dry and open to the air." C. "Ensure that your child gets plenty of fluids if they have an open wound or insect bite." D. "Make sure that your child bathes daily using soap, especially after playing outside."

Answer: A Children often pick at or scratch insect bites and wounds, so they should be monitored closely for rapidly progressing inflammation or signs of infection. Bathing daily will not necessarily prevent cellulitis. Keeping a wound dry and open to the air can increase the risk of infection. While adequate fluid intake is sound advice, it does not directly address cellulitis.

The nurse is preparing to perform a physical examination on a patient suspected to have pyelonephritis. Which physical assessment should the nurse perform? A. Percuss for costovertebral tenderness. B. Examine the shape and contour of the abdomen. C. Obtain a urinalysis. D. Palpate for suprapubic tenderness.

Answer: A Costovertebral tenderness is an assessment used to help diagnose kidney pathology. A patient with pyelonephritis will have tenderness in the area of percussion and palpation. A urinary tract infection (UTI) is associated with suprapubic tenderness. A urinalysis is a laboratory test that can be utilized with physical assessment findings to confirm the presence of pyuria, bacteria, and blood cells in the urine. The shape and contour of the abdomen is not an indicator of pyelonephritis.

The nurse is discussing cellulitis prevention with a patient who has diabetes mellitus. Which action should the nurse encourage the patient to carry out regularly to help reduce the risk for cellulitis? A. "Check skin for signs of injury or infection." B. "Maintain adequate fluid and food intake." C. "Exercise for at least 150 minutes two times per week." D. "Closely monitor blood sugar levels."

Answer: A It is important for individuals with diabetes who have a higher risk for loss of skin integrity or infection to check their skin regularly for signs of injury or infection. Adequate food and fluid intake, exercise, and monitoring of blood sugar levels are also important but not the best answer in this situation because cellulitis requires a break in skin integrity to gain access.

The nurse is teaching a patient about the antibiotic prescribed to treat their infection. Which information should the nurse include? A. "Be certain to take all the prescribed amount of the medication." B. "Remember pharmacotherapy, the disease process, and the prevention of contaminating others." C. "Monitor your levels of pain." D. "Be aware of the nature of parasitic infections to decrease the possibility of reinfection."

Answer: A It is important to teach patients receiving antibiotics to take the entire amount prescribed. Monitoring pain levels is important in teaching patients about analgesics. Instructions regarding parasitic reinfestations are necessary when prescribing antihelminthics. Extensive teaching regarding pharmacotherapy, disease process, and prevention of contaminating others is important when prescribing antiretrovirals.

The public health nurse is training a class about first aid methods. The nurse talks about the activity of pathogens in each stage of the infectious process, including one stage that could last for years. Which is a correct statement about the pathogens during this extended stage? A. "Pathogens replicate but do not cause manifestations." B. "Early clinical manifestations appear." C. "Pathogens proliferate and cause symptoms." D. "Pathogens do not come in contact with the host."

Answer: A It is the incubation period in which pathogens replicate but do not cause manifestations. It can last for years. Early clinical manifestations appear during the prodromal stage. Pathogens proliferate and cause symptoms during the illness stage. If pathogens do not come in contact with the host, there is no infection.

The nurse is teaching the patient about their new prescription for antibiotics. Which should the nurse include as the imminent problem with incomplete use of their prescription? A. Bacteria resistance B. Gangrene C. Severe infection D. Pneumonia

Answer: A Nurses should encourage patients to take the full regimen of antibiotics as prescribed. Bacterial resistance often results from incomplete antibiotic therapy, which can lead to more serious and resistant infections in the future. Lack of adherence to the antibiotic regimen may also increase the risk of recurrent infections, producing further complications. In addition, patients who have leftover antibiotics from one infection may tend to self-medicate, using those antibiotics for another infection, even if the infection is caused by a different organism. Using antibiotics for nonsusceptible organisms is another major cause of bacterial resistance.

A female patient presents with a urinary tract infection and is prescribed an antibiotic. The patient states, "Phenazopyridine has worked in the past to stop the symptoms, so why do I need an antibiotic?" Which statement by the nurse is accurate? A. "Phenazopyridine helps for reducing the pain, but it does not treat the infection." B. "Since you no longer have pain, you no longer have a urinary tract infection." C. "Come back after you stop taking the phenazopyridine if you have any symptoms." D. "Keep taking the phenazopyridine, because it seems to be working well by itself."

Answer: A Phenazopyridine is an analgesic, so it helps the pain, but it does not treat the infection. An antibiotic is needed to treat the infection. Easing the pain is worthwhile, but not if it delays active treatment of the infection. The patient does not need to stop the analgesic, nor does the patient need to make a return visit for treatment.

The nurse is caring for a patient diagnosed with acute pyelonephritis. The patient asks, "What exactly is this?" Which statement by the nurse is accurate? A. "An infection of the kidney that is caused by bacteria." B. "A decrease in renal perfusion from changes in microscopic blood vessels." C. "Inflammation of the ascending infection caused by the shrinking of the renal tubules." D. "Scarring of the renal tubules that occurs from prolonged inflammatory response."

Answer: A Pyelonephritis occurs due to an inflammation of the pelvis and parenchyma of the kidney. Acute pyelonephritis is caused by a bacterial infection. Scarring of the renal tubes, shrinking of the renal tubes resulting in the reduction of urine flow, and decreased renal profusion related to changes in microscopic blood vessels are a result of other types of infections of the kidney.

Which organism should the nurse include as the most common cause of cellulitis? A. Staphylococcus aureus B. Corynebacterium xerosis C. Group A Streptococcus D. Micrococcus luteus

Answer: A Staphylococcus aureus is the most common cause of cellulitis followed by group A Streptococcus. Corynebacterium xerosis and Micrococcus luteus are resident microorganisms of the skin.

The nurse is inspecting a wound on the upper arm of a patient. Which presentation should the nurse recognize as being consistent with cellulitis? A. Wound that is irregular in shape with well-defined borders and erythema present B. Wound that is irregular in shape with poorly defined borders and temperature of 99.2°F C. Wound that is regular in shape with well-defined borders and patient complaining of feeling tired D. Wound that is regular in shape with poorly defined borders and warm to the touch

Answer: A The affected area in cellulitis is usually irregular in shape with well-defined borders and the presence of erythema. Malaise, chills, and fever can also indicate cellulitis, but the accompanying wound description for each of these scenarios does not describe a wound due to cellulitis.

Which statement by the nurse demonstrates an understanding of the importance of monitoring the intake and output for a patient diagnosed with pyelonephritis? A. "I will be able to assess the hydration and renal function of the patient by monitoring the intake and output." B. "The intake and output will allow me to look at the color and clarity of the patient's urine." C. "I will evaluate the intake and output after a 24-hour period to assess the renal function of my patient." D. "I will use the measurements of the intake and output to evaluate the kidney infection in the patient."

Answer: A The intake and output is a reflection of hydration and renal function for a patient with pyelonephritis. A clinical manifestation of pyelonephritis is a fever that can contribute to dehydration. A decreased urine output for a patient with pyelonephritis may be related to dehydration or impaired renal function. The primary purpose of an intake and output is not to monitor the color and clarity of the urine. The intake and output for a patient with pyelonephritis should be monitored more frequently than every 24 hours. The intake and output is not used to monitor for infection.

The nurse reviewed CAUTI guidelines. Which statement demonstrates the nurse's understanding? A. "The catheter should be removed when the patient is ready to void without assistance." B. "The pericare should be scheduled to be completed prior to the patient's ambulating." C. "The catheter should be removed as soon as the order is received." D. "The catheter should be removed as soon as the patient can ambulate to the bathroom."

Answer: A The statement made by the new nurse that indicates an understanding of the care guidelines to prevent CAUTI is, "I will remove the catheter when the patient is ready to void without assistance." Prevention of CAUTI includes timely removal, care, and maintenance of the catheter. Pericare should not be delayed until the patient can ambulate, and it is not necessary to ambulate to the bathroom to void. Part of the CAUTI care guidelines include considering alternatives to a urinary catheter. Waiting for an order does not reflect patient advocacy and delays the removal of the catheter, increasing the patient's risk for CAUTI.

The nurse is concerned that a patient who has been in isolation for several days in the hospital may be experiencing sensory deprivation. Which clinical sign should the nurse assess? A. Hallucinations B. Incontinence C. Hypertension D. Diarrhea

Answer: A Two of the most common issues associated with isolation are sensory deprivation and decreased self-esteem related to feelings of inferiority. Sensory deprivation occurs when the environment lacks normal stimuli for the patient, such as communication with others. Nurses should be alert to common clinical signs of sensory deprivation, such as boredom, inactivity, slowness of thought, daydreaming, increased sleeping, thought disorganization, anxiety, hallucinations, and panic. Hypertension, diarrhea, and incontinence are negative symptoms that are not associated with being isolated.

The nurse is visiting an older adult patient with cellulitis whose daughter is staying to help her until she can care for herself again. Which is the priority nursing diagnosis this patient? A. Skin Integrity, Impaired B. Fluid Volume: Deficit, Risk for C. Infection, Risk for D. Family Processes, Interrupted

Answer: A While Family Processes, Interrupted is appropriate nursing diagnoses for a patient with cellulitis, Skin Integrity, Impaired is the priority. Impaired skin integrity is what causes complications associated with cellulitis, most notably sepsis. Fluid Volume: Deficit, Risk for is not a nursing diagnosis for cellulitis. Infection, Risk for is not a nursing diagnosis for cellulitis because the patient already has an infection.

How frequently should the nurse assess the affected site for a patient hospitalized with cellulitis to observe for any change in size or other complications? A. Every hour B. Every 2 hours C. Every 6-8 hours D. Every 4 hours

Answer: B For patients in the hospital, the nurse should assess the affected site frequently (at least every 2 hours) and trace the boundaries of the wound using a marker for comparison to determine if the wound is changing in size.

The nurse is discussing interventions to prevent infection with a group of new colleagues. Which statement indicates that this discussion has been​ effective? A. ​"Proper hand hygiene is the key to reducing the spread of​ infection." B. ​"Limiting exposure to the client to every 2 hours decreases the spread of​ infections." C. ​"The use of personal protective equipment is the main way to reduce the spread of​ infection." D. ​"Wearing gloves is the best way to reduce the spread of​ infection."

Answer: A ​Rationale: Hand hygiene is identified as the best way to prevent the spread of infection. Wearing gloves as a part of standard precautions is​ effective; however, doing so does not replace hand hygiene. It is unrealistic to limit client care to every 2 hours. Personal protective equipment is an approach to reduce the spread of​ infection; however, it does not replace hand hygiene.

The nurse is assessing a child who reports feeling nauseated and just​ "sick." Which type of organism should the nurse suspect is causing the​ child's illness? A. Virus B. Influenza C. Bacteria D. Parasite

Answer: A ​Rationale: Infections are a normal part of​ childhood, and most children experience some kind of infection from time to time. The majority of these infections are caused by​ viruses, and for the most part they are transient and relatively benign and can be overcome by the​ body's natural defenses and supportive care.​ Bacteria, influenza, and parasites are not the reason for common infections seen in childhood.

A client has an area of eschar over a wound. What is the reason the nurse expects this wound to be​ debrided? A. To remove dead tissue B. To approximate the wound edges C. To promote healing of deep tissues before superficial tissues D. To dry the tissues of the wound

Answer: A ​Rationale: Removal of dead tissue is needed to support healing. Wound debridement is done to remove dead​ tissue, slough, and debris from the wound bed. Debridement is not done to dry the tissues of the​ wound, approximate the wound​ edges, or promote healing of the deep tissues before superficial tissues.

An older adult client with diabetes has an inflamed area on a toe that is suspected of being cellulitis. Which manifestation of infection should the nurse expect in this​ client? (Select all that​ apply.) A. Inflammation B. Pain C. Fever D. Elevated WBC count E. Elevated RBC count

Answer: A, B ​Rationale: In older adult​ clients, common signs of infection such as fever and elevated WBC count may be absent with cellulitis. Inflammation and pain are universal manifestations of cellulitis. RBC counts do not increase in the presence of an infection.

The nurse is assessing a client diagnosed with cellulitis of the upper left arm. Which manifestation should the nurse anticipate finding with this​ client? (Select all that​ apply.) A. Erythema B. Swollen lymph glands C. Fever and chills D. ​Deep, firm, painful nodule E. Pustules with surrounding erythema

Answer: A, B, C ​Rationale: Cellulitis may present with systemic​ symptoms, such as swollen lymph​ glands, which signal an attempt to eliminate excessive localized fluid through the lymphatic system. Fever and​ chills, which are a physiological attempt to eliminate the responsible pathogen from the​ body, may also be present. Erythema is characteristic of cellulitis. Pustules with surrounding erythema represent​ folliculitis, not cellulitis.​ Deep, firm, painful nodules describe furuncles.

The public health nurse is teaching community members about the reasons to get an annual flu shot. Which reason should the nurse​ include? (Select all that​ apply.) A. The new vaccine has specific antigens predicted for that year. B. The predominant flu virus strain changes from year to year. C. People without health insurance are at higher risk of getting the flu. D. ​Infants, young​ children, and people aged 50 or older are more likely to get the flu. E. People living in apartment buildings have a higher probability of getting the flu.

Answer: A, B, D ​Rationale: The predominant flu virus strain changes from year to year. The new vaccine has specific antigens predicted for that year.​ Infants, young​ children, and people aged 50 or​ older, are more likely to get the flu. People living in apartment buildings or who lack health insurance are not at increased risk of getting the flu.

A​ preschool-age client is experiencing​ "burning" with urination and a fever of​ 102°F (38.9°C). Which intervention should the nurse make a priority​? ​(Select all that​ apply.) A. Administering prescribed fluids B. Providing warming blankets C. Teaching about vaccinations D. Monitoring intake and output closely E. Administering prescribed antipyretics

Answer: A, D, E ​Rationale: Treatment for an infection includes fluid​ therapy, monitoring of intake and​ output, and providing antipyretics as prescribed. The client has a fever and may be uncomfortable with a warming blanket. Vaccination teaching is not a priority for this client.

A patient who has been treated empirically for a urinary tract infection (UTI) over the past 3 days with the antibiotic nitrofurantoin is experiencing worsening symptoms. Which urine test should the nurse anticipate to hasten identification of the type of microorganism causing the UTI? A. Culture and sensitivity B. Urine Gram stain C. WBC count with a differential D. Urinalysis

Answer: B Although a culture and sensitivity is ordered to identify the infecting organism and its sensitivity to particular antibiotic(s), it takes 24-48 hours for the culture and up to another 24-48 hours to run the sensitivity. A Gram stain of the urine may be done more quickly to identify the infecting organism by type and can assist in determination of the use of either a gram-positive or gram-negative effective antibiotic. A urinalysis assesses for pyuria, bacteria, and blood cells in the urine. It is not used to determine the infecting organism. A WBC count with a differential detects typical changes associated with infection.

The parents of a newborn tell the nurse they are concerned about bringing the baby home to a household of relatives with various illnesses. Which response by the nurse is accurate? A. "Infants do not begin to synthesize their own immunoglobulins until after 6 months." B. "Newborns may not be able to respond to infections due to an underdeveloped immune system." C. "Newborns have naturally acquired immunity from the mother, but it is good only for 24 hours." D. "Newborns have a heightened response to infections and respond quickly with high fevers."

Answer: B Although newborns have some naturally acquired immunity that is transferred from the mother across the placenta at birth, they may not be able to respond to infections due to an underdeveloped immune system. As a result, in the first few months of life, newborns may not exhibit the signs/symptoms typically associated with infection (may not present with fever). Infants begin to produce their own immunoglobulins between 1 and 3 months of age.

Which factor poses the greatest risk for a urinary tract infection? A. Decreased intake of dairy products B. Placement of a urinary catheter C. Age of the patient D. Increase in urinary motility

Answer: B Any instrumentation of the urinary tract (for example, catheterization, cystoscopy) is a major risk factor for UTI. Even when performed under strict aseptic conditions, catheterization can result in bladder infection. Colonization of perineal skin by bowel flora is a common source of infection in catheterized women. An excess intake of milk and milk products is associated with urinary tract infections. Increased urinary motility decreases the retention of urine. There is an increased risk in older adults for UTIs, but placement of a catheter is invasive and poses the greatest risk.

A patient recently treated for a urinary tract infection (UTI) presents to the clinic. Significant findings include a temperature of 102.1°F (38.9°C) and flank tenderness. Which question asked by the nurse predominately relates to the clinical history and current assessment findings in the patient? A. "Do you completely empty your bladder every 6 hours?" B. "Did you finish your prescribed antibiotic for the UTI?" C. "How much fluid did you drink in the past 24 hours?" D. "Have you noticed any change in the color or odor of your urine?"

Answer: B Based on the assessment findings, it is important to determine if the patient completed the full course of the prescribed antibiotic. If the course of treatment with an antibiotic remains incomplete, the bacteria may continue to invade the renal system, resulting in an upper UTI and pyelonephritis. The patient is instructed to completely empty the bladder every 3-4 hours. Adequate fluid intake helps clear bacteria from the urinary system, but does not eradicate it. A urine sample will be obtained to analyze the color and odor of the urine.

The nurse is scheduling the lab technician to draw an antibiotic peak and trough level for a patient receiving an intravenous antibiotic. At which time should the nurse schedule the peak level? A. 1 hour prior to the next dose B. 30 minutes after administration C. 15 minutes prior to administration of the next dose D. 1-2 hours after administration

Answer: B By measuring blood levels at the predicted peak (1-2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough (lowest level, usually a few minutes before the next scheduled dose), healthcare personnel can determine whether the patient is maintaining a level within the therapeutic range at all times, thereby ensuring maximal effect from the drug.

The nurse is caring for an older adult who is reluctant to drink and holds their urine so that they do not have to get up often to the commode. The patient's daughter asks why their mother does not have a urinary catheter in place. Which response by the nurse provides the most accurate information? A. "Movement is easier without a catheter and encouraged so that additional complications do not occur." B. "Having a urinary catheter in place would increase your mother's risk of developing a urinary tract infection." C. "Infections from urinary catheters often result in kidney infections, which may result in renal failure." D. "The urinary catheter can reduce your mother's need to void, which could be a bigger problem later on."

Answer: B Catheter-associated urinary tract infection (CAUTI) has become a major healthcare concern and has been identified as one of the major healthcare-associated infections. Insertion of a urinary catheter increases the risk of developing a urinary tract infection. This is because the flushing action of the voiding process is no longer present, and bacteria from the perineal area can ascend on the catheter sides, farther up the urethra, and closer to the bladder. Although patient movement is encouraged postoperatively, it is important to offer the most specific response when teaching patients and family members. Referencing the potential development of complications is very general. Insertion of a urinary catheter does not reduce the patient's need to void; it may contribute to urinary retention over a prolonged period because the bladder muscle does not contract when a urinary catheter is in place. Having a urinary catheter in place increases the risk for cystitis; this could ascend and develop into a kidney infection, but is a less frequent occurrence.

A patient recently diagnosed with cellulitis asks the nurse for clarification about what it is. Which statement by the nurse provides an accurate description of cellulitis? A. "It is a bacterial infection that reflects a systemic response to an injury." B. "It is an acute bacterial infection of the dermis and underlying connective tissue." C. "A diagnosis of cellulitis is made when regional lymph node involvement occurs." D. "Cellulitis usually occurs on the torso or arms."

Answer: B Cellulitis is an acute bacterial infection of the dermis and underlying connective tissue, so this statement best describes cellulitis. It is not a systemic response to an injury. It is most common on the face and lower extremities, not the torso and upper arms. Regional lymph node involvement can occur with cellulitis, but it is not required to diagnose cellulitis.

The urgent care clinic nurse referred a patient with an acute bacterial infection on the face to a dermatologist. Which diagnosis does the nurse most likely suspect? A. Sepsis B. Cellulitis C. Otitis media D. Conjunctivitis

Answer: B Cellulitis, an acute bacterial infection of the dermis, could result in a referral to a dermatologist. Conjunctivitis is an infection in the eye. Otitis media is an infection in the ear. Sepsis is an infection in the whole body.

The nurse is caring for a child in the clinic diagnosed with a urinary tract infection (UTI). The parent asks the nurse, "How did my child get this?" Which statement by the nurse is appropriate? A. "Children have a very short urethra, making them susceptible to UTIs." B. "Children do not always urinate frequently enough, which can result in a UTI." C. "Children do not drink enough fluids, which can be attributed to UTIs." D. "Children have an immature immune system, which places them at risk for UTIs."

Answer: B Children typically void 5-6 times a day. Infrequent voiding, which is common in school-age children, results in incomplete emptying of the bladder and urinary stasis. Voluntarily suppressing the desire to urinate is a predisposing factor, because retention overdistends the bladder and can lead to an infection. Females have shorter urethras, which make them more susceptible to UTIs. Dehydration can result in a UTI in any patient. A healthy child's immune system does not predispose them to UTIs.

The nurse is caring for a patient admitted for the treatment of cellulitis. Which factor in the patient's assessment information increased the risk for cellulitis? A. Chronic obstructive pulmonary disease B. Diabetes mellitus C. Recent use of antibiotics D. Smoking

Answer: B Diabetes mellitus increases the risk for cellulitis. The other factors will also impact overall health, but they are not specific risk factors for cellulitis.

The preceptor is explaining to a new nurse the differences between a local infection and a systemic infection. Which statement by the new nurse demonstrates understanding? A. "If a patient has sepsis, they have a local infection." B. "If a patient has otitis media, that is an example of a local infection." C. "If a patient has a urinary tract infection, that is an example of a systemic infection." D. "If a patient has pneumonia, that is considered a systemic infection."

Answer: B Infections can be local or systemic. A local infection is limited to the specific part of the body where the microorganisms remain. Examples of local infections include otitis media, urinary tract infection (UTI), and pneumonia. If the microorganisms spread and damage different parts of the body, the result is a systemic infection. Sepsis is a systemic infection. When a culture of the individual's blood reveals bacteria, the condition is called bacteremia.

The nurse is caring for a patient being treated for an infection that involves the bilateral lower legs. Which action by the patient would indicate a need for the nurse to reinforce teaching about infection control? A. The patient avoids touching their eyes after applying a warm compress to the legs. B. The patient absentmindedly rubs their legs while watching television. C. The patient washes their hands after toileting. D. The patient washes their hands before eating.

Answer: B It is important to reinforce the teaching to avoid touching the wound unless medically necessary. Washing hands before eating and after toileting is good hand hygiene and demonstrates understanding of infection control. Avoiding touching the eyes and other mucous membranes is also a proper infection control measure.

A patient with cellulitis covering a large surface area on the lower leg has arrived at the clinic for treatment. Which collaborative intervention should the nurse anticipate from the healthcare provider? A. Treatment with topical antibiotics and oral pain relievers at home B. Referral to hospital for systemic antibiotics C. Recommendation to return home and keep the affected area elevated D. Treatment with oral antibiotics on an outpatient basis

Answer: B Patients with severe cases or a large affected surface area may be treated with systemic antibiotics and analgesics in the hospital to prevent sepsis. The patient would not be sent home or treated on an outpatient basis.

The nurse is caring for a child in the clinic with a history of urinary tract infections (UTIs). Which statement by the nurse indicates an understanding of the risk factors for UTIs in children? A. "Children's immune systems are not fully developed." B. "School-age children tend to void less frequently, resulting in urinary retention." C. "Children tend to consume large amounts of fluids frequently throughout the day and need to urinate often." D. "Children should take several bubble baths per week in order to keep the perineal area clean."

Answer: B School-age children typically only void 5-6 times a day. Infrequent voiding, which is common in school-age children, results in incomplete emptying of the bladder and urinary stasis. Voluntarily suppressing the desire to urinate is a predisposing factor, because retention overdistends the bladder and can lead to an infection. Children should avoid bubble baths to maintain the integrity of perineal tissues. Children do not necessarily drink large amounts of fluids and typically do not void frequently enough; this can predispose them to UTIs. A healthy child's immune system would be developed; this does not predispose a child to UTIs.

The nurse is caring for a patient with cellulitis on their right lower leg. The patient states that the lesion was the size of a dime yesterday. Which is the best way to assess if the affected area in cellulitis is changing in size? A. Photograph the affected area daily. B. Trace the border of the affected area with a marker. C. Note the relationship of the affected area to body landmarks. D. Measure the length of the widest part of the affected area with a ruler daily.

Answer: B The best way to assess if the affected area in cellulitis is changing in size is to trace the border with a marker at least every 2 hours. If any change occurs, the new boundaries should be traced.

The nurse is caring for a patient who has abdominal pain and painful urination. Which diagnosis should the nurse suspect based on these symptoms? A. Prostatitis B. Cystitis C. Epididymitis D. Pyelonephritis

Answer: B The combination of abdominal or suprapubic pain and dysuria are symptoms of cystitis. Clinical manifestations of pyelonephritis include chills and fever, malaise, vomiting, flank pain, costovertebral tenderness, and urinary frequency; symptoms of cystitis also may be present. Clinical manifestations of epididymitis and prostatitis include perineal, sacral, or scrotal pain and tenderness; difficulty voiding; and fever.

The nurse is providing discharge teaching to the family of an older adult post-treatment for cellulitis of the left lower arm. The nurse should inform the family to contact the healthcare provider when which manifestation occurs? A. Complaints of gastrointestinal upset B. Increased lethargy C. Warmth of the cellulitis area D. Temperature over 100F (37.8oC)

Answer: B The family should be taught to contact the provider if there is increased lethargy. The provider would not need to be contacted for a temperature below 101oF, warmth of the area, or complaints of gastrointestinal upset.

The nurse obtains a urine culture and sensitivity for a patient whose symptoms of pyelonephritis have worsened. The patient states, "I don't understand why I have to have more testing—why did they put me on an antibiotic that is not working?" The nurse should base a response on which factor? A. The characteristic of the organism needs to be identified. B. The most effective antibiotic needs to be identified. C. The location of the UTI needs to be confirmed. D. The amount of bacterial growth needs to be reevaluated.

Answer: B The purpose of a culture and sensitivity is to identify the infecting organism and the most effective antibiotic. A Gram stain of the urine is used to identify the infecting organism by shape and characteristic (gram-positive or gram-negative). The evaluation of the amount of bacterial growth is not a purpose of a culture and sensitivity. A urine culture and sensitivity cannot distinguish between a lower or upper UTI.

Which statement demonstrates the nurse's understanding of the physiological changes that place the obstetrical patient at risk for urinary tract infection (UTI)? A. "The stretching of the uterus causes a decreased sensation to urinate." B. "Incomplete bladder emptying results from pressure of the fetus." C. "Urinary stasis occurs due to the hormonal changes during pregnancy." D. "Preeclampsia is a risk factor for UTI."

Answer: B The risk for UTI increases during pregnancy, particularly during the second trimester, secondary to the pressure of the fetus, which causes urinary stasis and incomplete bladder emptying. The hormonal changes in pregnancy relax the smooth muscle, but are not associated with urinary stasis. UTIs are associated with an increased risk for preeclampsia. The stretching of the uterus does not interfere with the sensation to void.

A patient informs the nurse that their dialysis port looks red and is painful despite keeping it covered. Which patient statement reflects an understanding on how the port may have become infected? A. "The redness is probably not an infection." B. "My skin is open around the tube." C. "My tube is made of rubber." D. "The tube may have gotten caught while I slept."

Answer: B The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry. Often, microorganisms enter the body of a host by the same route they used to leave the source. For example, an airborne infection escapes its host, or carrier, via sneezing or coughing and is transmitted to a new host who inhales the microorganism through the nose or mouth. The mouth, throat, nose, ears, eyes, and genitalia are open to outside exposure and thus are the most frequent portals of entry for microorganisms. Cuts and tears in the skin also provide portals through which microorganisms enter and cause disease. Infection typically manifests with swelling and redness. Dialysis tubing material is not a major cause of infection. If the tube was covered, then it would not be able to catch on bedding during sleep and would remain intact.

The nurse is providing nutritional discharge instructions for a patient with a urinary tract infection (UTI). Which patient statement indicates the need for further teaching? A. "I will increase my intake of vitamin C." B. "I will limit my caffeine to 1 cup of coffee a day." C. "I will make sure the cranberry juice I am drinking is low in sugar." D. "I will make sure that I drink at least 2 liters of fluid a day."

Answer: B The statement that indicates the patient's need for further teaching is, "I will limit my caffeine to one cup of coffee a day." The patient should avoid all caffeinated beverages such as coffee, tea, and colas. A fluid intake of at least 2 liters per day is recommended to flush out the bacteria in the urinary tract. Cranberry juice that is low in sugar helps maintain the acidity in the urine to prevent the growth of bacteria. Vitamin C is recommended in the prevention of urinary tract infections.

A patient being treated for cellulitis develops tachycardia, tachypnea, and low white blood cell count. The patient's daughter asks the nurse what could possibly have happened. Which response by the nurse provides the best response? A. "The symptoms indicate that your mother may be developing osteomyelitis. I will contact her healthcare provider." B. "Your mother most likely has septicemia, which sometimes occurs with cellulitis." C. "Unfortunately, it means that the antibiotic isn't working, and we need to try another." D. "These are all symptoms that can accompany cellulitis, but we will keep a close eye on them."

Answer: B The symptoms being experienced are clinical manifestations of septicemia, which is a complication of cellulitis. They are neither normal symptoms of cellulitis nor symptoms of osteomyelitis. While the treatment (antibiotic) may be ineffective and lead to development of complications, it would not be the best answer to the question given the patient's symptoms.

The nurse is reviewing the lab results for a patient with cellulitis. Which component of the complete blood count is useful in diagnosing a patient with cellulitis? A. Red blood cell count B. White blood cell count C. Hematocrit D. Hemoglobin

Answer: B The white blood cell count is useful for the patient with cellulitis in determining the extent of infection. Red blood cell count and its indices—hemoglobin and hematocrit—are not helpful in the patient with cellulitis.

A client with a fever of​ 102.5°F (39.2°C),​ chills, and dyspnea is experiencing respiratory distress. Which collaborative intervention should the nurse identify as the priority​? A. Administer acetaminophen. B. Apply oxygen via face mask and notify the healthcare provider. C. Administer intravenous fluids of normal saline at 100​ mL/hr. D. Obtain a sputum culture.

Answer: B ​Rationale: Because the client is demonstrating signs of respiratory​ distress, applying oxygen is the priority. A sputum culture is a diagnostic tool for determining the reason for the distress.​ However, this is not the priority. Antipyretics assist with fever​ reduction; but this is not the priority. Hydration is a key element of managing clients with fever and​ pneumonia, but it is not the priority.

The nurse is assessing a client. What is the reason the nurse asks the client to rate the level of stress experienced over the last 6​ months? A. To determine if the client remembers events in the last 6 months B. To measure the​ client's severity of emotional stressors C. To determine if the client can use a health scale rating D. To document the​ client's ability to answer difficult questions

Answer: B ​Rationale: Excessive stress predisposes people to infections. The​ nature, number, and duration of physical and emotional stressors can influence susceptibility to infection. Stressors elevate blood​ cortisone, and the prolonged elevation of blood cortisone decreases​ anti-inflammatory responses, depletes energy​ stores, leads to a state of​ exhaustion, and decreases resistance to infection. The interview is not about answering difficult​ questions, using a health scale​ rating, or having a memory test.

A​ school-age client with a fever is being tested for possible kidney failure. Which collaborative intervention should the nurse make a priority for this​ client? A. Practicing medical asepsis B. Administering prescribed intravenous antibiotics C. Using sterile technique D. Performing hand hygiene

Answer: B ​Rationale: Providing prescribed medications is a collaborative intervention. Using sterile​ technique, hand​ hygiene, and medical asepsis are independent nursing interventions.

Which manifestation should the nurse consider to be a classic sign of cellulitis? A. Chills B. Lymphangitis C. Erythema D. Malaise

Answer: C A classic sign or symptom of cellulitis is erythema, which along with pain, warmth at the site, and edema, is part of the inflammatory process. Malaise, chills, and lymphangitis may also occur but are not considered classic signs or symptoms.

A patient diagnosed with a urinary tract infection (UTI) reports the pain at 7 on a 0-10 scale. Which drug classification should the nurse expect to find on the medication administration record (MAR)? A. Sulfonamide antibiotics B. Glycopeptide antibiotics C. Urinary analgesic D. Penicillin antibiotics

Answer: C A urinary analgesic is prescribed to treat the painful spasms that are associated with UTIs. Glycopeptide, sulfonamide, and penicillin antibiotics are commonly used in the treatment of the organism that caused the UTI, not the treatment of pain.

The nurse caring for a 6-year-old patient suspects that the child's intravenous (IV) site may be infected. Which clinical manifestation would support the nurse's finding? A. The IV site is cool to the touch. B. The IV tape is lifted on one side. C. The IV site is red and painful. D. The IV site is warm and puffy.

Answer: C An IV site that is red and painful may be infected. The nurse should mark the redness near the IV site to make sure it does not extend beyond the initial assessment. If further redness is noted, the healthcare provider should be notified. If an IV site is warm and puffy, the line may be infiltrated and need adjustments. An IV site that is cool to the touch is not an indication of possible infection. Lifted tape puts the site at risk for infection.

The nurse is talking to a young child's grandmother, who can't remember whether she gave aspirin or acetaminophen when the child had a fever. Which is the best advice the nurse should give the grandmother for the future? A. "Write down the medication given as soon as possible." B. "Do not give acetaminophen to children with a fever." C. "Do not give aspirin to children with a fever." D. "Aspirin or acetaminophen work equally well for fevers."

Answer: C Aspirin is not given to children with fevers because of the risk of Reye syndrome. Although recording the medication is important, this action is not as important as avoiding the 30% mortality rate of Reye syndrome. For that reason, aspirin or acetaminophen cannot be said to work equally well for fever. Acetaminophen can be given to children with a fever.

The nurse is teaching a parent preventive measures for decreasing the risk of urinary tract infections in their child. Which statement by the parent demonstrates an understanding of the preventive teaching? A. "I will use soy milk instead of dairy milk to prevent future UTIs." B. "I will use an antiseptic disposable wipe to cleanse my child after a bathroom visit to avoid future UTIs." C. "I will avoid giving my child citrus juices to drink." D. "I will have to redo the toilet training of my child after this to prevent another infection."

Answer: C Avoiding citrus juices is recommended for the prevention of UTI. It is unnecessary to redo the toilet training of a child. A toilet trained child may regress during the illness, but it should be considered a temporary situation. Avoiding excess dairy products is a recommendation to prevent UTIs; however, the child's nutritional needs still need to be met. Transitioning the child to soy milk may not provide the nutritional requirements of the child. Antiseptic solutions are used for catheter care, and their use on the perineal tissue can cause irritation. Cleansing with nonsterile gauze moistened with tap water and mild soap is as effective as using a prepackaged sterile towelette and is gentler on the mucous membranes.

The nurse is caring for a patient with an infection who has been prescribed an intravenous antibiotic. Thirty minutes after administering the antibiotic, the nurse has the lab technician draw a blood sample. What is this test measuring? A. The therapeutic range of the antibiotic B. The minimum level of the antibiotic C. The maximum blood level of the antibiotic D. The trough blood level of the antibiotic

Answer: C Blood is drawn at specific intervals after administration of antibiotics to measure antibiotic peak and trough levels. The peak level (maximum blood level of the antibiotic) is measured 30 minutes after the antibiotic is administered intravenously. The trough level (minimum blood level of the antibiotic) is measured about 15 minutes prior to the next dose. The therapeutic range refers to the minimum and maximum blood levels at which the drug is effective.

A patient with cellulitis asks the nurse what kind of medications they will need to take to treat the condition. Which response by the nurse best addresses this question? A. "Cellulitis often resolves on its own without complication, so we may wait and see." B. "Cellulitis can have viral or bacterial causes; it is hard to say what will be used until we are sure about the cause of your cellulitis." C. "Cellulitis is a bacterial infection, so you will need to take antibiotics." D. "Due to the inflammation and potential complications, several types of medications will be required."

Answer: C Cellulitis is a bacterial infection that is treated by antibiotics, so this is the best answer to this question. While antipyretics may also be used, generally several medications are not required. Cellulitis is not due to a virus nor is it advisable that the nurse wait to see if cellulitis resolves on its own.

The nurse is teaching a wife about contact precautions when changing a dressing on her husband after discharge. Which statement demonstrates that the wife understands the teaching? A. "I should only wear the gloves when removing and discarding the old dressing." B. "I should wash my hands after removing the gloves." C. "I should wash my hands before putting on gloves and after removing them." D. "I should use an alcohol-based cleanser before putting on gloves."

Answer: C Contact precautions are used for a patient who has or is suspected of having serious illnesses that are easily transmitted by direct patient contact or by contact with items in the patient's environment. Hand hygiene should be performed prior to donning gloves to protect the patient from any pathogens that may be on the caregiver's hands in case of a break in the barrier that could risk exposure to the patient. It should be performed after in case any small break in the gloves occurred and may have caused pathogens to come in contact with the caregiver's skin.

The nurse is teaching the parents of young children about the signs and symptoms of infection. Which statement by the nurse should be included? A. "They will always have a fever." B. "You will see a rash develop associated with the infection." C. "You will find a rapid onset of symptoms in a child." D. "The child will be in a great deal of pain."

Answer: C In children, acute otitis media or other viral infections may be associated with a rapid onset of symptoms and poor feeding. A fever will not always accompany an illness, and the child may even have a fever of unknown origin. A rash and pain may not accompany an infection.

The nurse is providing dietary teaching to a patient for the prevention of urinary tract infections (UTIs). Which patient statement indicates the the need for further teaching? A. "I will drink 2 glasses of low-sugar cranberry juice daily." B. "I will drink almond milk instead of regular milk." C. "I will increase my intake of vitamin A." D. "I will avoid drinking fruit juices every day."

Answer: C The statement made by the patient that indicates further teaching is needed is, "I will increase my intake of vitamin A." Taking ascorbic acid, drinking 2 glasses of low-sugar cranberry juice daily, reducing dairy consumption, and avoiding drinking fruit juices daily are dietary interventions to help prevent UTIs. These interventions help maintain the acidity of urine to prevent the growth of bacteria.

Which statement by the nurse explains the difference between medical and surgical asepsis? A. "Medical asepsis is cleaning and sanitizing mechanical equipment and surgical asepsis entails the cleaning of just surgical tools." B. "Medical and surgical asepsis are basically the same, only the location is different." C. "Medical asepsis confines a microorganism to a specific area, while surgical asepsis attempts to keep an area free of microorganisms." D. "Medical asepsis is keeping the area free of microorganisms, and surgical asepsis is containing the organisms present."

Answer: C Medical and surgical asepsis are not the same. Medical asepsis includes all practices intended to confine a specific microorganism to a specific area, thus limiting the number, growth, and transmission of microorganisms. In medical asepsis, objects are referred to as clean, which means that almost all microorganisms are absent, or dirty (soiled, contaminated), which means that microorganisms are likely to be present, some of which may be capable of causing infection. Surgical asepsis, or sterile technique, refers to practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores (microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques). Surgical asepsis is used for all procedures involving sterile areas of the body, which may include both mechanical equipment and surgical tools.

The nurse preceptor is reviewing assessment data collected by a new graduate who is providing care for an older adult patient diagnosed with cellulitis of the lower left leg. Which statement by the graduate should the preceptor clarify? A. "I didn't note any lines radiating away from the site, so lymphatic involvement is not likely." B. "The patient also has peripheral neuropathy, so the case of cellulitis is more severe." C. "I'm not sure that the patient has cellulitis. There is no apparent wound or skin break." D. "I used a marker to trace along the border so that we can monitor for a change in size."

Answer: C Older adults and adults with poor circulation, diabetes, or a weakened immune system may develop cellulitis without loss of skin integrity, so this statement would need clarification. The other statements reflect valid information concerning cellulitis.

A patient states, "I have been taking herbs for my upper respiratory infection." Which question by the nurse would be appropriate? A. "Why are you doing that?" B. "Who told you to do such a thing?" C. "What herbs are you currently taking?" D. "Are you aware that these are not monitored by the Food and Drug Administration (FDA)?"

Answer: C Over-the-counter (OTC) Echinacea and goldenseal, which are herbal supplements purported to eliminate upper respiratory infections, have been used for many years by the general public. Their use is often based on traditions and beliefs of the patient's particular cultural group. It is important that the nurse respond in a nonjudgmental manner when asking what other therapies the patient may be using.

Due to a higher risk for cellulitis, which patient should be encouraged to check the skin regularly for signs of injury and infection? A. Patient with chronic kidney disease (CKD) B. Patient with chronic obstructive pulmonary disease (COPD) C. Patient with peripheral neuropathy D. Patient with frequent episodes of eczema

Answer: C Patients with peripheral neuropathy have a much higher risk of cellulitis and should be encouraged to check their skin regularly. This is a common condition for patients with diabetes mellitus. Eczema, COPD, and CKD do not necessarily increase the risk of cellulitis as significantly as does peripheral neuropathy.

The nurse is discussing the prevention of cellulitis with a patient who has diabetes mellitus and recently experienced cellulitis of the lower leg while gardening. Which information should the nurse include to help the patient prevent another episode of cellulitis? A. "Monitor for inflammation and redness around any wounds you may have, and report such signs immediately." B. "Make sure to drink plenty of fluids each day and maintain a balanced diet." C. "Wear pads on your knees when you are gardening to help prevent an injury." D. "Check your blood sugar routinely and administer insulin as ordered to keep your blood sugar in the normal range."

Answer: C Skin protection is an important part of preventing cellulitis, so the patient should be encouraged to wear knee pads when gardening. Monitoring for inflammation can help identify signs of cellulitis early on, but not necessarily prevent it. Fluids, proper nutrition, and adequate blood sugar control can all help support overall health and wound healing but will not necessarily help to protect the skin directly.

An adult is being discharged post-hospitalization for cellulitis. Which teaching point is the highest priority for the nurse to discuss with this patient? A. Pain control B. Mobility restrictions C. Infection control D. Medication compliance

Answer: C The educational need of the highest priority for a patient being discharged to home post-hospitalization for cellulitis is infection control. Pain control, medication compliance, and possible mobility restrictions may also be important but are not the highest priority.

Which statement by the nurse demonstrates understanding of standard precautions? A. "Standard precautions are designed for EMTs on the scene of an accident." B. "Standard precautions are not regulated." C. "Standard precautions are designed for hospital-based care." D. "Standard precautions are relative to the patient."

Answer: C The following facts are related to standard precautions. - These precautions are designed for all patients in the hospital. - They apply to: *Blood. *All body fluids, excretions, and secretions except sweat. *Nonintact (broken) skin. *Mucous membranes. - They are designed to reduce the risk of transmission of microorganisms from recognized and unrecognized sources.

The nurse is caring for a patient diagnosed with a urinary tract infection as a result of impaired urinary elimination. Which nursing intervention is appropriate for a patient with the nursing diagnosis of impaired urinary elimination? A. Balancing rest with activity B. Recommending warm sitz baths C. Measuring intake and output D. Administering analgesics

Answer: C The patient experiencing the nursing diagnosis of impaired urinary elimination would benefit most from the nurse measuring intake and output. Monitoring elimination provides information on the patient's fluid status and renal function. Balancing rest with activity, analgesics, and warm sitz baths are interventions for pain.

The nurse is caring for a client with cellulitis. What is the reason the nurse applies warm saline compresses to the​ area? A. Tissue integrity maintenance B. Infection control C. Enhanced blood flow D. Pain reduction

Answer: D ​Rationale: Applying warm compresses to the affected area of a client with cellulitis is a comfort measure meant to reduce pain. Warm compresses will not control infection. The warm compresses are not used to enhance blood flow or maintain tissue integrity.

The nurse is providing wound care teaching to a patient with cellulitis before discharge. Which statement by the patient would require clarification? A. "I should wash the wound with soap and water at least once daily." B. "I will scrub my hands with soap and water for 20 seconds before and after touching the infected area." C. "Once I am home, I should start opening my wound to the air to allow healing." D. "I will set up a way to properly dispose of all contaminated materials from the wound care."

Answer: C The wound should be kept at a proper moisture, because moist wounds heal faster than do dry wounds. Covering the wound helps to maintain a moist environment for healing. The wound should be washed with soap and water at least once daily, and hands should be scrubbed before and after wound care. All contaminated materials should be properly disposed of.

The patient has a wound that has been requiring frequent surgical debridement. Which patient statement indicates a correct understanding of the purpose of debridement? A. "Debridement is applying a sterile dressing." B. "Debridement reduces pain." C. "Debridement is done to remove dead skin." D. "Debridement is a nonsterile procedure."

Answer: C Wound irrigation and debridement are done to remove dead tissue, slough, and debris from the wound bed. Wound debridement is an important factor in the healing process, and after debridement a special dressing is applied to keep the site moist and ensure appropriate healing. Other surgical interventions, such as amputation of a toe or foot with gangrene, may be used, depending on the site of the infection. Debridement can sometimes be painful, so it should be done with extreme care. To avoid infection, it should be a sterile procedure.

The nurse is preparing a presentation on infections. Which factor regarding chronic infections should be​ included? A. Chronic infections only affect susceptible hosts. B. Chronic infections do not affect young children. C. Chronic infections can persist for long periods. D. Chronic infections generally appear suddenly.

Answer: C ​Rationale: Chronic infections develop slowly over a period of time and can persist for long periods. Acute and chronic infections can affect susceptible​ hosts, especially young children who do not have strong immune systems.

The infection control nurse is discussing the pharmacologic challenges of treating infection with a group of nurses. Which statement should the infection control nurse​ include? A. ​"We offer the agent that we have samples of in our​ office." B. ​"We try at least two agents to see which is more​ effective." C. ​"We look for an effective agent with little​ toxicity." D. ​"We look at the newest agent on the​ market."

Answer: C ​Rationale: Once the causative agent and affected body system have been​ identified, specific therapy to cure the infectious disease can begin. The perfect​ anti-infective agent destroys pathogens while preserving host​ cells, is effective against many organisms while not promoting the development of​ resistance, distributes to necessary​ tissues, and remains in the body for relatively long periods. Because no available antimicrobial meets all these​ criteria, healthcare providers look for an agent that is​ effective, has little​ toxicity, can be administered with relative​ convenience, and is cost effective. In the process of​ selection, characteristics of both the client and the infecting organism are considered. Treatment of an infection is not focused on the newest​ agent, the use of multiple​ agents, or using samples of agents in the office.

A client with an upper respiratory infection is receiving radiation treatments. What is the reason the nurse explains the risk of infection to the​ client? A. Radiation only kills the targeted cells. B. Radiation is only destructive to tissue. C. Radiation kills both cancerous and healthy cells. D. Radiation is lethal to only cancerous cells.

Answer: C ​Rationale: Some medical therapies may predispose an individual to infection. Radiation treatments for cancer destroy not only cancerous cells but also some normal​ cells, thereby rendering the client more vulnerable to infection.

A patient with a urinary tract infection (UTI) states, "I will take my antibiotic, but I really do not like taking medication. What else can I do for the discomfort?" Which intervention should the nurse recommend to the patient to promote comfort based on the understanding of complementary therapy? A. Adding chamomile oil to the bathwater B. Integrating saw palmetto into the treatment plan C. Drinking adequate fluids D. Aromatherapy

Answer: D A complementary therapy that can be recommended to the patient to promote comfort is aromatherapy. Drinking adequate fluids is important for urination to flush out the bacteria, but this is not a complementary therapy. Adding bergamot, sandalwood, lavender, or juniper oil to bathwater may help relieve the discomfort of a UTI. Palmetto has an antiseptic effect and may be beneficial in treating or preventing UTIs. Prior to integrating herbal remedies into the plan of care, the nurse should advise the patient to consult a qualified herbologist for recommended doses and appropriate use.

A patient diagnosed with a urinary tract infection provides a urine sample for culture and sensitivity. The patient asks, "I know I have an infection, so why do you have to do this test?" Which is an accurate response by the nurse? A. "The test can identify the changes associated with the infection." B. "Bacteria and blood cells can be identified in the urine." C. "The test provides an evaluation of kidney function." D. "It enables your healthcare provider to choose an effective antibiotic."

Answer: D A urine culture and sensitivity is a diagnostic test that helps the healthcare provider choose the most effective antibiotic to treat the UTI. A urinalysis test identifies bacteria and blood cells in the urine. A white blood cell count identifies characteristic changes associated with the infection. An intravenous pyelography helps to evaluate renal excretory function.

The nurse is caring for a patient diagnosed with a urinary tract infection (UTI) who rates the pain as 3 on a scale of 0-10. Which comfort measure should the nurse initiate in addition to administering prescribed treatment for pain relief? A. Encourage the patient to change position. B. Encourage the patient to void. C. Limit fluid intake. D. Apply warm packs to the perineum.

Answer: D Applying warm packs to the perineum is a comfort measure the nurse can initiate. Warmth relaxes muscles, relieves spasms, and increases local blood supply. Changing position will not alleviate the discomfort of a UTI. Limiting fluids would concentrate the urine and inhibits flushing out the infection. Voiding will prevent the discomfort of the infection.

The nurse is completing an assessment on a child admitted with cellulitis of the right lower leg. The family reports that they recently returned from vacation, and the child developed the symptoms of cellulitis shortly after their return. During the assessment, the nurse notes a small wound on the child's shin. Which question should the nurse ask the parents to provide information to help guide treatment decisions? A. "Did your child complain of severe pain when this occurred or in the time since?" B. "Did the wound bleed much after it happened?" C. "Did you clean the wound when it happened and apply antibiotic ointment?" D. "Did this wound occur when your child was swimming in a lake or pond?"

Answer: D Asking if the wound occurred while swimming in possibly contaminated water such as a lake can help to determine the causative organism and possible antibiotic choice, so this is an important question to ask. Asking about wound bleeding at time of injury, wound care, and pain at time of injury will not help guide treatment decisions.

The nurse caring for a patient with a wound on the lower leg. Which symptom should the nurse consider as a distinctive manifestation in assessing for the presence of cellulitis? A. Tingling B. Numbness C. Elevated white blood count D. Inflammation

Answer: D Cellulitis is an acute bacterial infection of the dermis. Its chief symptom is inflammation, which includes intense pain, heat, redness, and swelling. An elevated white blood count may accompany cellulitis, but it can be caused by other conditions as well. Numbness and tingling are not common symptoms in cellulitis.

The nurse is providing discharge instructions to the parents of a female child diagnosed with a UTI. Which information is most important for the nurse to include in the teaching to prevent future UTIs? A. Give the child a bubble bath every day. B. Teach the child to wash the hands before and after using the bathroom. C. Notify the provider if the child experiences discomfort during urination. D. Ensure the child is voiding every 3-4 hours each day.

Answer: D Children typically void 5-6 times a day. Infrequent voiding, which is common in school-age children, results in incomplete emptying of the bladder and urinary stasis. Voluntarily suppressing the desire to urinate is a predisposing factor, because retention overdistends the bladder and can lead to an infection. The symptoms of infection depend on the location and the patient's age. A child with a UTI may not present with dysuria. Avoiding bubble baths helps maintain the integrity of the perineum and prevents UTIs. It is not necessary for a child to wash the hands prior to going to the bathroom.

A patient is admitted to the hospital for a bacterial infection and has been having episodes of foul-smelling, watery diarrhea. Which precautions should the nurse use? A. Droplet precautions B. Recommendation to discontinue the antibiotics C. Bloodborne precautions D. Contact precautions

Answer: D Contact precautions are used for patients who are known to have or are suspected of having serious illnesses that are easily transmitted by direct patient contact or by contact with items in the patient's environment. According to the CDC, such illnesses include gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria; specific enteric infections, such as C. difficile, enterohemorrhagic Escherichia coli 0157:H7, Shigella, and hepatitis A, in patients who wear diapers or are incontinent; respiratory syncytial virus, parainfluenza virus, and enteroviral infections in infants and young children; and highly contagious skin infections, such as herpes simplex virus, impetigo, pediculosis, and scabies. Droplet precautions would be assigned for someone with a respiratory infection. The recommendation to discontinue the antibiotics would have to come from the healthcare provider, following an assessment of the symptoms. The nurse should follow bloodborne precautions if the nurse comes into contact with any material that may contain blood.

Which factor should the nurse include as a bladder irritant when teaching a patient with UTI? A. Low-sugar cranberry juice B. Foods high in oxalate C. Mineral water D. Citrus juices

Answer: D Fluids that may irritate the bladder, including caffeinated beverages, alcohol, and soft drinks with citrus juices, should be avoided. Drinking low-sugar cranberry juice in particular is recommended to help fight UTIs. Mineral water and foods high in oxalate are not part of treatment or prevention of UTI.

Which statement describes the makeup of viruses? A. "They include yeasts and molds." B. "There are several hundred species." C. "They include protozoa." D. "They consist of mainly nucleic acid."

Answer: D Four major categories of microorganisms cause infection in humans: bacteria, viruses, fungi, and parasites. Bacteria are by far the most common infection-causing microorganisms. Several hundred species of bacteria can cause disease in humans and can live and be transported through air, water, food, soil, body tissues and fluids, and inanimate objects. Viruses consist primarily of nucleic acid and therefore must enter living cells to reproduce. Common virus families include the rhinovirus (causes the common cold), hepatitis, herpes, and HIV. Fungi include yeasts and molds. Candida albicans is a yeast considered normal flora in the human vagina. Parasites live on other organisms. They include protozoa, such as the one that causes malaria, helminths (worms), and arthropods (mites, fleas, and ticks).

The nurse is assessing a 2-year-old patient for signs and symptoms that may be associated with an infection. Which assessment finding most reflects the manifestation of acute infection? A. Sweaty, moist skin B. Pearly-gray tympanic membrane C. Sharp increase in appetite D. Rapid onset of symptoms

Answer: D In children, acute otitis media or other viral infections may be associated with a rapid onset of symptoms and poor feeding. A nonbulging, nonretracted, pearly-gray tympanic membrane is a normal assessment finding that is not associated with an infection. Pallor, mottled, or flushed dry skin may be associated with an infection, not sweaty, moist skin.

The nurse is teaching infection control to a patient with an open wound on their lower leg. Which patient statement would require additional teaching? A. "I should wash my hands after toileting." B. "I should avoid touching my eyes after applying a warm compress to the affected area." C. "I should wash my hands before eating." D. "I can scratch my wound around the edge of my bandage if it itches."

Answer: D It is important to reinforce the teaching to avoid touching the wound unless medically necessary. Washing hands before eating and after toileting is good hand hygiene and demonstrates understanding of infection control. Avoiding touching the eyes and other mucous membranes is also a proper infection control measure.

Which statement by the nurse explains the difference between a pathogen and an opportunistic pathogen? A. "A pathogen causes disease in a susceptible individual, while an opportunistic pathogen causes disease in healthy individuals." B. "A true pathogen causes illness in those already sick." C. "A pathogen does not pose a danger to the human body." D. "A pathogen causes disease in a healthy individual, whereas an opportunistic pathogen causes disease in susceptible individuals."

Answer: D Microorganisms vary in pathogenicity (ability to produce disease); thus, a pathogen is a microorganism that causes disease. Many microorganisms that are normally harmless can cause disease under certain circumstances. A "true" pathogen causes disease or infection in a healthy individual, whereas an opportunistic pathogen causes disease only in susceptible individuals. Microorganisms also vary in their virulence, or severity of the diseases they produce, and in their degree of communicability. For example, the common cold virus is more readily transmitted than the bacillus that causes leprosy.

A pregnant patient visits the office for a routine monthly checkup and shares that their 4-year-old child is going to daycare and there seems to be an outbreak of chickenpox. The patient asks whether the fetus will be harmed if she contracts chickenpox. Which is the nurse's accurate response? A. "Chickenpox is not harmful during pregnancy." B. "Chickenpox will not be transferred to the fetus." C. "Chickenpox causes hydrocephalus in the fetus." D. "Chickenpox can cause birth defects in an unborn fetus."

Answer: D Pregnant women need special considerations if they contract an infection that may cause birth defects, such as rubella, cytomegalovirus (CMV), parvovirus, and chickenpox. CMV is the most common infection that causes birth defects. Pregnant women should be educated about the risks of infection and ways to prevent infection during pregnancy. If a pregnant woman has an infection, it can be transmitted to the newborn. Infections that can be transmitted from the mother to the newborn include HIV, group B Streptococcus, CMV, and listeriosis.

The nurse is reviewing a plan of care for a patient with cellulitis. The nurse notes that the patient is receiving systemic antibiotics. Which condition should the nurse consider appropriate for this therapy? A. When cellulitis is caused by Streptococcus B. When cellulitis is located on the trunk C. When facial cellulitis is present D. When cellulitis affects a large surface area

Answer: D Systemic antibiotics administered in the hospital are indicated for severe cellulitis or if the cellulitis affects a large area of the body. Facial cellulitis, streptococcal cellulitis, and cellulitis on the trunk are not necessarily treated in the hospital unless they meet the criteria described above.

The patient asks the nurse, "How did I get this urinary tract infection (UTI)?" Which common causative factor should the nurse include in the response? A. Urinary stasis in the urinary bladder B. Congenital strictures in the urethra C. An infection elsewhere in the body D. An ascending infection from the urethra

Answer: D The most common cause of a UTI is an ascending infection from the urethra. Congenital strictures and urinary retention can lead to infection, but these are not the most common causes. Systemic infections are rarely causes of UTIs.

The nurse is caring for a patient who presents with symptoms of a urinary tract infection (UTI). Which collaborative intervention should the nurse anticipate to determine appropriate treatment? A. Cystoscopy B. Pelvic examination C. Intravenous pyelography D. Urine culture and sensitivity

Answer: D The patient suspected of having a urinary tract infection will have a urine culture and sensitivity ordered to determine the best course of pharmacologic treatment. Urine culture and sensitivity tests identify the infective organism and the most effective antibiotic for treatment. A pelvic examination is useful to assess structural changes of the urinary tract. An intravenous pyelogram is used to evaluate the structure and excretory function of the kidneys, ureters, and bladder. A cystoscopy is used to provide direct visualization of the bladder through a cystoscope.

An older adult patient presents with symptoms that appear to be influenza. The patient does not know what led to the sickness. Which statement by the nurse explains the term reservoir as it applies to this patient's condition? A. "You can only get the flu by touching someone who has it." B. "The flu virus is present in your home." C. "The flu is spread on airborne pathogens." D. "Someone you were near at the grocery store had the flu."

Answer: D There are many reservoirs, or sources, of microorganisms. Common sources are other humans—the other shopper in the grocery store, the patient's own microorganisms, plants, animals, and the general environment. People are the most common source of infection for others and for themselves. For example, an individual with an influenza virus frequently spreads it to others. Stating that the flu is airborne or present in the patient's home doesn't explain the concept of reservoir. Nor does stating that the patient can only get the flu by touch explain the concept of a reservoir.

The nurse is evaluating a patient who has completed an antibiotic regimen for a urinary tract infection (UTI). Which assessment will determine effective treatment? A. Observation of urine B. Patient being afebrile C. Completion of antibiotic D. Urinalysis

Answer: D Urinalysis is used to evaluate the treatment of a UTI. A urinalysis is used to provide more accurate information than a sensory exam of the urine. Completion of the antibiotic is not an indicator that the infecting organism has been effectively treated. Not all patients with UTIs have fever.

The nurse caring for a patient with a history of urinary tract infections (UTIs) states that vesicoureteral reflux is suspected as the causative factor. Which statement by the nurse further explains this? A. "Vesicoureteral reflux is a result of an accumulation of urine that has flowed back into your kidneys." B. "Vesicoureteral reflux results because you do not voluntarily completely empty your bladder." C. "Vesicoureteral reflux is a condition where bladder spasms cause irritation of the lining of your bladder." D. "Vesicoureteral reflux involves backflow of urine from the bladder back into your kidneys."

Answer: D Vesicoureteral reflux is a condition in which urine moves from the bladder back toward the kidney. It is seen in adults when bladder outflow is obstructed and is a common risk factor in children who develop pyelonephritis. Hydronephrosis is an accumulation of urine in the renal pelvis as a result of obstructed outflow. Vesicoureteral reflux is not a result of the patient not voluntarily emptying their bladder. Bladder spasms do not cause irritation of the bladder mucosa.

The nurse is teaching a group of new mothers about the best way to prevent infections in children. Which statement by the new mothers should indicate to the nurse that the teaching was​ effective? A. ​"My child has a natural immunity to most​ microorganisms." B. ​"I should make sure my child takes a full spectrum of​ vitamins." C. ​"I should not take my child out in public more than once a​ week." D. ​"Proper hand hygiene should be used​ consistently."

Answer: D ​Rationale: Hand​ hygiene, comprehensive​ immunizations, proper​ nutrition, adequate​ hydration, and appropriate rest are essential to preventing or treating infections in children. Children do not have natural immunity. Vitamin supplements are used if prescribed by the healthcare professional. There is no reason to restrict the​ child's exposure to others.