Question 1

A nurse is caring for a client with septicemia. What assessment by the nurse best addresses the potential for ineffective peripheral perfusion?

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 2

The nurse is providing discharge teaching to a client recovering from pneumonia. Which client statement indicates that additional teaching is needed?

Accepted Answer

A)Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. Because the pneumococcal vaccine is made of antigens from 23 types of pneumococcus, a type of bacteria, it only protects against bacterial pneumonias.
B)Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. Because the pneumococcal vaccine is made of antigens from 23 types of pneumococcus, a type of bacteria, it only protects against bacterial pneumonias.
C)Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. Because the pneumococcal vaccine is made of antigens from 23 types of pneumococcus, a type of bacteria, it only protects against bacterial pneumonias.
D)Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. Because the pneumococcal vaccine is made of antigens from 23 types of pneumococcus, a type of bacteria, it only protects against bacterial pneumonias.

Question 3

The nurse is caring for a client who develops a fever and productive cough after abdominal surgery. Which orders should the nurse expect from the healthcare provider? 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 included in routine testing for this scenario. The client likely has an infectious disease that 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 included in routine testing for this scenario. The client likely has an infectious disease that 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 included in routine testing for this scenario. The client likely has an infectious disease that 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 included in routine testing for this scenario. The client likely has an infectious disease that 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 included in routine testing for this scenario. The client likely has an infectious disease that is not contagious. Isolation precautions are usually not ordered for noncontagious infections.

Question 4

The nurse is caring for an older adult client who developed sepsis from a pressure ulcer while residing in a long-term care facility. The family asks how they can help prevent this from happening again in the future. Which response by the nurse is best?

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 5

Which type of pneumonia rarely occurs in individuals with normal immune function?

Accepted Answer

A)Individuals who are significantly immunocompromised are at significant risk of developing pneumonia caused by Pneumocystis jiroveci. Immunity to P. jiroveci is nearly universal, except in those who are immunocompromised. The influenza virus, Mycoplasma pneumoniae, and Streptococcus pneumonia are all common causes of pneumonia in the general population.
B)Individuals who are significantly immunocompromised are at significant risk of developing pneumonia caused by Pneumocystis jiroveci. Immunity to P. jiroveci is nearly universal, except in those who are immunocompromised. The influenza virus, Mycoplasma pneumoniae, and Streptococcus pneumonia are all common causes of pneumonia in the general population.
C)Individuals who are significantly immunocompromised are at significant risk of developing pneumonia caused by Pneumocystis jiroveci. Immunity to P. jiroveci is nearly universal, except in those who are immunocompromised. The influenza virus, Mycoplasma pneumoniae, and Streptococcus pneumonia are all common causes of pneumonia in the general population.
D)Individuals who are significantly immunocompromised are at significant risk of developing pneumonia caused by Pneumocystis jiroveci. Immunity to P. jiroveci is nearly universal, except in those who are immunocompromised. The influenza virus, Mycoplasma pneumoniae, and Streptococcus pneumonia are all common causes of pneumonia in the general population.

Question 6

The nurse in an inner city clinic is providing a health screening for a homeless client with a history of drug abuse. The client has a chronic nonproductive cough. For which should the nurse expect to screen this client?

Accepted Answer

A)The homeless client who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this client for TB. There is no evidence to support the need to screen the client for sickle cell disease, herpes zoster, or sick sinus syndrome.
B)The homeless client who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this client for TB. There is no evidence to support the need to screen the client for sickle cell disease, herpes zoster, or sick sinus syndrome.
C)The homeless client who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this client for TB. There is no evidence to support the need to screen the client for sickle cell disease, herpes zoster, or sick sinus syndrome.
D)The homeless client who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this client for TB. There is no evidence to support the need to screen the client for sickle cell disease, herpes zoster, or sick sinus syndrome.

Question 7

The nurse is admitting a client to the intensive care unit. Earlier, the client presented to the emergency department in early septic shock. Given this information, which assessment findings should the nurse anticipate? 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 8

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

Question 9

Which intervention should the nurse carry out to manage fever in a client with pneumonia? Select all that apply.

Accepted Answer

A)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)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)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)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)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 10

A 1-month-old infant is admitted to the hospital with a temperature of 102°F. What is the rationale for a complete septic workup?

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 11

Which of the following is not one of the four distinct patterns of pneumonia?

Accepted Answer

A)The four distinct patterns of pneumonia are lobar pneumonia, bronchopneumonia, interstitial pneumonia, and miliary pneumonia. Alveolar pneumonia is not a typical pattern for pneumonia.
B)The four distinct patterns of pneumonia are lobar pneumonia, bronchopneumonia, interstitial pneumonia, and miliary pneumonia. Alveolar pneumonia is not a typical pattern for pneumonia.
C)The four distinct patterns of pneumonia are lobar pneumonia, bronchopneumonia, interstitial pneumonia, and miliary pneumonia. Alveolar pneumonia is not a typical pattern for pneumonia.
D)The four distinct patterns of pneumonia are lobar pneumonia, bronchopneumonia, interstitial pneumonia, and miliary pneumonia. Alveolar pneumonia is not a typical pattern for pneumonia.

Question 12

List the pathophysiology concepts related to the onset of sepsis in sequential order.

Accepted Answer

The pathophysiology of sepsis occurs as follows: Endotoxin released by microorganisms sets off an out-of-control inflammatory process; macrophage-producing cytokines are released; vasodilation with increased capillary permeability and fluid leak; neutrophils arrive and multiply, occluding capillaries.

Question 13

Which finding supports the nurse's evaluation that an older adult client with sepsis has maintained a normal mental status?

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 14

The nurse is preparing to assess an older adult client admitted with tuberculosis. Which assessment finding does the nurse anticipate?

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 more common in younger adults but 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 more common in younger adults but 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 more common in younger adults but 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 more common in younger adults but are not considered presenting symptoms of tuberculosis in the older adult.

Question 15

What is the primary rationale for maintaining adequate hydration in clients with pneumonia?

Accepted Answer

A)Maintaining adequate hydration can help in all four of these areas depending on the nature of the client's condition. However, for clients with pneumonia, the most important reason to maintain adequate hydration is that this helps keep secretions in the lungs thin, which makes them easier to expectorate. This helps keep the airway clear, which is a priority for clients with pneumonia.
B)Maintaining adequate hydration can help in all four of these areas depending on the nature of the client's condition. However, for clients with pneumonia, the most important reason to maintain adequate hydration is that this helps keep secretions in the lungs thin, which makes them easier to expectorate. This helps keep the airway clear, which is a priority for clients with pneumonia.
C)Maintaining adequate hydration can help in all four of these areas depending on the nature of the client's condition. However, for clients with pneumonia, the most important reason to maintain adequate hydration is that this helps keep secretions in the lungs thin, which makes them easier to expectorate. This helps keep the airway clear, which is a priority for clients with pneumonia.
D)Maintaining adequate hydration can help in all four of these areas depending on the nature of the client's condition. However, for clients with pneumonia, the most important reason to maintain adequate hydration is that this helps keep secretions in the lungs thin, which makes them easier to expectorate. This helps keep the airway clear, which is a priority for clients with pneumonia.

Question 16

The nurse is providing teaching on preventing 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 17

One method of preventing sepsis in hospitalized clients is

Accepted Answer

A)One risk factor for developing sepsis is not using aseptic techniques and good hand washing techniques when inserting a catheter. Following standard guidelines for using aseptic and hand washing techniques when inserting or removing a catheter can help prevent sepsis. Not all clients who are at risk for sepsis need to be placed in a negative airflow room or require airborne precautions during assessment. Teaching proper techniques for using tampons will help prevent sepsis, but this is more appropriate for clients in the community rather than hospitalized clients.
B)One risk factor for developing sepsis is not using aseptic techniques and good hand washing techniques when inserting a catheter. Following standard guidelines for using aseptic and hand washing techniques when inserting or removing a catheter can help prevent sepsis. Not all clients who are at risk for sepsis need to be placed in a negative airflow room or require airborne precautions during assessment. Teaching proper techniques for using tampons will help prevent sepsis, but this is more appropriate for clients in the community rather than hospitalized clients.
C)One risk factor for developing sepsis is not using aseptic techniques and good hand washing techniques when inserting a catheter. Following standard guidelines for using aseptic and hand washing techniques when inserting or removing a catheter can help prevent sepsis. Not all clients who are at risk for sepsis need to be placed in a negative airflow room or require airborne precautions during assessment. Teaching proper techniques for using tampons will help prevent sepsis, but this is more appropriate for clients in the community rather than hospitalized clients.
D)One risk factor for developing sepsis is not using aseptic techniques and good hand washing techniques when inserting a catheter. Following standard guidelines for using aseptic and hand washing techniques when inserting or removing a catheter can help prevent sepsis. Not all clients who are at risk for sepsis need to be placed in a negative airflow room or require airborne precautions during assessment. Teaching proper techniques for using tampons will help prevent sepsis, but this is more appropriate for clients in the community rather than hospitalized clients.

Question 18

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, 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 atelectasis, renal failure, or reduced peristalsis.
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 atelectasis, renal failure, or reduced peristalsis.
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 atelectasis, renal failure, or reduced peristalsis.
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 atelectasis, renal failure, or reduced peristalsis.

Question 19

Which diagnostic test result is consistent with a diagnosis of septic shock?

Accepted Answer

A)During septic shock, fluid leaks from the intravascular to the extravascular spaces, causing hemoglobin and hematocrit concentrations that are higher than normal. During septic shock, the blood pH will be lower than normal (indicating acidosis), and the PaCO₂ and potassium level will increase. B)During septic shock, fluid leaks from the intravascular to the extravascular spaces, causing hemoglobin and hematocrit concentrations that are higher than normal. During septic shock, the blood pH will be lower than normal (indicating acidosis), and the PaCO₂ and potassium level will increase. C)During septic shock, fluid leaks from the intravascular to the extravascular spaces, causing hemoglobin and hematocrit concentrations that are higher than normal. During septic shock, the blood pH will be lower than normal (indicating acidosis), and the PaCO₂ and potassium level will increase. D)During septic shock, fluid leaks from the intravascular to the extravascular spaces, causing hemoglobin and hematocrit concentrations that are higher than normal. During septic shock, the blood pH will be lower than normal (indicating acidosis), and the PaCO₂ and potassium level will increase.

Question 20

The provider has ordered fluid administration for a pediatric client with pneumonia. The client weighs 81.6 lb (37 kg). The nurse should expect to administer ________ mL of fluid per day for this client.

Accepted Answer

The answer of The provider has ordered fluid administration for...

Quiz 9: Infection