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A family member of a client in a long-term care facility asks why the nurse cannot insert a catheter so the client will not develop skin breakdown from being wet. What should the explanation include when the nurse responds to the family member?
- A. Catheters are no longer used for treatment of incontinence.
- B. Older adult residents are able to have catheters inserted if the family requests them.
- C. The invasive nature of the catheter provides a portal for infection.
- D. If a catheter is inserted, it must be flushed with normal saline daily.
Correct Answer: C
Rationale: Catheters provide a portal for infection because they are invasive. Although catheters are not used as frequently in older adults for the control of urinary incontinence, there are some bed-confined clients who use them. Family requests for catheters may be considered, but physicians make the decision if it will benefit the client. Catheters are not flushed daily with anything.
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The nurse is caring for a client with breast cancer who has been receiving chemotherapy. The client was admitted with an infected lesion on their left leg. The health care provider has ordered filgrastim. What will filgrastim do for this client? Select all that apply.
- A. Increase platelet count
- B. Boost the immune system
- C. Increase white blood cell production
- D. Boost red blood cell production
- E. Increase hematocrit level
Correct Answer: B,C
Rationale: Bone marrow transplantation or administration of drugs that boost white blood cell production, such as filgrastim, may help immunosuppressed clients. Neupogen does not increase the platelet count, hematocrit level, or boost red blood cell production.
The intensive care unit nurse is caring for a client with a transmissible spongiform encephalopathy. The nurse knows that this type of encephalopathy is caused by what type of infectious agent?
- A. Prion
- B. Protozoa
- C. Helminth
- D. Rickettsia
Correct Answer: A
Rationale: A prion is a protein that does not contain nucleic acid. Research suggests that normal prions present in brain cells protect against dementia. When a prion mutates, however, it is capable of becoming an infectious agent and altering other normal prion proteins into similar mutant copies. The mutant prions, which can be formed by genetic predisposition or acquired by transmission between the same or similar infected animal species, cause transmissible spongiform encephalopathies. Transmissible spongiform encephalopathies are not caused by protozoa, helminths, or rickettsias.
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.
The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority education should healthcare providers receive?
- A. Using contact precautions on all clients in the hospital
- B. Administering antibiotics to all clients prophylactically
- C. Performing hand hygiene
- D. Emptying trash cans immediately in client's rooms
Correct Answer: C
Rationale: Infections with multidrug-resistant microorganisms are very difficult to destroy with current pharmacologic agents, increasing the need to be vigilant about performing hand hygiene measures. It is unnecessary to use contact precautions, administer antibiotics prophylactically, or empty trash cans immediately for the preventions of multidrug-resistant infections.
A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
- A. An induration of 12 mm
- B. An uneven erythemic area
- C. An induration of less than 1 mm
- D. An induration of 4 mm
Correct Answer: A
Rationale: The size of the induration, not including the surrounding area of erythema, is measured in millimeters. The measurement determines whether the reaction is significant. For example, a tuberculin skin test is considered positive if the induration is 10 mm or greater in persons with no known risk factors for TB; smaller measurements are significant in certain risk groups, such as immunocompromised clients. The other answers are not indicative of positive results.