Nokea
A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician is planning to remove the dead and damaged tissue. What type of procedure will the nurse prepare the client for?
- A. Application of a dry dressing
- B. Debridement
- C. Administration of filgrastim (Neupogen)
- D. Inject antibiotics into the wound
Correct Answer: B
Rationale: Debridement is the removal of dead and damaged tissue surgically. Application of a dry dressing will not debride the wound, nor will the administration of Neupogen or injecting antibiotics into the wound.
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A nurse on the unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow?
- A. Avoid notifying the supervisor of the injury until the client's infectious status is confirmed.
- B. Avoid revealing the identity of the client or source of blood.
- C. Be tested for disease antibodies at appropriate intervals.
- D. Document the injury in writing after the client's infectious status is confirmed.
Correct Answer: C
Rationale: If a needlestick injury has occurred, the nurse should be tested for disease antibodies immediately and at appropriate intervals thereafter. The nurse should document the injury in writing immediately and should not wait until the client's infectious status is confirmed. The nurse should also notify the supervisor of the injury immediately and identify the person or source of blood, if possible.
The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?
- A. The client feels restless and hungry.
- B. The client exhibits an increased urinary output.
- C. The client's heart rate is greater than 90 beats/minute.
- D. The client's respiratory rate is less than 20 breaths/minute.
Correct Answer: C
Rationale: A heart rate greater than 90 beats/minute or a respiratory rate greater than 20 breaths/minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.
A client visits the clinic reporting a circular rash on the upper right arm. The rash is diagnosed as tinea corporis. For what type of infection does the nurse anticipate the client will be treated?
- A. Rickettsiae
- B. Protozoans
- C. Mycoplasma
- D. Fungus
Correct Answer: D
Rationale: One type of fungal infection is superficial (dermatophytoses), which affect the skin, hair, and nails; examples include tinea corporis, or ringworm, and tinea pedis, also known as athlete's foot. Rickettsiae, protozoans, and mycoplasma have different characteristics and transmission than fungus.
A client comes to the clinic reporting fever, chills, and coughing. The client is found to be positive for influenza. The nurse is aware that influenza is transmitted from one infected person to another. What type of infectious disorder is this considered?
- A. Localized
- B. Generalized
- C. Communicable disease
- D. Health-care-associated
Correct Answer: C
Rationale: Communicable diseases are infectious disorders that are transmitted from one infected species to another. Common signs and symptoms are the same as generalized plus organ-specific or disease-specific manifestations. Examples of the infections transmitted are influenza, chickenpox, and tuberculosis. Localized infection is confined to a small area such as a furuncle (boil). Generalized infection is a systemic or widespread infection in one or two organs such as urosepsis. A health-care-associated infection is acquired in a health care agency.
A client is diagnosed with a viral illness and requests an antibiotic to 'cure' the illness. When the request is refused by the physician, the client states to the nurse, 'I will never get better.' What is the best response by the nurse?
- A. I will speak with the physician again. You will only get better while taking an antibiotic.'
- B. Prescribing antibiotics for a viral infection may result in drug-resistant bacteria.'
- C. You need to think positively, and you will get better soon.'
- D. Taking antibiotics when you don't need them will make you sick.'
Correct Answer: B
Rationale: Causes of antibiotic resistance, a consequence of bacterial mutations that interfere with the mechanism of antibiotic action, are related to inappropriate prescription of antibiotics for viral (rather than bacterial) infection. Because viral infections are often self-limiting, with symptoms control, the client will get better. Indicating that the client is not thinking positively is a nontherapeutic comment. Informing the client that taking unnecessary antibiotics will cause illness is not detailed enough to be an informative response.