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The nurse gave a client an injection and, when attempting to recap the needle, sustained a needlestick injury to the finger. What is the priority action by the nurse?
- A. Report the injury or exposure to the supervisor.
- B. Document the injury in writing.
- C. Receive instructions on monitoring potential symptoms and medical follow-up.
- D. Receive the most appropriate postexposure prophylaxis.
Correct Answer: A
Rationale: Should needlestick injury or other exposure to a potential blood-borne pathogen occur, healthcare workers are advised to follow postexposure recommendations; report the injury or exposure to one's supervisor immediately; document the injury in writing; identify the person or source of blood; obtain the HIV and HBV statuses of the source of blood, if it is legal to do so. Unless the client gives permission, testing and revealing HIV status are prohibited. Obtain counseling on the potential for infection. Receive the most appropriate postexposure prophylaxis; be tested for disease antibodies at appropriate intervals. Receive instructions on monitoring potential symptoms and medical follow-up.
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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.
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.
A client is admitted to the acute care facility for vomiting and diarrhea. An intravenous (IV) catheter is inserted for the delivery of IV fluids. A family member is with the client and observes the nurse enter the room and begin touching the IV site without washing hands or wearing gloves. Why should the client and family member be concerned with the nurse's actions?
- A. The client will have an allergic reaction to the IV.
- B. The nurse could develop the same symptoms.
- C. The client will develop a healthcare-associated infection.
- D. Dislodging of the IV catheter.
Correct Answer: C
Rationale: Healthcare-associated infections are infections acquired while receiving care in a healthcare agency that were not active, incubatory, or chronic at admission. They occur for many reasons. Hospitalized clients are more susceptible to infections than well people because they are exposed to pathogens in the healthcare environment; may have incisions or invasive equipment (e.g., IV lines) that compromise skin integrity; or may be immunosuppressed from poor nutrition, their disease process, or its treatment. Also, because healthcare personnel are in frequent and direct contact with many clients who harbor various microorganisms, the risk for transmitting pathogenic microorganisms between and among clients is high. Allergic reaction to the IV, the nurse developing the same symptoms, and dislodging of the IV catheter are not the priority concerns.
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.
Which of the following would be considered a mechanical defense mechanism?
- A. Cast
- B. Coughing
- C. Clothing
- D. Sunscreen
Correct Answer: B
Rationale: Mechanical defense mechanisms are physical barriers that prevent microorganisms from gaining entry or expel microorganisms before they multiply. Examples are the skin and mucous membranes, physiologic reflexes (e.g., sneezing, coughing, vomiting), and macrophages. Casts, clothing, and sunscreen do not keep microorganisms from gaining entry to the body.