Nokea
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.
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The nurse is caring for a client with an abscess on the back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physician will order to determine the type of bacteria present in the exudate?
- A. A sensitivity test
- B. Test for ova and parasites
- C. White blood cell (WBC) count
- D. A culture
Correct Answer: D
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 test for ova and parasites is a stool specimen that is examined for evidence of any forms in the infecting microorganism's life cycle. A WBC count may determine that infection is present in the body but does not isolate the bacteria. A sensitivity test is done to determine which antibiotic inhibits the growth of a nonviral microorganism and will be most effective in treating the infection.
A client arrives at the emergency department reporting severe diarrhea and vomiting that began after ingesting a hot dog at the ballpark 6 hours ago. How does the nurse understand that the contaminated food was transmitted to the client?
- A. Droplet
- B. Airborne
- C. Vehicle
- D. Vector
Correct Answer: C
Rationale: Vehicle is the route of transmission for this client's illness. It is found on or in contaminated food, water, objects, or equipment and can occur from eating or drinking tainted products. The route of transmission, droplet is by a spray of moist particles within a 3-foot radius of infected persons. Airborne is a route of transmission that is a suspension and transport on air currents beyond 3 feet. An infection by vector is found on infected animals or insect to susceptible persons.
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.
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 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.