Question 1

A patient is prescribed a trough blood level to evaluate the therapeutic effect of an antibiotic. The nurse realizes that this blood level should be drawn

Accepted Answer

A trough blood level is the lowest level of medication in the blood and is typically drawn just before the next dose of medication is administered. This ensures that the medication has fully absorbed and metabolized in the body, providing an accurate reading of the medication's effectiveness. Drawing the blood level 1-2 hours after the oral or 30 minutes after the intravenous administration would not accurately reflect the trough level. Drawing the blood level during the infusion of the antibiotic would result in a peak level, not a trough level.

Question 2

The nurse is planning care for a patient at risk for developing an infection. Which of the following interventions would the nurse include in this patient's plan of care?

Accepted Answer

Hand hygiene is the most effective way to prevent the spread of infections and is a fundamental practice in infection control.

Question 3

The nurse is instructing a patient on ways to prevent the onset of an infection. Which of the following should be included in these instructions?

Accepted Answer

Washing hands after using disposable tissues for nasal secretions is an important infection prevention measure as it helps to avoid the spread of germs from the hands to other parts of the body or to other people.

B, C and D are incorrect choices as reusing disposable razors increases the risk of infection, taking antibiotics until symptoms subside may lead to antibiotic resistance and limited interactions with people or crowds helps to prevent the spread of infectious diseases.

Question 4

An elderly patient has a small pressure ulcer located on the coccyx. Which of the following should the nurse do to promote healing of this patient's wound?

Accepted Answer

Encouraging high-protein food choices in the patient's diet can help promote healing of the pressure ulcer. Protein is important for tissue repair and regeneration. Limiting carbohydrate intake and restricting caloric intake may not be necessary for a small pressure ulcer on the coccyx. Encouraging high intake of vitamin E may help with wound healing, but it should not be the primary focus.

Question 5

The nurse, caring for patient diagnosed with a lung infection, realizes that which of the following immunoglobulin levels will be elevated for this patient?

Accepted Answer

The answer of The nurse, caring for patient diagnosed with...

Question 6

A patient is receiving intravenous vancomycin for the treatment of Clostridium difficile. The nurse assesses the patient for flushing, tachycardia, and hypotension during the infusion this medication because these symptoms indicate which of the following?

Accepted Answer

Flushing, tachycardia, and hypotension are symptoms of red man syndrome, a common adverse reaction to intravenous vancomycin.

Question 7

A patient's white blood cell count is 11,000/mm³. The nurse realizes that this value represents which of the following?

Accepted Answer

The white blood cell count represents the total number of circulating leukocytes, including all types of white blood cells such as neutrophils, eosinophils, and basophils.

Question 8

Which of the following assessment findings would indicate that a patient is experiencing a systemic reaction associated with an inflammatory response?

Accepted Answer

Edematous groin lymph nodes indicate a systemic reaction as they suggest lymphatic involvement, which is part of the body's systemic response to inflammation.

Question 9

A patient diagnosed with active tuberculosis is being admitted to the hospital. The nurse should prepare for this patient to be placed in which type of isolation?

Accepted Answer

Tuberculosis is a highly contagious disease that spreads through the air when an infected person talks, coughs, or sneezes. Therefore, the patient should be placed in airborne precautions to prevent the transmission of the bacteria to others. This includes placing the patient in a negative pressure room and providing the patient with a mask to wear when outside of the room.

Question 10

A patient is diagnosed with a positive tuberculosis skin test. The nurse realizes that this response is due to which of the following?

Accepted Answer

A positive tuberculosis skin test indicates a cell-mediated inflammatory response to the antigen in the test, which is the primary mechanism of immune response against tuberculosis. The other options are not relevant to this specific response.

Question 11

A patient is diagnosed with an antibiotic-resistant infection. Which of the following can the nurse do to reduce the spread of this infection?

Accepted Answer

Isolating the supplies used when caring for the patient helps prevent cross-contamination and reduces the spread of the antibiotic-resistant infection to other patients and healthcare workers.

Question 12

A patient sustains fractures to the ribs, both femurs, and one humerus. When planning care for this patient's immunologic status, the nurse should include which of the following?

Accepted Answer

Monitoring the complete blood count daily is important for assessing the patient's immunologic status, as changes in white blood cell count, hemoglobin, and platelets can indicate infection or other immune system dysfunction. Limiting iron-rich foods, performing passive range of motion to unaffected extremities, and keeping the patient on bed rest are not directly related to immunologic status.

Question 13

A patient who just delivered a newborn baby is concerned that the baby will "catch" a cold from one healthcare provider who was coughing and sneezing in the delivery room. With which of the following should the nurse respond to this patient?

Accepted Answer

The nurse should assure the patient that the newborn baby has some protection from infections from the time of birth as they receive antibodies from the mother during pregnancy. Isolating the baby or having everyone check the baby's temperature is not necessary unless there are signs of infection. It is not appropriate to tell the patient that the healthcare provider should not have been participating in their care without further information about the provider's illness.

Question 14

A patient tells the nurse that he's happy that his wife did not "catch" the same cold from which he has recently recovered. The nurse realizes that which of the following most likely occurred in his wife?

Accepted Answer

The fact that the patient's wife did not catch the same cold suggests that she has immunity to the virus. Since she did not exhibit any symptoms of the illness, it is likely that her body had already encountered and fought off the virus, leaving T-helper cells with memory of the previous exposure. This would allow her body to quickly recognize and fight off the virus if it were encountered again. Choice B, C, and D do not involve the development of immunity.

Question 15

The nurse, caring for a patient recovering from a splenectomy, realizes that which of the following will occur regarding this patient's immunity?

Accepted Answer

The spleen plays a role in filtering blood and removing old or damaged red blood cells, as well as producing certain types of immune cells. However, other organs such as the liver and bone marrow can take over these functions after a splenectomy. Therefore, option A is the correct answer. Option B is incorrect as the patient will not necessarily need to avoid infections every day of their life. Option C is incorrect as edematous lymph glands are not a common effect of a splenectomy. Option D is incorrect as the thymus gland does not perform the same functions as the spleen.

Question 16

A patient recovering from knee surgery is experiencing a surgical infection. Which of the following would indicate that the patient is demonstrating signs of a systemic reaction?  Select all that apply.

Accepted Answer

An elevated white blood cell count (WBC) and the presence of bands, which are immature white blood cells, can indicate a systemic reaction to an infection. Erythema and pain at the surgical site are localized symptoms, while a respiratory rate of 16 falls within a normal range and is not indicative of a significant systemic reaction.

Question 17

The nurse would be concerned that a patient is exhibiting signs and symptoms of inflammation when which of the following are assessed in a leg wound?  Select all that apply.

Accepted Answer

Leg edema, severe pain from swelling, and severe erythema of leg are all indicators of inflammation in a wound. A cool leg to touch and decreased peripheral pulses could be indicative of decreased blood flow, but not necessarily inflammation.

Question 18

While reviewing the white blood cell count differential for a patient, the nurse notes that the basophil count is elevated. Which of the following does this laboratory value indicate to the nurse?

Accepted Answer

An elevated basophil count often indicates an acute hypersensitivity/allergic reaction.

Question 19

A patient has been intubated to receive care in the intensive care unit. Which of the following types of infections is this patient at risk for developing?

Accepted Answer

Patients who are intubated are at a high risk for developing ventilator-associated pneumonia. This occurs when bacteria enter through the endotracheal tube and settle in the lungs.

Question 20

The nurse is concerned that an elderly patient could be at risk for developing an infection when which of the following interventions is implemented?

Accepted Answer

Urinary catheterization may increase the risk of developing a urinary tract infection, especially in elderly patients who may have impaired immune systems or chronic conditions. The other interventions mentioned do not typically increase the risk of infection.

Quiz 12: Nursing Care of Patients with Infections