Nokea
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.
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A client is suspected of sepsis from a postsurgical incision infection. What characteristic(s) of sepsis would the nurse recognize? Select all that apply.
- A. Temperature of 102 F
- B. Heart rate of 120 beats/minute
- C. Respiratory rate of 24 breaths/minute
- D. PaCO2 of 42 mm Hg
- E. Blood pressure of 120/80 mm Hg
Correct Answer: A,B,C
Rationale: Two or more of the following characterize sepsis: temperature greater than 100.4 F (38 C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000 cells/mm, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis, and a PaCO2 of 42 mm Hg is not an indicator.
A family member wants to donate blood for a client who needs a blood transfusion. What information from the family member would make them ineligible for donation?
- A. The family member was serving in the military in England in 1993 for 2 years.
- B. The family member had a surgical procedure 4 years previously for an inguinal hernia.
- C. The family member received a blood transfusion 10 years previously at a hospital in Canada.
- D. The family member takes an antihypertensive medication for control of blood pressure.
Correct Answer: A
Rationale: The American Red Cross bans blood collection from anyone who has lived in the United Kingdom for a total of 6 months or longer between 1980 and 1996, lived in various countries in Europe including while serving in the military since 1980, received a blood transfusion in the United Kingdom, or lived 5 or more years in various European countries from 1980 to the present. There is a higher risk among these potential donors for BSE or 'mad cow disease.' The other answers are not exclusion criteria for donating blood.
A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis?
- A. Hemoglobin of 12 mg/dL
- B. Lymphocytes 1,500
- C. Neutrophils of 3,150/mms
- D. White blood cell (WBC) count of 22,000 cells/mm
Correct Answer: D
Rationale: The body manufactures more WBCs as needed, a process referred to as leukocytosis. The WBC of 22,000 cells/mms indicates an abundance of white blood cells. Hemoglobin does not represent the presence of infection. The lymphocytes and neutrophils are within normal range and do not demonstrate leukocytosis.
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.
The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
- A. Minimal social contact
- B. Regular immunizations
- C. Thorough handwashing
- D. Sufficient food intake
Correct Answer: C
Rationale: Hand hygiene remains the single most important measure to prevent the spread of infection. It reduces the number of transient and resident microorganisms. Sufficient food intake helps restore biologic defense mechanisms but does not prevent spread of infections. Although minimal social contact and regular immunizations may help prevent the spread of infection, especially community-acquired infections, these are not practical measures.