Nokea
The nurse has been injured with a needlestick while caring for a newly admitted client and informs the charge nurse. What is the next thing the injured nurse should do?
- A. Document the injury in writing.
- B. Obtain the client's HIV status.
- C. Get instructions on monitoring potential symptoms.
- D. Report the injury to the supervisor.
Correct Answer: A
Rationale: Should an injury occur, health care workers are advised to follow postexposure recommendations: (1) Report the injury to one's supervisor immediately; (2) document the injury in writing; (3) identify the person or source of blood, if possible; and (4) obtain the HIV and hepatitis B 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; (5) obtain counseling on the potential for infection; (6) receive the most appropriate postexposure prophylaxis; (7) be tested for disease antibodies at appropriate intervals; and (8) receive instructions on monitoring potential symptoms and medical follow-up.
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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 nurse is giving an educational talk to a local parent-teacher association. A parent asks how to help the family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?
- A. Encourage your family to adopt a healthy diet and exercise regimen.
- B. Encourage your family to stop smoking.
- C. Make sure your family has all their childhood immunizations.
- D. Make sure your family has regular check-ups.
Correct Answer: C
Rationale: To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular check-ups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.
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 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.
A client has received a diagnosis of Lyme disease. What does the nurse understand about the transmission of infection resulting in this disease?
- A. The disease is spread by a prion.
- B. The disease is spread by single-celled fungi-like microorganisms
- C. The disease is spread by helminths
- D. The disease is spread by arthropods.
Correct Answer: D
Rationale: Example of arthropods includes fleas, ticks, lice, mosquitoes, and mites. Some rickettsial diseases that are spread by arthropods include Lyme disease. Prions may mutate and can be formed by genetic predisposition or acquired by transmission between the same or similar infected animal species and are not the same as arthropods. The disease is not spread by single-celled fungi-like microorganisms or helminths.