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A client is admitted with possible sepsis. Which action should the nurse perform first?
- A. Administer antibiotics.
- B. Give an antipyretic.
- C. Place the client in isolation.
- D. Obtain specified cultures.
Correct Answer: D
Rationale: Prior to administering antibiotics, the nurse must obtain the ordered cultures. Broad-spectrum antibiotics will be administered until the culture results are available to ensure the infection is appropriately treated.
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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 hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action should the nurse take?
- A. Ensure that the radiology department is aware of the isolation precautions.
- B. Plan to travel with the client to ensure appropriate precautions are used.
- C. No special precautions are needed when this client moves on unit.
- D. Notify the physician that the client cannot leave the room for the CT scan.
Correct Answer: A
Rationale: Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.
Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?
- A. Assessing skin and mucous membranes
- B. Consistently using appropriate hand hygiene
- C. Administering antibiotics promptly
- D. Teaching visitors not to visit if they are ill
Correct Answer: B
Rationale: Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members' contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly, but will not prevent infection from occurring. Teaching visitors not to visit when they are ill will also help prevent infection, but not to the degree that hand hygiene will.
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.