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The nurse has admitted a new client to the unit. This client has an open draining sore on the leg. What diagnostic test would the nurse anticipate being ordered?
- A. Platelet count
- B. Culture and sensitivity
- C. Sputum culture
- D. Urinalysis
Correct Answer: B
Rationale: A culture identifies bacteria in a specimen taken from a person with symptoms of an infection. The source of the specimen may be body fluids or wastes, such as blood, sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound. A platelet count would not tell the nurse about the infection. A sputum culture would not be indicated for a leg wound, nor would a urinalysis.
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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.
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.
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.
The nurse is working on a gerontology unit. A family member calls and tells the nurse they want to bring the family in to see one of the clients on the unit. The family member is concerned because several of the family members have colds. What instructions should the nurse provide to someone with a respiratory infection?
- A. Avoid intake of frozen foods.
- B. Avoid visiting older adults.
- C. Avoid direct sunlight.
- D. Avoid meats and other protein-rich foods.
Correct Answer: B
Rationale: The nurse should instruct anyone with respiratory infections to avoid visiting older adults until symptoms subside; older adults are more susceptible to infections because their defense mechanisms are less efficient. It is not essential for the client to avoid frozen or protein-rich foods or direct sunlight.
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.