Question 1

An older adult client with sepsis has been admitted to the nursing unit.The nurse is planning care and determines that one goal for this client is to maintain normal mental status.Which outcome evaluation implies that the goal has been met?

Accepted Answer

A) A client who responds to questions appropriately is alert and oriented. Restlessness or agitation in a client with sepsis can be a sign that the client's condition is deteriorating. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent.
B) A client who responds to questions appropriately is alert and oriented. Restlessness or agitation in a client with sepsis can be a sign that the client's condition is deteriorating. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent.
C) A client who responds to questions appropriately is alert and oriented. Restlessness or agitation in a client with sepsis can be a sign that the client's condition is deteriorating. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent.
D) A client who responds to questions appropriately is alert and oriented. Restlessness or agitation in a client with sepsis can be a sign that the client's condition is deteriorating. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent.

Question 2

A 1-month-old infant is admitted to the hospital with a temperature of 102°F.For which reason will this infant receive a septic work-up?

Accepted Answer

A) A child less than 3 months of age with a temperature higher than 100.4°F should be evaluated for sepsis because the child is at increased risk secondary to an immature immune system. The child is not evaluated for sepsis because of the absence of sweat glands, inadequate red blood cells, or poor lung elasticity.
B) A child less than 3 months of age with a temperature higher than 100.4°F should be evaluated for sepsis because the child is at increased risk secondary to an immature immune system. The child is not evaluated for sepsis because of the absence of sweat glands, inadequate red blood cells, or poor lung elasticity.
C) A child less than 3 months of age with a temperature higher than 100.4°F should be evaluated for sepsis because the child is at increased risk secondary to an immature immune system. The child is not evaluated for sepsis because of the absence of sweat glands, inadequate red blood cells, or poor lung elasticity.
D) A child less than 3 months of age with a temperature higher than 100.4°F should be evaluated for sepsis because the child is at increased risk secondary to an immature immune system. The child is not evaluated for sepsis because of the absence of sweat glands, inadequate red blood cells, or poor lung elasticity.

Question 3

The nurse is preparing an educational session on sepsis.Which should the nurse include as a major risk factor for the development of this health problem?

Accepted Answer

A) Sepsis is an entire-body inflammatory process. Sepsis is most often the result of gram-positive infections from Staphylococcus and Streptococcus bacteria but may also follow gram-negative bacterial infections such as Pseudomonas, Escherichia coli, and Klebsiella. A portal of entry for sepsis is the urinary system. Leukocytosis occurs with sepsis if the client is able to mount an immune response. An elevated temperature is a manifestation of sepsis.
B) Sepsis is an entire-body inflammatory process. Sepsis is most often the result of gram-positive infections from Staphylococcus and Streptococcus bacteria but may also follow gram-negative bacterial infections such as Pseudomonas, Escherichia coli, and Klebsiella. A portal of entry for sepsis is the urinary system. Leukocytosis occurs with sepsis if the client is able to mount an immune response. An elevated temperature is a manifestation of sepsis.
C) Sepsis is an entire-body inflammatory process. Sepsis is most often the result of gram-positive infections from Staphylococcus and Streptococcus bacteria but may also follow gram-negative bacterial infections such as Pseudomonas, Escherichia coli, and Klebsiella. A portal of entry for sepsis is the urinary system. Leukocytosis occurs with sepsis if the client is able to mount an immune response. An elevated temperature is a manifestation of sepsis.
D) Sepsis is an entire-body inflammatory process. Sepsis is most often the result of gram-positive infections from Staphylococcus and Streptococcus bacteria but may also follow gram-negative bacterial infections such as Pseudomonas, Escherichia coli, and Klebsiella. A portal of entry for sepsis is the urinary system. Leukocytosis occurs with sepsis if the client is able to mount an immune response. An elevated temperature is a manifestation of sepsis.

Question 4

The nurse is caring for a client who develops a fever and productive cough after having an appendectomy.Which prescriptions should the nurse expect from the healthcare provider for this health problem? Select all that apply.

Accepted Answer

A) The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not routine testing for this scenario. The client likely has an infectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections.
B) The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not routine testing for this scenario. The client likely has an infectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections.
C) The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not routine testing for this scenario. The client likely has an infectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections.
D) The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not routine testing for this scenario. The client likely has an infectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections.
E) The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not routine testing for this scenario. The client likely has an infectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections.

Question 5

The healthcare provider prescribes a client to have peak and trough blood levels drawn to evaluate the therapeutic effect of an IV antibiotic.When should the nurse schedule the blood samples to be drawn? Select all that apply.

Accepted Answer

A) Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range-that is, the minimum and maximum blood levels at which the drug is effective-is known for a given drug. 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, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.
B) Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range-that is, the minimum and maximum blood levels at which the drug is effective-is known for a given drug. 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, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.
C) Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range-that is, the minimum and maximum blood levels at which the drug is effective-is known for a given drug. 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, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.
D) Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range-that is, the minimum and maximum blood levels at which the drug is effective-is known for a given drug. 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, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.
E) Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range-that is, the minimum and maximum blood levels at which the drug is effective-is known for a given drug. 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, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.

Question 6

The nurse identifies the diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a client with septicemia.Which intervention will address this client's health problem?

Accepted Answer

A) Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but a change in skin color will alert the nurse immediately of decreased tissue perfusion.
B) Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but a change in skin color will alert the nurse immediately of decreased tissue perfusion.
C) Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but a change in skin color will alert the nurse immediately of decreased tissue perfusion.
D) Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but a change in skin color will alert the nurse immediately of decreased tissue perfusion.

Question 7

An older adult client is admitted with pneumonia.Which manifestations would the nurse expect to find when assessing this client? Select all that apply.

Accepted Answer

A) Frequently, caregivers or family members note that the client looks generally ill. The client is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20.
B) Frequently, caregivers or family members note that the client looks generally ill. The client is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20.
C) Frequently, caregivers or family members note that the client looks generally ill. The client is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20.
D) Frequently, caregivers or family members note that the client looks generally ill. The client is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20.
E) Frequently, caregivers or family members note that the client looks generally ill. The client is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20.

Question 8

A toddler-age child with otitis media is prescribed amoxicillin clavulanate 250 mg/5 mL three times daily by mouth for 10 days.Which should the nurse teach the mother about this medication?

Accepted Answer

A) Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon could contain less than 5ml, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.
B) Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon could contain less than 5ml, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.
C) Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon could contain less than 5ml, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.
D) Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon could contain less than 5ml, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.

Question 9

List the pathophysiology concepts related to the onset of sepsis in sequential order.
A) Macrophage-producing cytokines are released.
B) Endotoxin released by microorganisms sets off an out-of-control inflammatory process.
C) Neutrophils arrive and multiply, occluding capillaries.
D) Vasodilation with increased capillary permeability and fluid leak.

Accepted Answer

The answer of List the pathophysiology concepts related to the...

Question 10

The nurse is providing care to a client with pneumonia is has a fever.Which interventions should the nurse use to attain the goal of normal body temperature? Select all that apply.

Accepted Answer

A) Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance.
B) Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance.
C) Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance.
D) Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance.
E) Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance.

Question 11

An older adult client is recovering in the intensive care unit (ICU)from septicemia.Which intervention will help prevent further infection for this client?

Accepted Answer

A) Good oral and skin care will prevent breakdown and prevent entry by bacteria. In order to prevent skin breakdown and promote respiratory function, the client is turned at least every 2 hours. The Foley drainage bag is always kept below the level of the client's bladder to prevent reflux. There is no evidence that this client has a wound.
B) Good oral and skin care will prevent breakdown and prevent entry by bacteria. In order to prevent skin breakdown and promote respiratory function, the client is turned at least every 2 hours. The Foley drainage bag is always kept below the level of the client's bladder to prevent reflux. There is no evidence that this client has a wound.
C) Good oral and skin care will prevent breakdown and prevent entry by bacteria. In order to prevent skin breakdown and promote respiratory function, the client is turned at least every 2 hours. The Foley drainage bag is always kept below the level of the client's bladder to prevent reflux. There is no evidence that this client has a wound.
D) Good oral and skin care will prevent breakdown and prevent entry by bacteria. In order to prevent skin breakdown and promote respiratory function, the client is turned at least every 2 hours. The Foley drainage bag is always kept below the level of the client's bladder to prevent reflux. There is no evidence that this client has a wound.

Question 12

A nurse is caring for an older adult client admitted to the hospital with pneumonia.The client asks the nurse what can be done to decrease the risk for developing pneumonia in the future.Which responses by the nurse are the most appropriate? Select all that apply.

Accepted Answer

A) Research indicates a high rate of pneumonia in clients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex. Alcohol interferes with the actions of macrophages. Studies suggest that supplements containing micronutrients that approximate the recommended dietary allowances can assist in preventing infections. A balanced diet can also decrease the risk of respiratory infections. Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function. Telling the client he cannot decrease his risk in the future is incorrect.
B) Research indicates a high rate of pneumonia in clients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex. Alcohol interferes with the actions of macrophages. Studies suggest that supplements containing micronutrients that approximate the recommended dietary allowances can assist in preventing infections. A balanced diet can also decrease the risk of respiratory infections. Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function. Telling the client he cannot decrease his risk in the future is incorrect.
C) Research indicates a high rate of pneumonia in clients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex. Alcohol interferes with the actions of macrophages. Studies suggest that supplements containing micronutrients that approximate the recommended dietary allowances can assist in preventing infections. A balanced diet can also decrease the risk of respiratory infections. Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function. Telling the client he cannot decrease his risk in the future is incorrect.
D) Research indicates a high rate of pneumonia in clients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex. Alcohol interferes with the actions of macrophages. Studies suggest that supplements containing micronutrients that approximate the recommended dietary allowances can assist in preventing infections. A balanced diet can also decrease the risk of respiratory infections. Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function. Telling the client he cannot decrease his risk in the future is incorrect.
E) Research indicates a high rate of pneumonia in clients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex. Alcohol interferes with the actions of macrophages. Studies suggest that supplements containing micronutrients that approximate the recommended dietary allowances can assist in preventing infections. A balanced diet can also decrease the risk of respiratory infections. Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function. Telling the client he cannot decrease his risk in the future is incorrect.

Question 13

An older adult client who resides in a long-term care facility is admitted to the hospital with sepsis.The family is tearful and does not understand how their family member got so sick from a bed sore.What should the nurse teach the family to help in the care of the client?

Accepted Answer

A) Poor nutritional status and a slow-functioning immune system contribute to the risk for sepsis in the older client. The family can help by assisting and encouraging the client to take in the proper nourishment needed. The family is not responsible for IV or dressing changes. Assisting the client to the bathroom should be done by the staff who are responsible for client safety.
B) Poor nutritional status and a slow-functioning immune system contribute to the risk for sepsis in the older client. The family can help by assisting and encouraging the client to take in the proper nourishment needed. The family is not responsible for IV or dressing changes. Assisting the client to the bathroom should be done by the staff who are responsible for client safety.
C) Poor nutritional status and a slow-functioning immune system contribute to the risk for sepsis in the older client. The family can help by assisting and encouraging the client to take in the proper nourishment needed. The family is not responsible for IV or dressing changes. Assisting the client to the bathroom should be done by the staff who are responsible for client safety.
D) Poor nutritional status and a slow-functioning immune system contribute to the risk for sepsis in the older client. The family can help by assisting and encouraging the client to take in the proper nourishment needed. The family is not responsible for IV or dressing changes. Assisting the client to the bathroom should be done by the staff who are responsible for client safety.

Question 14

The nurse is preparing to assess an older adult client admitted with tuberculosis.Which manifestations does the nurse anticipate for this client?

Accepted Answer

A) Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers. Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult.
B) Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers. Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult.
C) Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers. Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult.
D) Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers. Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult.

Question 15

A nurse working in the intensive care unit (ICU)is receiving a client diagnosed with early septic shock from the emergency department (ED).The nurse will recognize which symptoms associated with this condition? Select all that apply.

Accepted Answer

A) Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock.
B) Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock.
C) Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock.
D) Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock.
E) Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock.
F) Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock.

Question 16

An adolescent client is brought to the emergency department (ED)with fatigue,weight loss,a dry cough,and night sweats.The family just recently immigrated to the United States.Based on this data,for which potential risk should the nurse include when planning care for this client?

Accepted Answer

A) This client was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax. Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
B) This client was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax. Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
C) This client was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax. Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
D) This client was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax. Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.

Question 17

The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a client with pneumonia who is experiencing copious amounts of respiratory secretions.Which intervention should the nurse include in this client's plan of care?

Accepted Answer

A) Chest percussion can help clear secretions. Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a client with pneumonia; however, they would be aligned with a different nursing diagnosis. Patients with pneumonia are encouraged to increase fluid intake.
B) Chest percussion can help clear secretions. Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a client with pneumonia; however, they would be aligned with a different nursing diagnosis. Patients with pneumonia are encouraged to increase fluid intake.
C) Chest percussion can help clear secretions. Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a client with pneumonia; however, they would be aligned with a different nursing diagnosis. Patients with pneumonia are encouraged to increase fluid intake.
D) Chest percussion can help clear secretions. Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a client with pneumonia; however, they would be aligned with a different nursing diagnosis. Patients with pneumonia are encouraged to increase fluid intake.

Question 18

The nurse is teaching the parents of an infant who is diagnosed with acute otitis media.Which is the priority teaching point for these parents?

Accepted Answer

A) Parents are taught to administer acetaminophen to relieve the discomfort and decrease fever associated with acute otitis media. Decongestants are not recommended for treatment of acute otitis media. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended. Placing infants to sleep with a pacifier can increase the incidence of otitis media.
B) Parents are taught to administer acetaminophen to relieve the discomfort and decrease fever associated with acute otitis media. Decongestants are not recommended for treatment of acute otitis media. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended. Placing infants to sleep with a pacifier can increase the incidence of otitis media.
C) Parents are taught to administer acetaminophen to relieve the discomfort and decrease fever associated with acute otitis media. Decongestants are not recommended for treatment of acute otitis media. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended. Placing infants to sleep with a pacifier can increase the incidence of otitis media.
D) Parents are taught to administer acetaminophen to relieve the discomfort and decrease fever associated with acute otitis media. Decongestants are not recommended for treatment of acute otitis media. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended. Placing infants to sleep with a pacifier can increase the incidence of otitis media.

Question 19

The nurse is caring for an older adult client who is hospitalized with a second episode of pneumonia in the past 18 months.The client has expressed frustration to the nurse and states,"I never got sick when I was younger.Why is this happening?" Which response by the nurse is most appropriate?

Accepted Answer

A) As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation.
B) As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation.
C) As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation.
D) As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation.

Question 20

A client is admitted to the intensive care unit with a systemic infection.Which manifestations will the nurse most likely assess in this client? Select all that apply.

Accepted Answer

A) Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. Edema and pain are symptoms of a local infection.
B) Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. Edema and pain are symptoms of a local infection.
C) Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. Edema and pain are symptoms of a local infection.
D) Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. Edema and pain are symptoms of a local infection.
E) Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. Edema and pain are symptoms of a local infection.

Quiz 9: Infection