Question 1

The nurse is concerned that a client with bowel and bladder dysfunction is at risk for developing an infection.Which actions should the nurse take to help reduce this client's risk for developing an infection? Select all that apply.
A) Turn and reposition the client every 2 hours.
B) Monitor intake and output.
C) Provide hygienic care after episodes of incontinence.
D) Use standard precautions when handling linen after episodes of incontinence.
E) Cover wounds with antibiotic ointment and sterile gauze.

Accepted Answer

A) Turning and repositioning is an intervention to maintain tissue integrity. Monitoring for dehydration will help reduce the risk of developing an infection because of bowel and bladder dysfunction. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will reduce the risk of transmitting an infection. Covering wounds with antibiotic ointment and sterile gauze is an intervention to maintain tissue integrity.
B) Turning and repositioning is an intervention to maintain tissue integrity. Monitoring for dehydration will help reduce the risk of developing an infection because of bowel and bladder dysfunction. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will reduce the risk of transmitting an infection. Covering wounds with antibiotic ointment and sterile gauze is an intervention to maintain tissue integrity.
C) Turning and repositioning is an intervention to maintain tissue integrity. Monitoring for dehydration will help reduce the risk of developing an infection because of bowel and bladder dysfunction. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will reduce the risk of transmitting an infection. Covering wounds with antibiotic ointment and sterile gauze is an intervention to maintain tissue integrity.
D) Turning and repositioning is an intervention to maintain tissue integrity. Monitoring for dehydration will help reduce the risk of developing an infection because of bowel and bladder dysfunction. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will reduce the risk of transmitting an infection. Covering wounds with antibiotic ointment and sterile gauze is an intervention to maintain tissue integrity.
E) Turning and repositioning is an intervention to maintain tissue integrity. Monitoring for dehydration will help reduce the risk of developing an infection because of bowel and bladder dysfunction. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will reduce the risk of transmitting an infection. Covering wounds with antibiotic ointment and sterile gauze is an intervention to maintain tissue integrity.

Question 2

The nurse is preparing discharge instructions for an older adult client with cellulitis of the leg.What should the nurse teach the client and family regarding ways to prevent this health problem from occurring in the future?
A) "Keep the client off her leg as much as possible."
B) "Bring the client to the doctor if there is a fall."
C) "Maintain a healthy diet."
D) "Do not allow the client to walk without assistance."

Accepted Answer

A) Older adult clients are susceptible to cellulitis, as their immune system and skin are compromised as they age. The best preventive measure to maintain skin integrity and a healthier immune system is good nutrition. Exercise is a good way to promote health, including walking. There is no data to support that the client needs assistance to ambulate. Cellulitis can occur on any part of the body, so preventing the client from using body parts, such as the legs, is not reasonable and does not prevent cellulitis. The nurse would instruct the family regarding signs and symptoms of developing cellulitis after a fall. It is not always necessary to bring the client to the doctor for a fall if no injuries were sustained.
B) Older adult clients are susceptible to cellulitis, as their immune system and skin are compromised as they age. The best preventive measure to maintain skin integrity and a healthier immune system is good nutrition. Exercise is a good way to promote health, including walking. There is no data to support that the client needs assistance to ambulate. Cellulitis can occur on any part of the body, so preventing the client from using body parts, such as the legs, is not reasonable and does not prevent cellulitis. The nurse would instruct the family regarding signs and symptoms of developing cellulitis after a fall. It is not always necessary to bring the client to the doctor for a fall if no injuries were sustained.
C) Older adult clients are susceptible to cellulitis, as their immune system and skin are compromised as they age. The best preventive measure to maintain skin integrity and a healthier immune system is good nutrition. Exercise is a good way to promote health, including walking. There is no data to support that the client needs assistance to ambulate. Cellulitis can occur on any part of the body, so preventing the client from using body parts, such as the legs, is not reasonable and does not prevent cellulitis. The nurse would instruct the family regarding signs and symptoms of developing cellulitis after a fall. It is not always necessary to bring the client to the doctor for a fall if no injuries were sustained.
D) Older adult clients are susceptible to cellulitis, as their immune system and skin are compromised as they age. The best preventive measure to maintain skin integrity and a healthier immune system is good nutrition. Exercise is a good way to promote health, including walking. There is no data to support that the client needs assistance to ambulate. Cellulitis can occur on any part of the body, so preventing the client from using body parts, such as the legs, is not reasonable and does not prevent cellulitis. The nurse would instruct the family regarding signs and symptoms of developing cellulitis after a fall. It is not always necessary to bring the client to the doctor for a fall if no injuries were sustained.

Question 3

A pediatric client is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection.Which nursing interventions are appropriate when providing care to this client? Select all that apply.
A) Encourage adequate fluid intake.
B) Monitor for allergic reaction.
C) Assess renal and liver function.
D) Obtain a baseline electrocardiogram.
E) Monitor vital signs.

Accepted Answer

A) Nursing interventions to support antibiotic therapy include encouraging an adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. A baseline electrocardiogram is appropriate for antimalarial medication.
B) Nursing interventions to support antibiotic therapy include encouraging an adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. A baseline electrocardiogram is appropriate for antimalarial medication.
C) Nursing interventions to support antibiotic therapy include encouraging an adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. A baseline electrocardiogram is appropriate for antimalarial medication.
D) Nursing interventions to support antibiotic therapy include encouraging an adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. A baseline electrocardiogram is appropriate for antimalarial medication.
E) Nursing interventions to support antibiotic therapy include encouraging an adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. A baseline electrocardiogram is appropriate for antimalarial medication.

Question 4

The nurse is assessing an older adult client who is recovering following a cholecystectomy.Which factor would increase this client's susceptibility to infection?
A) Intact mucous membranes
B) Surgical incision
C) Dry skin
D) Active bowel sounds

Accepted Answer

A) Certain factors will increase a client's susceptibility to microorganism growth and infection. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection.
B) Certain factors will increase a client's susceptibility to microorganism growth and infection. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection.
C) Certain factors will increase a client's susceptibility to microorganism growth and infection. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection.
D) Certain factors will increase a client's susceptibility to microorganism growth and infection. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection.

Question 5

A client is being treated for trachoma after returning from a safari trip to Africa.Which potential complication should the nurse consider when planning this client's care?
A) Scarring of the cornea
B) Eye muscle weakness
C) Damaged iris
D) Retinal detachment

Accepted Answer

A) Trachoma is a chronic form of conjunctivitis that causes the formation of granulation tissue that is abraded by the lashes, leading to scarring of the cornea and eventual blindness. The other options are not potential complications to this type of conjunctivitis.
B) Trachoma is a chronic form of conjunctivitis. The eye muscles, retina, and iris are not affected by the disease. The other options are not potential complications to this type of conjunctivitis
C) Trachoma is a chronic form of conjunctivitis. The eye muscles, retina, and iris are not affected by the disease. The other options are not potential complications to this type of conjunctivitis
D) Trachoma is a chronic form of conjunctivitis. The eye muscles, retina, and iris are not affected by the disease. The other options are not potential complications to this type of conjunctivitis

Question 6

The nursing is caring for a client who is hospitalized for cellulitis of the foot.Which nursing diagnoses should the nurse use to plan this client's care? Select all that apply.
A) Social Isolation related to skin infection
B) Altered Skin Integrity related to skin infection
C) Acute Pain related to skin infection
D) Disturbed Sleep Pattern related to skin infection
E) Powerlessness related to inability to control the infection

Accepted Answer

A) Clients with cellulitis have Altered Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given.
B) Clients with cellulitis have Altered Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given.
C) Clients with cellulitis have Altered Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given.
D) Clients with cellulitis have Altered Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given.
E) Clients with cellulitis have Altered Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given.

Question 7

A nurse is planning an in-service on preventing infection for the hospital staff nurses on a medical-surgical unit.Which nursing intervention is most effective in reducing the risk of infections?
A) Raising the temperature in the client's room
B) Assessing vital signs once daily
C) Wearing a mask for client care
D) Performing hand hygiene

Accepted Answer

A) Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Raising the temperature in a client's room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.
B) Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Raising the temperature in a client's room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.
C) Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Raising the temperature in a client's room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.
D) Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Raising the temperature in a client's room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.

Question 8

The nurse is providing discharge instructions to a client recovering from cellulitis.Which client statement indicates that this teaching has been effective?
A) "I will monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site."
B) "If the lesion looks healed, I will stop taking the antibiotics so that I will not develop resistance to antibiotics."
C) "If pustules develop, I will squeeze the lesion to remove the pus."
D) "Drainage from the site is an expected finding, and I should not be concerned."

Accepted Answer

A) The client will need to be taught to monitor for the signs and symptoms of infection. Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. Changes in the color, amount, and odor from drainage are cause for concern and should be monitored. The physician must be notified if these symptoms occur. Pustules are never to be squeezed open, as there is risk of greater infection. Stopping antibiotics before the doses are complete causes resistance.
B) The client will need to be taught to monitor for the signs and symptoms of infection. Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. Changes in the color, amount, and odor from drainage are cause for concern and should be monitored. The physician must be notified if these symptoms occur. Pustules are never to be squeezed open, as there is risk of greater infection. Stopping antibiotics before the doses are complete causes resistance.
C) The client will need to be taught to monitor for the signs and symptoms of infection. Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. Changes in the color, amount, and odor from drainage are cause for concern and should be monitored. The physician must be notified if these symptoms occur. Pustules are never to be squeezed open, as there is risk of greater infection. Stopping antibiotics before the doses are complete causes resistance.
D) The client will need to be taught to monitor for the signs and symptoms of infection. Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. Changes in the color, amount, and odor from drainage are cause for concern and should be monitored. The physician must be notified if these symptoms occur. Pustules are never to be squeezed open, as there is risk of greater infection. Stopping antibiotics before the doses are complete causes resistance.

Question 9

The nurse is teaching a group of adolescents at a local high school about skin infections.Which students does the nurse identify as at an increased risk for developing cellulitis? Select all that apply.
A) The female student who plucks her eyebrows.
B) The student with diabetes.
C) The student practicing hand hygiene.
D) The student who squeezes pimples.
E) The student who engages in contact sports.

Accepted Answer

A) The student who plucks hair risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes is at risk for foot lesions, which can lead to cellulitis if left untreated. Hand hygiene does not pose a risk for cellulitis. Contact sports do not pose a risk for cellulitis.
B) The student who plucks hair risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes is at risk for foot lesions, which can lead to cellulitis if left untreated. Hand hygiene does not pose a risk for cellulitis. Contact sports do not pose a risk for cellulitis.
C) The student who plucks hair risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes is at risk for foot lesions, which can lead to cellulitis if left untreated. Hand hygiene does not pose a risk for cellulitis. Contact sports do not pose a risk for cellulitis.
D) The student who plucks hair risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes is at risk for foot lesions, which can lead to cellulitis if left untreated. Hand hygiene does not pose a risk for cellulitis. Contact sports do not pose a risk for cellulitis.
E) The student who plucks hair risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes is at risk for foot lesions, which can lead to cellulitis if left untreated. Hand hygiene does not pose a risk for cellulitis. Contact sports do not pose a risk for cellulitis.

Question 10

A client receiving intravenous antibiotics for 3 days as treatment for cellulitis is being prepared for discharge.Which discharge order should the nurse anticipate for this client?
A) Low-sodium diet prescribed
B) Home healthcare aide for the client
C) Oral antibiotics to be continued at home
D) Orders for evaluation by physical therapy

Accepted Answer

A) Antibiotics should be taken for 10 days; therefore, the nurse anticipates oral antibiotics to be continues at home. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs home physical therapy.
B) Antibiotics should be taken for 10 days; therefore, the nurse anticipates oral antibiotics to be continues at home. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs home physical therapy.
C) Antibiotics should be taken for 10 days; therefore, the nurse anticipates oral antibiotics to be continues at home. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs home physical therapy.
D) Antibiotics should be taken for 10 days; therefore, the nurse anticipates oral antibiotics to be continues at home. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs home physical therapy.

Question 11

The nurse is teaching a child care class for mothers of young children.What should the nurse teach as being the most common mode of transmission of infectious disease?
A) Children who are playing board games
B) Children who are sitting together eating meals
C) Children who are playing with the same toy
D) Children who don't wash their hands after using the bathroom

Accepted Answer

A) The fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission.
B) The fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission.
C) The fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission.
D) The fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission.

Question 12

A home health nurse manager is instructing new staff regarding evidence-based practices of wound management.Which will the manager's teaching include? Select all that apply.
A) "Wounds should be kept dry and should not be covered until a scab forms."
B) "Allowing a wound to remain dry or applying a dry wound covering may slow the healing process."
C) "Wound covering helps maintain a dry environment, decreasing the chance of infection such as cellulitis."
D) "Proper wound moisture management can reduce pain and improve the cosmetic outcome."
E) "Three methods for proper wound management include cleansing techniques, proper wound covering, and ointment application."

Accepted Answer

A) Individuals with open wounds are more susceptible to contracting a skin infection such as cellulitis. Many believe wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps to maintain a moist environment, decreasing the chance of infection such as cellulitis. The three methods of proper moist wound management include cleansing techniques, proper wound covering, and ointment application. Proper wound moisture management also reduces pains and improves the cosmetic outcome.
B) Individuals with open wounds are more susceptible to contracting a skin infection such as cellulitis. Many believe wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps to maintain a moist environment, decreasing the chance of infection such as cellulitis. The three methods of proper moist wound management include cleansing techniques, proper wound covering, and ointment application. Proper wound moisture management also reduces pains and improves the cosmetic outcome.
C) Individuals with open wounds are more susceptible to contracting a skin infection such as cellulitis. Many believe wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps to maintain a moist environment, decreasing the chance of infection such as cellulitis. The three methods of proper moist wound management include cleansing techniques, proper wound covering, and ointment application. Proper wound moisture management also reduces pains and improves the cosmetic outcome.
D) Individuals with open wounds are more susceptible to contracting a skin infection such as cellulitis. Many believe wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps to maintain a moist environment, decreasing the chance of infection such as cellulitis. The three methods of proper moist wound management include cleansing techniques, proper wound covering, and ointment application. Proper wound moisture management also reduces pains and improves the cosmetic outcome.
E) Individuals with open wounds are more susceptible to contracting a skin infection such as cellulitis. Many believe wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps to maintain a moist environment, decreasing the chance of infection such as cellulitis. The three methods of proper moist wound management include cleansing techniques, proper wound covering, and ointment application. Proper wound moisture management also reduces pains and improves the cosmetic outcome.

Question 13

The nurse is teaching a client with cellulitis about ways to avoid future infections.Which client statements indicate that teaching has been effective? Select all that apply.
A) "I should use antibiotic soap to cleanse the wounds."
B) "I should eat a lot of rice to increase my intake of vitamin C."
C) "I will contact the doctor if I have a temperature of 99.5°F or higher."
D) "I will not swim in lakes."
E) "I can stop taking the antibiotics when the swelling subsides."

Accepted Answer

A) It is recommended that the client wash affected areas with an antibacterial soap. The water in lakes can be contaminated and can cause an infection. Vitamin C-rich foods include citrus fruits and strawberries, but not rice. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered.
B) It is recommended that the client wash affected areas with an antibacterial soap. The water in lakes can be contaminated and can cause an infection. Vitamin C-rich foods include citrus fruits and strawberries, but not rice. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered.
C) It is recommended that the client wash affected areas with an antibacterial soap. The water in lakes can be contaminated and can cause an infection. Vitamin C-rich foods include citrus fruits and strawberries, but not rice. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered.
D) It is recommended that the client wash affected areas with an antibacterial soap. The water in lakes can be contaminated and can cause an infection. Vitamin C-rich foods include citrus fruits and strawberries, but not rice. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered.
E) It is recommended that the client wash affected areas with an antibacterial soap. The water in lakes can be contaminated and can cause an infection. Vitamin C-rich foods include citrus fruits and strawberries, but not rice. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered.

Question 14

An adolescent is diagnosed with cellulitis from picking the scabs on healing facial pimples.The mother scolds the child for eating too many oily foods that cause the acne.Based on this data,which topic is priority when providing education to the child and mother?
A) Antibiotics are the best way to prevent cellulitis.
B) Oily foods do not cause pimples or cellulitis.
C) Consumption of oily foods poses an increased risk for cellulitis.
D) Popping the pimples spreads the germs over the face.

Accepted Answer

A) Foods do not cause acne and, therefore, cellulitis. Antibiotics are the best way to treat, not prevent, cellulitis. Popping pimples drives the infection deeper into the skin and may cause more serious infections.
B) Foods do not cause acne and, therefore, cellulitis. Antibiotics are the best way to treat, not prevent, cellulitis. Popping pimples drives the infection deeper into the skin and may cause more serious infections.
C) Foods do not cause acne and, therefore, cellulitis. Antibiotics are the best way to treat, not prevent, cellulitis. Popping pimples drives the infection deeper into the skin and may cause more serious infections.
D) Foods do not cause acne and, therefore, cellulitis. Antibiotics are the best way to treat, not prevent, cellulitis. Popping pimples drives the infection deeper into the skin and may cause more serious infections.

Question 15

The nurse is caring for a client who is being discharged following an appendectomy.Which instruction is the most important for the nurse to teach this client regarding wound healing?
A) "Thoroughly irrigate the wound with hydrogen peroxide once a day."
B) "Apply a lubricating lotion to the edges of the wound twice a day."
C) "Add more fruits and vegetables to your diet."
D) "Notify the healthcare provider if you notice swelling, warmth, or tenderness at the wound site."

Accepted Answer

A) A client being discharged with a surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.
B) A client being discharged with a surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.
C) A client being discharged with a surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.
D) A client being discharged with a surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.

Question 16

The nurse is teaching a class on infection control.Which nursing measure is most appropriate in breaking a link in the chain of infection?
A) Place contaminated linens in a paper bag.
B) Use personal protective equipment (PPE).
C) Cover one's cough by placing the mouth in the hand.
D) Wear sterile gloves for client care.

Accepted Answer

A) PPE, according to OSHA standards, has to be used whenever the situation dictates and is a nursing measure to break a link in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Covering one's mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. However, the cough should be covered in the elbow, not in the hand. Non-sterile gloves have to be worn when providing certain aspects of client care. The gloves should be changed between client, and hands are to be washed.
B) PPE, according to OSHA standards, has to be used whenever the situation dictates and is a nursing measure to break a link in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Covering one's mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. However, the cough should be covered in the elbow, not in the hand. Non-sterile gloves have to be worn when providing certain aspects of client care. The gloves should be changed between client, and hands are to be washed.
C) PPE, according to OSHA standards, has to be used whenever the situation dictates and is a nursing measure to break a link in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Covering one's mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. However, the cough should be covered in the elbow, not in the hand. Non-sterile gloves have to be worn when providing certain aspects of client care. The gloves should be changed between client, and hands are to be washed.
D) PPE, according to OSHA standards, has to be used whenever the situation dictates and is a nursing measure to break a link in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Covering one's mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. However, the cough should be covered in the elbow, not in the hand. Non-sterile gloves have to be worn when providing certain aspects of client care. The gloves should be changed between client, and hands are to be washed.

Question 17

The nurse is caring for a client who is experiencing a systemic infection after a total knee replacement.Which diagnostic tests will be used to validate the presence of this infection? Select all that apply.
A) Serum electrolyte levels
B) Urinalysis
C) White blood cell differential
D) White blood cell count
E) Wound culture

Accepted Answer

A) Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.
B) Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.
C) Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.
D) Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.
E) Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.

Question 18

A nurse is caring for a client diagnosed with Erysipelas whose lower extremities are bright red and raised with well-defined borders.(See image.)Which is the most likely causative organism of this condition? 
A) Group B streptococcus.
B) Group A streptococcus.
C) Staphylococcus aureus.
D) Candida albicans.

Accepted Answer

A) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders.
B) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders.
C) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders.
D) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders.

Question 19

The nurse is assessing a young adult college student who is experiencing red,swollen eyes that are oozing a yellowish drainage.The client is complaining of photophobia.Which is the most appropriate question for the nurse to ask the client?
A) "Have you had extra caffeine this week?"
B) "Did you get sand in your eye recently?"
C) "Have you been exposed to HIV?"
D) "Have any of your friends experienced these symptoms?"

Accepted Answer

A) The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.
B) The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.
C) The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.
D) The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.

Question 20

A nurse is assessing a client who recently returned from a camping trip.The client is experiencing edema in the right foot.When assessing the foot,the nurse notes a sore and suspects cellulitis.Which further data will the nurse assess to support the suspicion?
A) BUN and creatinine
B) Breath sounds
C) Blood cultures
D) Redness, pain, and drainage at the site

Accepted Answer

A) Classic signs of cellulitis are swelling, pain, redness, and possibly drainage at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot. Blood cultures are ordered by the physician and are not nursing assessments.
B) Classic signs of cellulitis are swelling, pain, redness, and possibly drainage at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot. Blood cultures are ordered by the physician and are not nursing assessments.
C) Classic signs of cellulitis are swelling, pain, redness, and possibly drainage at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot. Blood cultures are ordered by the physician and are not nursing assessments.
D) Classic signs of cellulitis are swelling, pain, redness, and possibly drainage at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot. Blood cultures are ordered by the physician and are not nursing assessments.

Quiz 9: Infection

The nurse is concerned that a client with bowel and bladder dysfunction is at risk for developing an infection.Which actions should the nurse take to help reduce this client's risk for developing an infection? Select all that apply.

The nurse is preparing discharge instructions for an older adult client with cellulitis of the leg.What should the nurse teach the client and family regarding ways to prevent this health problem from occurring in the future?

A pediatric client is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection.Which nursing interventions are appropriate when providing care to this client? Select all that apply.

The nurse is assessing an older adult client who is recovering following a cholecystectomy.Which factor would increase this client's susceptibility to infection?

A client is being treated for trachoma after returning from a safari trip to Africa.Which potential complication should the nurse consider when planning this client's care?

The nursing is caring for a client who is hospitalized for cellulitis of the foot.Which nursing diagnoses should the nurse use to plan this client's care? Select all that apply.

A nurse is planning an in-service on preventing infection for the hospital staff nurses on a medical-surgical unit.Which nursing intervention is most effective in reducing the risk of infections?

The nurse is providing discharge instructions to a client recovering from cellulitis.Which client statement indicates that this teaching has been effective?

The nurse is teaching a group of adolescents at a local high school about skin infections.Which students does the nurse identify as at an increased risk for developing cellulitis? Select all that apply.

A client receiving intravenous antibiotics for 3 days as treatment for cellulitis is being prepared for discharge.Which discharge order should the nurse anticipate for this client?

The nurse is teaching a child care class for mothers of young children.What should the nurse teach as being the most common mode of transmission of infectious disease?

A home health nurse manager is instructing new staff regarding evidence-based practices of wound management.Which will the manager's teaching include? Select all that apply.

The nurse is teaching a client with cellulitis about ways to avoid future infections.Which client statements indicate that teaching has been effective? Select all that apply.

An adolescent is diagnosed with cellulitis from picking the scabs on healing facial pimples.The mother scolds the child for eating too many oily foods that cause the acne.Based on this data,which topic is priority when providing education to the child and mother?

The nurse is caring for a client who is being discharged following an appendectomy.Which instruction is the most important for the nurse to teach this client regarding wound healing?

The nurse is teaching a class on infection control.Which nursing measure is most appropriate in breaking a link in the chain of infection?

The nurse is caring for a client who is experiencing a systemic infection after a total knee replacement.Which diagnostic tests will be used to validate the presence of this infection? Select all that apply.

A nurse is caring for a client diagnosed with Erysipelas whose lower extremities are bright red and raised with well-defined borders.(See image.) Which is the most likely causative organism of this condition?

The nurse is assessing a young adult college student who is experiencing red,swollen eyes that are oozing a yellowish drainage.The client is complaining of photophobia.Which is the most appropriate question for the nurse to ask the client?

A nurse is assessing a client who recently returned from a camping trip.The client is experiencing edema in the right foot.When assessing the foot,the nurse notes a sore and suspects cellulitis.Which further data will the nurse assess to support the suspicion?