Nokea
The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
- A. Minimal social contact
- B. Regular immunizations
- C. Thorough handwashing
- D. Sufficient food intake
Correct Answer: C
Rationale: Hand hygiene remains the single most important measure to prevent the spread of infection. It reduces the number of transient and resident microorganisms. Sufficient food intake helps restore biologic defense mechanisms but does not prevent spread of infections. Although minimal social contact and regular immunizations may help prevent the spread of infection, especially community-acquired infections, these are not practical measures.
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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.
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 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 nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?
- A. Acute
- B. Chronic
- C. Secondary
- D. Opportunistic
Correct Answer: D
Rationale: An opportunistic or superinfection occurs among immunocompromised hosts. Examples would be yeast infections in the mouth, bladder infections, gastroenteritis, and Pneumocystis carinii. An acute infection has a sudden onset with serious and sometimes life-threatening manifestations. A chronic infection is an extended infection that resists treatment. A secondary infection is a complication of some other disease process that occurred first.