Question 1

The nurse is caring for a group of medical-surgical patients.Which patient is most at risk for developing an infection?

Accepted Answer

The patient who is recovering from a right total hip arthroplasty has had a surgical procedure wherein bone was removed from the body and an implant was placed within the patient.The patient has a large incision from surgery.The patient also has an intravenous infusion to provide fluids and medication.All these breaks in the skin increase the likelihood of infection.The patient has been given anaesthetics and medication for pain.Both of these depress the respiratory system and have the potential to decrease the expansion of alveoli and to increase the chance of infection in the respiratory system.The other patients may have one break in the skin when an intravenous infusion is used.

Question 2

The patient and the nurse are discussing Rickettsia rickettsii,the cause of Rocky Mountain spotted fever.Which patient statement to the nurse indicates understanding regarding the mode of transmission of this disease?

Accepted Answer

Each infectious disease has a specific mode of transmission: a component of the chain of infection.Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks.Wearing a repellent that is designed for repelling ticks,mosquitoes,and other insects can help in preventing transmission of this disease.Drinking plenty of uncontaminated water,wearing sunscreen,and using alcohol-based hand gels for cleaning hands are all important activities to participate in while camping,but they do not contribute to or prevent transmission of this disease.

Question 3

Which of these interventions would take priority and should be included in a plan of care for a patient who presents with pneumonia?

Accepted Answer

Systemic infection causes more generalized symptoms than does local infection.This type of infection can result in fever,fatigue,nausea and vomiting,and malaise.The nurse should be alert for changes in the patient's level of activity and responsiveness.Respiratory infection may result in a productive cough with purulent sputum,shortness of breath,and activity intolerance.Nurses do not assume but assess and communicate with the patient about pain,temperature,and ice chips.Asking these questions would not be a priority as much as assessing the patient and determining the effect that the systemic infection is having on the patient.

Question 4

The nurse is caring for a patient who is susceptible to infection.Which of the following nursing interventions will assist in decreasing the risk of infection?

Accepted Answer

When protein intake is inadequate as a result of poor diet,the rate of protein breakdown exceeds that of tissue synthesis.A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces the body's defences against infection and impairs wound healing.Teaching the patient about fall prevention,how to measure temperature,or about the effects of alcohol does not decrease the risk of infection.

Question 5

The nurse is caring for a school-aged child who has injured his leg after a bicycle accident.To determine whether the child is experiencing a localized inflammatory response,the nurse should assess for which of these signs and symptoms?

Accepted Answer

The body's cellular response to an injury is seen as inflammation.Inflammation can be triggered by physical agents,chemical agents,or microorganisms.Signs of localized inflammation include swelling,redness,heat,pain or tenderness,and loss of function in the affected body part.Systemic signs of inflammation include fever,malaise,and anorexia,as well as nausea and vomiting.Chest pain,shortness of breath,and nausea and vomiting are signs and symptoms of a cardiac alteration.Dizziness and disorientation to time,date,and place may indicate a neurologic alteration.

Question 6

The nurse is caring for a patient in the labour and delivery area.When an assessment of the patient for dilatation and effacement is nearly completed,the electronic infusion device being used on the IV infusion sounds an alarm.Which of these actions is most appropriate for the nurse to take?

Accepted Answer

Medical asepsis or clean technique includes procedures to decrease the number of organisms present and to prevent the transfer of organisms.Wearing gloves while assessing the dilatation and effacement of a patient in labour,removing gloves,washing hands after contact with body fluids,and then assessing the IV infusion will assist in the prevention and transfer of any potential organisms to this intravenous line.Completing the assessment,removing gloves,and silencing the alarm leaves out the crucial step of decontaminating and washing the hands.Discontinuing the assessment and assessing the infusion leaves out removing the gloves and decontamination,as well as completing the assessment for the patient.Discontinuing the assessment,removing gloves,using hand gel,and assessing the infusion is incorrect because,upon exposure to body fluids,washing hands is appropriate.

Question 7

The nurse is caring for a patient with an incision.Which of the following actions would best indicate an understanding of medical and surgical asepsis?

Accepted Answer

The nurse should use clean gloves (medical asepsis)to remove contaminated dressings and should use sterile supplies,including gloves and dressings (surgical asepsis-sterile technique),to reapply sterile dressings.Wearing sterile gowns and gloves is not necessary for removing soiled dressings.Donning clean gloves to dress a sterile wound would contaminate the sterile supplies.Utilizing clean supplies for a sterile dressing would not help in decreasing the number of microbes at the incision site.

Question 8

The nurse is inserting a peripherally inserted central catheter (PICC)into the patient.Aware of the potential for health care-associated infection,the nurse is careful to do which of the following?

Accepted Answer

One of the sites for health care-associated infection is the bloodstream.Bloodstream infection can be caused by improper care of the needle insertion site.Two percent chlorhexidine gluconate is an antiseptic solution that,when applied properly and allowed to dry,reduces microbial counts at the insertion site.Selecting the correct catheter size,using nonallergenic tape and dressings,and utilizing local anaesthetic are important steps for individualized patient care and are typically part of the procedure,but they do not affect the cause of a health care-associated infection by,for example,decreasing microbial counts at the insertion site.

Question 9

The nurse is admitting a patient with an infectious disease process.What question would be appropriate for a nurse to ask this patient?

Accepted Answer

Some factors increase the susceptibility of an individual to infection.These include age,nutritional status,presence of chronic disease,trauma,and smoking.The other questions are part of an admission assessment process but are not pertinent to the infectious disease process.

Question 10

The nurse is caring for an adult patient in the clinic who is a victim of flooding and has been evacuated.The patient presents with signs and symptoms of a urinary tract infection.Along with needed education surrounding this diagnosis,the nurse teaches the patient about rest,exercise,eating properly,and how to utilize deep breathing and visualization.Which of the following explanations would best support these nursing interventions?

Accepted Answer

The body responds to emotional or physical stress by the general adaptation syndrome.If stress extends for long periods of time,this can lead to exhaustion,whereby energy stores are depleted and the body has no defences against invading organisms.Techniques of deep breathing and visualization may be helpful with pain,but none of the interventions listed is a standard intervention taught at every health care visit.

Question 11

A patient with diabetes presents to the clinic for a dressing change.The wound is located on the right foot and has purulent yellow drainage.Which of these interventions would be most appropriate for the nurse to provide?

Accepted Answer

Localized infections are most common in the skin or with mucous membrane breakdown.The nurse should wear gloves and other personal protective equipment as appropriate when examining or providing treatment to localized infected areas.Positioning the patient,explaining the procedure,and reviewing the medication list are all tasks that need to be completed,but preventing the spread of infection takes precedence.

Question 12

The infection control nurse is reviewing data for the medical-surgical unit.The nurse notices a spike in postoperative infections on this unit and categorizes this type of health care-associated infection as which infections?

Accepted Answer

An exogenous organism is one that is present outside the patient.A postoperative infection is an exogenous infection because the organism that has caused the infection originates from outside the body.An example is Staphylococcus aureus.An endogenous organism is part of the normal flora of residing virulent organisms that could cause infection.An endogenous infection can occur when part of the patient's flora becomes altered,and overgrowth results.Iatrogenic infection results from a diagnostic or therapeutic procedure such as a colonoscopy.Nosocomial infection is the term formerly used for health care-acquired infection.

Question 13

The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access device.Which nursing intervention is priority in this procedure?

Accepted Answer

Patients with disease processes of the immune system are at particular risk for infection.These diseases include leukemia,acquired immune deficiency syndrome (AIDS),lymphoma,and aplastic anemia.These disease processes weaken the defences against an infectious organism.Any time an intravenous device is accessed,aseptic technique must be maintained with wearing of appropriate personal protective equipment,preparation of the skin,and use of sterile gloves,sterile supplies,appropriate flushing,and appropriate discontinuation.Reviewing the procedure with the patient,positioning the patient,and gathering the supplies are all important steps in the procedure but are not the priority in the procedure.

Question 14

The nurse is dressed and is preparing to care for a patient in the perioperative area.The nurse has scrubbed her hands and has donned a sterile gown and gloves.Which action would indicate a break in sterile technique?

Accepted Answer

Once a nurse is gowned and gloved with sterile gown and gloves,touching nonsterile protective eyewear would indicate a break in sterile technique.Sterile objects remain sterile only when touched by another sterile object.Standing with hands folded on chest is common practice and prevents arms and hands from touching unsterile objects.Accepting sterile supplies from the surgeon who has opened them with the appropriate technique is acceptable.Staying with a sterile table once opened is a common practice to ascertain that no one or nothing has contaminated the table.

Question 15

A woman presents to the clinic with reports of a white discharge and itching in the vaginal area.During the health history,which of these questions should the nurse prioritize?

Accepted Answer

The body contains normal flora (microorganisms)that live on the surface of skin,saliva,oral mucosa,gastrointestinal tract,and genitourinary tract.The normal flora of the vagina causes vaginal secretions to achieve a low pH.This inhibits the growth of many microorganisms.Antibiotics and oral contraceptives can disrupt normal flora in the vagina,which can lead to an overgrowth of Candida albicans in that area.It is important to ask the patient about current medications to obtain information that may assist with diagnosis.Visiting the physician is important for the patient's health maintenance.Learning about the patient's eating and sleeping habits will assist in the plan of care.

Question 16

The nurse is providing an educational session for a group of preschool workers.The nurse reminds the group that the most important thing to do to prevent the spread of infection is what?

Accepted Answer

The most important thing that individuals can do to prevent the spread of infection is to perform hand hygiene before and after eating,going to the bathroom,changing a diaper,and wiping a nose,as well as after cleaning toys or tables,after picking up after the children,and between touching each individual child.It is important for preschool children to have a nutritious diet;a healthy individual can fight infection more effectively.A physician,along with the parent,makes decisions about dietary supplements.Cleaning the toys can decrease the number of pathogens but is not the most important way to prevent the spread of infection.

Question 17

The nurse is providing an education session to an adult community group about the effects of smoking.Which of the following is the most important point to be included in the educational session?

Accepted Answer

A normal defence mechanism against infection in the respiratory tract is the cilia lining the upper airways of the lungs and normal mucus.When a patient inhales a microbe,the cilia and mucus trap the microbe and sweep them up and out to be expectorated or swallowed.Smoking may alter this defence mechanism and increase the patient's potential for infection.Smoking can be expensive,the smell does cling to hair and clothing,and the tar within the smoke can alter the colour of a patient's nails.These points can be included in the education but do not constitute the most important information.

Question 18

Which of the following nursing actions would most increase a patient's risk for developing a health care-associated infection?

Accepted Answer

Using clean technique (medical asepsis)to insert a urinary catheter would place the patient at risk for a health care-associated infection.Urinary catheters need to be inserted with sterile technique,also referred to as surgical asepsis.This involves eliminating all microorganisms,including pathogens and spores,from an object or area.Placing a catheter into a sterile body cavity such as the bladder necessitates sterile technique.Sterile technique should also be used in suctioning an airway because the airway is considered a sterile body cavity.Keeping the urinary catheter drainage bag below the bladder helps decrease the risk of developing a health care-associated infection because it prevents reflux of urine from the bag back into the bladder.Bottled solutions may be used repeatedly during a 24-hour period;however,special care is needed to ensure that the solution in the bottle remains sterile.After 24 hours,the solution should be discarded.

Question 19

Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response?

Accepted Answer

One sign of the inflammatory response,particularly after an injury,is swelling or edema.Resting the affected injured area,applying ice as ordered,wrapping the area to provide support-particularly if it is an extremity-and elevating the injured area will help decrease swelling or edema.Turning,coughing,and deep breathing are utilized for postoperative patients and for immobilized patients to help prevent an infectious process such as pneumonia.Orientation to date,time,and place is assessed in many patients who may be confused.Passive range of motion is utilized for individuals who need to improve movement of their extremities,including immobilized patients.

Question 20

The patient underwent a surgical procedure,and povidone-iodine (Betadine)was utilized in the surgical preparation.Two days postoperatively,the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage.The patient reports tenderness at the incision site.The patient's temperature is 38.1°C (100.5°F)and the white blood cell count (WBC)is 10,500/mm³ (10.5 × 10?/L).Which nursing action should the nurse take?

Accepted Answer

Organisms enter the body in several different ways.Proper skin preparation for surgery is essential for decreasing the chance of infection.The nursing assessment indicates signs and symptoms of infection,and the health care provider should be notified.Changing the dressing may be a need during the shift but is not a first priority.Checking to see about the skin preparation used 2 days ago may or may not be useful information at this time.Collecting supplies for culture may be necessary after the nurse talks to the physician.

Quiz 33: Infection Control