Nokea
The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection.
- A. Colonization by host bacteria
- B. Gastrointestinal secretions
- C. Inflammatory processes
- D. Skin and mucous membranes
Correct Answer: D
Rationale: The skin and mucous membranes are the most important barrier against infection because they provide a physical and chemical barrier that prevents pathogens from entering the body. The other options are also barriers, but are considered secondary to skin and mucous membranes.
You may also like to solve these questions
A client with an infection has a fever. What actions by the nurse help increase the client's comfort?
- A. Administer antipyretics around the clock.
- B. Change the client's gown and linens when damp.
- C. Offer cool fluids to the client frequently.
- D. Place ice bags in the warm areas.
- E. Provide a fan to help cool the client.
Correct Answer: B,C
Rationale: Comfort measures appropriate for this client include offering frequent cool drinks and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.
A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is most important?
- A. Monitor for signs of neurological deterioration.
- B. Administer antipyretics to reduce fever.
- C. Place the client in droplet precautions.
- D. Obtain a lumbar puncture for CSF analysis.
Correct Answer: C
Rationale: Since meningitis is suspected, placing the client in droplet precautions is critical to prevent the spread of infection, especially if it is caused by pathogens like Neisseria meningitidis. Monitoring for neurological deterioration and obtaining a lumbar puncture are important but secondary to initiating precautions. Administering antipyretics addresses symptoms but not the spread of infection.
A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action should the nurse take?
- A. Ensure that the radiology department is aware of the isolation precautions.
- B. Plan to travel with the client to ensure appropriate precautions are used.
- C. No special precautions are needed when this client moves on unit.
- D. Notify the physician that the client cannot leave the room for the CT scan.
Correct Answer: A
Rationale: Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.
A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important?
- A. Document findings and continue monitoring.
- B. Notify the provider and request antibiotics.
- C. Place the client in protective isolation.
- D. Tell the client this signifies inflammation.
Correct Answer: B
Rationale: A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics to address the potential bacterial infection.
A student nurse asks why brushing clients' teeth with a toothbrush in the intensive care unit is important to reduce the number of infections. The answer is?
- A. It mechanically removes biofilm on teeth.
- B. It is easier to clean all surfaces with a brush.
- C. Oral care is important to all care clients.
- D. Toothbrushes last longer than oral swabs.
Correct Answer: A
Rationale: Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.