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A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Elevate the arm above the level of the heart.
- B. Use a fan to help cool the client if feverish.
- C. Place cool, wet cloths on top of the wound.
- D. Take the client's temperature.
Correct Answer: A
Rationale: Elevating the extremity above the level of the heart will help with swelling and pain. Fans are not recommended as they can disperse microbes. Placing a cool, wet cloth on the wound may macerate the broken skin. Taking the client's temperature provides data but does not increase comfort.
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A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is most important?
- A. Monitor for signs of neurological deterioration.
- B. Administer antipyretics to reduce fever.
- C. Place the client in droplet precautions.
- D. Obtain a lumbar puncture for CSF analysis.
Correct Answer: C
Rationale: Since meningitis is suspected, placing the client in droplet precautions is critical to prevent the spread of infection, especially if it is caused by pathogens like Neisseria meningitidis. Monitoring for neurological deterioration and obtaining a lumbar puncture are important but secondary to initiating precautions. Administering antipyretics addresses symptoms but not the spread of infection.
A client is being treated for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which medication does the nurse anticipate administering?
- A. Vancomycin
- B. Limit visitors to immediate family only
- C. Wash hands only after taking off gloves
- D. Wear a respirator when handling urine output
Correct Answer: A
Rationale: Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager should reduce the number of infections?
- A. Auditing staff members hand hygiene practices
- B. Ensuring clients are placed in appropriate isolation
- C. Establishing a policy to treat urinary infections quickly
- D. Teaching staff members about infection control methods
Correct Answer: A
Rationale: All methods will help prevent infection; however, health care workers' lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.
A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important?
- A. Document findings and continue monitoring.
- B. Notify the provider and request antibiotics.
- C. Place the client in protective isolation.
- D. Tell the client this signifies inflammation.
Correct Answer: B
Rationale: A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics to address the potential bacterial infection.
The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection.
- A. Colonization by host bacteria
- B. Gastrointestinal secretions
- C. Inflammatory processes
- D. Skin and mucous membranes
Correct Answer: D
Rationale: The skin and mucous membranes are the most important barrier against infection because they provide a physical and chemical barrier that prevents pathogens from entering the body. The other options are also barriers, but are considered secondary to skin and mucous membranes.