Nokea
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.
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A client informs the nurse, 'I think I am getting sick.' The chief symptoms of the client are low-grade fever, headache, and having no energy. What stage of the infection does the nurse recognize the client is experiencing?
- A. Incubation period
- B. Prodromal stage
- C. Acute stage
- D. Convalescent stage
Correct Answer: B
Rationale: In the prodromal stage, the initial symptoms appear; they may be vague and nonspecific. Possible symptoms include mild fever, headache, and loss of usual energy. The incubation period does not exhibit any recognizable symptoms. The acute stage is when the symptoms become severe and specific to the affect tissue or organ. The convalescent stage is when symptoms subside as the host overcomes the infectious agent.
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.
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.
A client comes to the clinic and informs of having a 'painful area under my armpit.' The nurse observes a 2-cm raised area that is erythremic and has a white substance inside of it. What does the nurse suspect the client may be experiencing?
- A. A lesion
- B. An abscess
- C. A fluid-filled vesicle
- D. A cancerous tumor
Correct Answer: B
Rationale: To prevent the spread of pathogens to adjacent tissues, a fibrin barrier forms around the injured area. Inside the barrier, a thick, white exudate (pus) accumulates. This collection of pus is called an abscess, which may break through the skin and drain or continue to enlarge internally. A lesion would not be filled with pus, nor would a cancerous tumor. A fluid-filled vesicle is associated with a viral type illness.
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.