Nokea
Which of the following would be considered a mechanical defense mechanism?
- A. Cast
- B. Coughing
- C. Clothing
- D. Sunscreen
Correct Answer: B
Rationale: Mechanical defense mechanisms are physical barriers that prevent microorganisms from gaining entry or expel microorganisms before they multiply. Examples are the skin and mucous membranes, physiologic reflexes (e.g., sneezing, coughing, vomiting), and macrophages. Casts, clothing, and sunscreen do not keep microorganisms from gaining entry to the body.
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A client informs the nurse of having been using a douche to cleanse the vagina on a daily basis and is now experiencing itching and burning in the vaginal area. What should the nurse explain to the client that occurs when the vaginal pH is changed?
- A. It causes destruction of the normal flora of the vagina and allows the development of vaginal infections.
- B. The bottle must be contaminated with bacteria, and when the pH is changed, it allows the bacteria to enter the vaginal area.
- C. It will cause an allergic reaction in the vaginal area.
- D. When the vaginal pH is changed, it allows cancer cells to spread from the vagina to the cervix.
Correct Answer: A
Rationale: The acid environment is unfavorable for the multiplication of pathogenic bacteria and fungi. A change in vaginal pH or destruction of the normal flora, however, can promote the development of a vaginal infection. Bacteria do not cause the vaginal pH to change; the pH change allows bacteria to grow. Change in vaginal pH does not cause an allergic reaction and does not allow the development of cancer cells.
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.
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.
A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has received treatment with three courses of antibiotics without eliminating the infection. What does the nurse understand has occurred with the client?
- A. The client has a multidrug-resistant strain of bacteria.
- B. The client has been misdiagnosed and has another type of microorganism present.
- C. Staphylococcus aureus cannot be treated by antibiotics.
- D. Staphylococcus aureus is a fungus and must be treated with an antifungal agent, not an antibiotic.
Correct Answer: A
Rationale: Some bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli, are developing multidrug resistance, the ability to remain unaffected by antimicrobial drugs such as antibiotics. There are no facts to indicate the client has been misdiagnosed. Staphylococcus aureus is treated with antibiotics and is a bacterium, not a fungus.
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.