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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.
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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.
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 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 client with an infection has a fever. What actions by the nurse help increase the client's comfort?
- A. Administer antipyretics around the clock.
- B. Change the client's gown and linens when damp.
- C. Offer cool fluids to the client frequently.
- D. Place ice bags in the warm areas.
- E. Provide a fan to help cool the client.
Correct Answer: B,C
Rationale: Comfort measures appropriate for this client include offering frequent cool drinks and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.
A student nurse asks why brushing clients' teeth with a toothbrush in the intensive care unit is important to reduce the number of infections. The answer is?
- A. It mechanically removes biofilm on teeth.
- B. It is easier to clean all surfaces with a brush.
- C. Oral care is important to all care clients.
- D. Toothbrushes last longer than oral swabs.
Correct Answer: A
Rationale: Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.