Saunder's Fundamental's of Care
The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding? 1.Acyclovir 2.Ceftriaxone 3.Azithromycin 4.Penicillin G benzathine
2.Ceftriaxone Treatment for gonorrhea consists of antibiotic therapy, usually with ceftriaxone and doxycycline. Acyclovir is the treatment for genital herpes simplex virus; azithromycin is the treatment for Chlamydia infection, and penicillin G benzathine is the treatment for syphilis.
The nurse teaches the mother of a child diagnosed with bacterial conjunctivitis about measures to prevent transmission of the infection. Which statement by the mother indicates a need for further teaching? 1."Hands need to be washed frequently." 2."A clean washcloth can be used to wipe my child's eyes." 3."It is all right to share towels and washcloths as long as they are bleached after use." 4."The eye drops must be given as prescribed, and hands need to be washed before and after instillation."
3."It is all right to share towels and washcloths as long as they are bleached after use." Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These measures include frequent hand washing and not sharing towels and washcloths, regardless of the bleaching process. Options 2 and 4 are also correct treatment measures.
The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother? 1."In about 2 months." 2."When the jaundice disappears." 3."One week after the onset of jaundice." 4."At the beginning of the next academic year."
3."One week after the onset of jaundice." Because HAV is not infectious 1 week after the onset of jaundice, a return to school at that time is permitted if the child feels well enough. Options 1, 2, and 4 are incorrect.
A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the mother asks the nurse when the child can return to school, what should the appropriate response be? 1."The child can return to school immediately." 2."The child cannot return to school until seen by the health care provider in 1 week." 3."The child should be kept home until the antibiotic eye drops have been administered for 24 hours." 4."The child should be kept home until the antibiotic eye drops have been administered for 72 hours."
3."The child should be kept home until the antibiotic eye drops have been administered for 24 hours." Viral conjunctivitis is extremely contagious. The child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hours.
A nursing instructor asks a nursing student about a client admitted with tuberculosis (TB). What comment by the student indicates that there is a need for further teaching? 1."It is transmitted by the airborne route." 2."It is a fast-growing infectious disease." 3."People who have been in constant close contact with the infected person will need to be tested and treated if necessary." 4."The risk for transmission is reduced after the infectious person has received proper medication therapy for 2 to 3 weeks and clinical improvement occurs."
2."It is a fast-growing infectious disease." Mycobacterium tuberculosis is a nonmoving, slow-growing (not fast-growing), acid-fast rod transmitted via the airborne route. The other options are accurate statements.
The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse should plan to admit the client to a room that has which properties? 1.Venting to the outside and ultraviolet light 2.Ultraviolet light and 3 air exchanges per hour 3.Ten air exchanges per hour and venting to the outside 4.Venting to the outside, 6 air exchanges per hour, and ultraviolet light
4.Venting to the outside, 6 air exchanges per hour, and ultraviolet light
A client who is admitted for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The assistive personnel (AP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. What should the nurse tell the AP? 1.Enteric precautions should be instituted for the client. 2.Gloves and mask should be used by caregivers in the client's room. 3.Contact isolation should be initiated because the disease is highly contagious. 4.Standard precautions are sufficient because the disease is transmitted sexually.
4.Standard precautions are sufficient because the disease is transmitted sexually.
The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement? 1."I should use disposable plates, forks, and knives." 2."I should cough into tissues and throw them away carefully." 3."It's important to cover my mouth if I laugh, sneeze, or cough." 4."It's very important to wash my hands after I touch my mask, tissues, or body fluids."
1."I should use disposable plates, forks, and knives." Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. The client should cover the mouth with a tissue when laughing, coughing, or sneezing and should dispose of tissues carefully. The client also may need to wear a mask as advised by the primary health care provider. It is important to perform proper hand washing after contact with body substances, tissues, or face masks.
A registered nurse (RN) is providing instructions to an assistive personnel (AP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the AP to use which protective item when giving the bed bath? 1.A gown and gloves 2.Gloves and goggles 3.A gown and goggles 4.Gloves and shoe protectors
1.A gown and gloves
The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client? 1.Avoid frequent douching. 2.Undergarments made of nylon are best. 3.Intrauterine devices are a good birth control method. 4.It is necessary to change sanitary pads only every 8 hours.
1.Avoid frequent douching. The client who has been diagnosed with PID should avoid frequent douching because it decreases the natural flora that controls the growth of infectious organisms. The client should wear cotton undergarments, and clothes should not fit tightly. Intrauterine devices increase the client's susceptibility to infection. Sanitary pads should be changed at least every 4 hours. Tampons should not be used during the acute infection, and some primary health care providers may recommend avoiding them indefinitely. The client also should avoid strong soaps, sprays, powders, and similar products that will irritate the perineum.
A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort? 1.Directly observed therapy 2.More medication instructions 3.Involvement of the family in teaching 4.Reinforcement by the primary health care provider
1.Directly observed therapy Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. Ultimately the client may be required to have directly observed therapy to reduce the risk to the public. This involves having a responsible person actually observe the client taking the medication each day.
The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness? 1.Raw oysters 2.Bottled water 3.Pasteurized milk 4.Products with sorbitol
1.Raw oysters
A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction? 1."I should drink large amounts of fluids." 2."I should use a hot mist vaporizer to liquefy secretions." 3."I should try to sleep with the head of the bed elevated." 4."I should apply heat, such as a wet pack, over the sinuses."
2."I should use a hot mist vaporizer to liquefy secretions." The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The client should be instructed to use a humidifier to help liquefy secretions and promote drainage. Consumption of large amounts of fluids is important to help liquefy secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. The nurse instructs the client to apply heat in the form of wet packs over the affected sinuses to promote comfort and help resolve the infection.
An assistive personnel (AP) is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client? 1.Used soap and water to cleanse the perineal area 2.Allowed the drainage tubing to rest under the leg 3.Kept the drainage bag below the level of the bladder 4.Used the drainage tubing port to obtain urine samples
2.Allowed the drainage tubing to rest under the leg Proper care of an indwelling urinary catheter is especially important to prevent infection in the client. The drainage tubing is not placed under the client's leg; for the same reason, the drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder. The tubing must drain freely at all times. The perineal area is cleansed thoroughly, using mild soap and water at least twice a day and following a bowel movement. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens.
A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1.Five blood cultures are negative. 2.Three sputum cultures are negative. 3.A blood culture and a chest x-ray are negative 4.A sputum culture and a tuberculin skin test are negative.
2.Three sputum cultures are negative.
The nurse is providing orientation to a newly graduated nurse. During a discussion of isolation procedures, which statement by the graduate nurse indicates a need for further review of isolation guidelines? 1."A client with tuberculosis will be placed on airborne precautions." 2."I will wear a mask when working with an isolated client who has a tracheostomy." 3."I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room." 4."I will remove the gown and gloves and wash my hands before leaving the client's room."
3."I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room."
The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by 1 of the scouts indicates a need for further instruction? 1."I need to bring a hat to wear during the trip." 2."I should wear long-sleeved tops and long pants." 3."I should not use insect repellents because it will attract the ticks." 4."I need to wear closed shoes and socks that can be pulled up over my pants."
3."I should not use insect repellents because it will attract the ticks."
The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a doughnut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation? 1.Offer the client a cup of coffee. 2.Get a cup of coffee and join the conversation. 3.Ask the nurse to refrain from eating and drinking in that area. 4.Appreciate what a wonderful therapeutic relationship this nurse and client have.
3.Ask the nurse to refrain from eating and drinking in that area.
A man is admitted to the hospital with the diagnosis of urethritis secondary to chlamydial infection. What precaution should the nurse implement for this client? 1.Enteric 2.Contact 3.Standard 4.Reverse isolation
3.Standard Chlamydial infection is a sexually transmitted infection and frequently is called nongonococcal urethritis in the male client. It requires no special precautions other than standard precautions. Caregivers cannot acquire the disease during administration of care, and using standard precautions is the only necessary measure.
The nurse is preparing to insert an intravenous (IV) angiocatheter into a client's inner forearm. Before cannulating the vein, what motion will the nurse implement to cleanse the site? 1.Scrubbing from the wrist toward the elbow 2.Scrubbing from the elbow toward the wrist 3.Using a circular motion from the center outward 4.Using a circular motion inward toward the center
3.Using a circular motion from the center outward The nurse cleans the skin by using a circular motion from inward to outward. This is the standard, accepted aseptic technique to carry microorganisms away from the insertion site. The same technique is used to cleanse any area requiring surgical asepsis. Options 1, 2, and 4 are incorrect procedures and do not represent aseptic technique.
The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room? 1.Wash hands and don a surgical mask. 2.Wash hands and wear a gown and gloves. 3.Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. 4.The nurse needs no precautions. The client is instructed to cover the mouth and nose when coughing.
3.Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. The nurse wears a HEPA respirator mask when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Options 1, 2, and 4 offer inadequate protection. In addition, a surgical mask will not protect against Mycobacterium tuberculosis.
Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process? 1.Wearing protective garb when visiting the infant 2.Washing the hands before leaving the infant's room 3.Telling a family member who has asthma that he should not visit the infant 4.Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant
4. Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant's room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs.
The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others? 1.Strict isolation 2.Enteric precautions 3.Contact precautions 4.Blood and body fluid precautions
4.Blood and body fluid precautions
A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed? 1.Left side-lying 2.Right side-lying 3.Prone with the head flat 4.Supine in semi-Fowler's
4.Supine in semi-Fowler's Placing the client in a semi-Fowler's position allows gravity to aid in drainage of the abdominal cavity. This helps to prevent the formation of abscesses high in the abdomen. Abscesses in this location could rupture, potentially causing peritonitis. The color, odor, and amount of vaginal secretions also are noted and recorded. Options 1, 2, and 3 will not aid in gravity drainage.
A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance? 1.The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2.The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3.The family will be treated prophylactically, and the client will not be contagious after 1 continuous week of medication therapy. 4.The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.
4.The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client usually is not contagious after taking the medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or medication-resistant tuberculosis.
The school nurse prepares a list of home care instructions for the parents of schoolchildren diagnosed with pediculosis capitis. Which instruction should the nurse include in the list? 1.Soak combs and brushes in warm water. 2.Use anti-lice sprays on all bedding and furniture. 3.Take all bedding and linens to the cleaners to be dry cleaned. 4.Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits.
4.Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits. Pediculosis capitis is an infestation of the hair and scalp with lice. Thorough home cleaning is necessary to remove any lice or nits that may fall from the host. Combs and brushes should be soaked in hot water for 10 minutes or a pediculicide for 1 hour. Anti-lice sprays are unnecessary and may be harmful. In addition, they should never be used on a child or on bedding or linens. Bedding and linens should be washed with hot water and dried on a hot setting. Items that cannot be washed should be dry cleaned or sealed in plastic bags in a warm place for 2 weeks.
The nurse is giving a bed bath to a client and discovers that an additional washcloth and towel are needed. Which is the most appropriate action to take to obtain the needed items? 1.Ask the unit secretary to get the needed items. 2.Ask a family member to obtain the needed items. 3.Borrow the client's roommate's washcloth and towel. 4.Wash hands, leave the client's room, and obtain the needed items.
4.Wash hands, leave the client's room, and obtain the needed items. To avoid spreading the client's germs, the nurse's hands must be washed before leaving. By going to the linen room without washing the hands first, the nurse will spread those germs into the clean linen. It is not appropriate to ask the unit secretary or a family member to obtain the supplies. It is never appropriate to borrow other clients' supplies because this action may spread germs.
A client has been receiving a series of medications as part of intravenous antineoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client? 1.Ammonia level of 20 mcg/dL (33.3 mcmol/L) 2.Platelet count of 100,000 mm3 (100 × 109/L) 3.International normalized ratio (INR) of 1.2 seconds 4.White blood cell (WBC) count of 2000 mm3 (2 × 109/L)
4.White blood cell (WBC) count of 2000 mm3 (2 × 109/L) The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). When the WBC count drops, neutropenic precautions should be implemented to protect the client from infection. Bleeding precautions should be initiated when the platelet count drops; bleeding precautions include avoiding trauma such as from rectal temperatures or injections. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal INR is 0.81 to 1.2 for someone who is not on anticoagulant therapy.