Chapter 25: Care of Patients with Infection Nursing School Test Banks

Chapter 25: Care of Patients with Infection

Test Bank

MULTIPLE CHOICE

1. After an infection control in-service, which statement by the nurse demonstrates an accurate understanding of the mode of transmission of influenza?

a.

I will not develop the infection unless I have physical contact with the client.

b.

I should wear an N95 respirator to provide care for the client with influenza.

c.

I should try to stay at least 3 feet away from the client, if at all possible.

d.

The infection is spread through droplets suspended in the air and inhaled.

ANS: C

Influenza is transmitted via droplets. Droplets are produced when a person talks or sneezes and travel short distances (up to 3 feet) but are not suspended in the air for long. Staff should stay at least 3 feet (1 m) away from a client with droplet infection. Actual physical contact with the client is not necessary for infection to occur. It is not necessary for staff to wear an N95 respirator mask for Droplet Precautions; these masks are used in the care of clients with tuberculosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Planning)

2. The nurse is told that a client with measles is being admitted. Which action by the nurse is best?

a.

Implement Contact Precautions.

b.

Check negative airflow monitors.

c.

Ensure that hand sanitizer is readily available.

d.

Place the client in a room with another measles client.

ANS: B

Clients with measles require Airborne Precautions, which include being placed in a room with specially monitored negative airflow. Before admitting the client with measles, the nurse should ensure that the airflow monitors are working properly. Contact Precautions are not used for measles. Having hand sanitizer is always a good idea, but it is not the most important action. Placing the client with another measles client is a possible action if more than one case is present (e.g., during an outbreak), but the most important thing is to ensure that Airborne Precautions can be maintained for safety.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Planning)

3. A client and his family are waiting for the results of clinical tests to determine whether the client has an infection. They are becoming anxious. What is the most important assessment that the nurse should make of the client and family members?

a.

Understanding of insurance reimbursement for testing

b.

Use of appropriate coping mechanisms for anxiety

c.

Understanding of the infectious disease process

d.

Understanding of the diagnostic procedures

ANS: D

Assess the clients and familys level of understanding about various diagnostic procedures and the time required to obtain test results. This is more important than whether the family has any understanding of their insurance and will help reduce anxiety if understanding is accurate. The client with an infectious disease often has psychosocial concerns. Delay in diagnosis caused by the need to wait for clinical test results produces anxiety. Plan education on infection risk reduction when the client and the family are ready to learn.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important?

a.

Check the IV for patency.

b.

Assess the client for allergies.

c.

Double check the five rights.

d.

Teach the client about the drug.

ANS: B

All actions are appropriate and important before administering any medications. However, client safety is the priority. The nurse should first assess the client for medication allergies by asking the client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not protect the client from an allergic reaction.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

5. A client is being treated with acetaminophen (Tylenol). Which assessment finding is most likely to occur after a dose of the medication?

a.

A febrile seizure

b.

Nausea and vomiting

c.

Episodes of sweating

d.

Syncope

ANS: C

Be alert for waves of sweating after each dose. Sweating may be accompanied by a fall in blood pressure, followed by return of fever. These unpleasant side effects of antipyretic therapy often can be alleviated by liberal administration of fluids and by regular scheduling of drug administration.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 446

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

6. Which client does the nurse consider to be at increased risk for infection?

a.

Young adult who wears contact lenses

b.

Adult with type 1 diabetes mellitus

c.

Adult with known hypersensitivity to latex

d.

Adolescent using analgesics for migraine headaches

ANS: B

Clients with diabetes are at greater risk for infection for many reasons. The disease affects the vascular system, preventing normal immune defenses from reaching sites of injury or invasion. The elevated glucose level in the extracellular fluid provides a rich growth medium for microorganisms, especially bacteria and fungi. Wearing contact lenses might put a client at slightly higher risk for eye infection. Hypersensitivity to latex puts a client at risk for anaphylaxis, but not at increased risk for infection. The use of analgesics will not put a client at risk for infection.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 444

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant requires intervention by the registered nurse?

a.

Using an alcohol-based hand rub after caring for a client with diarrhea

b.

Washing hands for 20 seconds using warm water and friction

c.

Cleaning especially carefully under fingernails and around a wedding band

d.

Using chlorhexidine for handwashing when caring for clients on neutropenic precautions

ANS: A

Alcohol-based hand rubs are not effective against spore-forming organisms such as Clostridium difficile, which is a common cause of diarrhea among hospitalized clients. The nursing assistant should wash hands with soap after caring for such clients in case they have an undiagnosed infection with this bacterium. The other actions are appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Communication and Documentation

8. The nurse is caring for a client with a large leg wound that has been slow to heal. Which action by the nurse is most appropriate?

a.

Use Contact Precautions when caring for the client.

b.

Double-glove when providing wound care.

c.

Help the client choose high-protein items at meals.

d.

Assess the clients knowledge of causative factors.

ANS: C

Good nutrition is important for any client with infection, and protein is critical for wound healing. No information in the question would lead the nurse to use Contact Precautions, and double-gloving is not needed for wound care. Assessing knowledge of causative factors may help prevent another wound, but does not take priority over ensuring good nutrition.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Implementation)

9. A client comes to the emergency department with a fever, diarrhea, and general malaise. Which information obtained during assessment does the nurse communicate immediately to the health care provider?

a.

Blood pressure of 110/90 mm Hg

b.

Allergy to aspirin

c.

The client having just returned from a 14-day trip to Asia

d.

A blood transfusion 12 years ago

ANS: C

Travel can expose the client to infectious organisms that he or she might not ordinarily encounter in the local community, increasing the chance that infection could lead to illness. The clients diastolic blood pressure is slightly high but would not need to be reported immediately. The aspirin allergy should be noted on the clients chart but most likely will not be a factor in the clients immediate problem. A blood transfusion 12 years ago would not likely be the cause of the clients current problems.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

10. While sponging a client who has a high fever, the nurse observes the client shivering. Which is the nurses priority action?

a.

Administering oral acetaminophen

b.

Placing a heated blanket on the client

c.

Stopping sponging the client

d.

Warming up the water and continuing sponging

ANS: C

Shivering is an indication that the client is being cooled too fast. The nurse should stop the sponging and immediately assess the clients temperature. The sponging should not continue, even if the temperature of the water is increased. Acetaminophen should not be administered without knowledge of the clients temperature, nor should a heated blanket be applied.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Planning)

11. The new nurse is caring for a client with a high temperature. Which action by the nurse warrants intervention by the new nurses preceptor?

a.

Sponging the client while monitoring for shivering

b.

Applying cool packs to the clients axillae and groin

c.

Monitoring the clients temperature more often than ordered

d.

Obtaining a fan from central supply for the clients room

ANS: D

The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Communication and Documentation

12. A client has been admitted with suspected Clostridium difficile infection. Which medication does the nurse plan to administer as a priority?

a.

Metronidazole (Flagyl)

b.

Acetaminophen (Tylenol)

c.

Tetracycline (Sumycin)

d.

Doxycycline (Vibramycin)

ANS: A

Metronidazole and vancomycin are the antibiotics of choice for C. difficile infection. Tylenol might be used if the client is febrile. The other two antibiotics are not appropriate.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 449

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Effects/Outcomes) MSC: Integrated Process: Nursing Process (Planning)

13. An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2 F (37.3 C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate?

a.

Perform a Mini-Mental Status Examination.

b.

Assess the client for other signs of infection.

c.

Document the findings and continue to monitor.

d.

Assess the clients pain level and treat if needed.

ANS: B

Because of an age-related decline in immune function, an older adults normal temperature may be 1 to 2 lower than normal. A temperature of 99.2 F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Nursing Process (Assessment)

14. A client is being treated at home for vancomycin-resistant Enterococcus (VRE). The client and the family are worried about spreading the infection. Which action by the nurse is best?

a.

Instruct the client to use a separate bathroom.

b.

Encourage the family to stay 3 feet away from the client.

c.

Tell the client to cough into tissues and dispose of them immediately.

d.

Teach the family ways to increase their immune system functioning.

ANS: A

VRE can live on surfaces for days or even weeks. Inanimate objects such as toilet seats or door handles can easily become contaminated and spread infection. The other actions are not necessary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Teaching/Learning

15. A client has scabies. In addition to Standard Precautions, which information is most important to communicate to visitors and health care providers?

a.

Do not allow children to visit.

b.

Wear gloves when entering the room.

c.

Wear a mask when within 3 feet of the client.

d.

Keep head covered when providing care.

ANS: B

Contact Precautions are necessary when providing care to a client infected with the skin parasite scabies. Gloves are required when entering a contact isolation room.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Planning)

16. Before discharge, the nurse confirms that the client understands antibiotic therapy for a wound infection by which statement?

a.

I should take the antibiotic until my temperature is normal.

b.

If my temperature elevates, I should increase my dose of antibiotic.

c.

If my drainage is clear, I do not need the antibiotic.

d.

I need to take the medication until the prescription is finished.

ANS: D

Antibiotic therapy is most effective when the client takes the prescribed medication for the entire coursenot just when symptoms are present. A major nursing responsibility is to reinforce to clients the necessity of completing the antibiotic regimen to ensure that the organism is eradicated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

17. A client has been admitted for the second time to treat tuberculosis (TB). Which referral does the nurse initiate as a priority?

a.

Social worker to see if the client can afford the medications

b.

Visiting nurses to arrange directly observed therapy on dismissal

c.

Psychiatric nurse liaison to assess reasons for noncompliance

d.

Infection control nurse to arrange testing for drug resistance

ANS: B

The client has a risk of noncompliance as evidenced by the second admission to treat TB. When the client is dismissed, he or she most likely will need to be placed on directly observed therapy to ensure compliance. The other referrals may be appropriate depending on the clients needs.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareReferrals) MSC: Integrated Process: Nursing Process (Planning)

18. The nurse is caring for a client with a suspected infection. Which action by the nurse is most appropriate?

a.

Give antibiotics as soon as possible to prevent sepsis.

b.

Obtain all required cultures, then administer the antibiotic.

c.

Wait for culture results to give the most appropriate antibiotic.

d.

Defer cultures unless the client shows signs of drug resistance.

ANS: B

The best diagnostic test for infection is a culture and sensitivity. The nurse should first collect any ordered cultures. Then the nurse should administer the ordered antibiotic. Because final culture results take 72 hours, empiric antibiotic therapy should be started before the results are back.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

19. The nurse reviews laboratory results for a client and notes that the erythrocyte sedimentation rate (ESR) is 32 mm/hr. What action by the nurse is best?

a.

Document the findings and call the health care provider.

b.

Assess the client for any manifestations of infection or inflammation.

c.

Review the clients chart to see what medications have been given.

d.

Call the physician and request blood cultures and a chest x-ray.

ANS: B

The ESR is elevated (normal is <20 mm/hr) and indicates inflammation, which could be the result of an infectious process. The nurse should assess the client for manifestations of infection or inflammation before notifying the health care provider. Documentation is always important. Medications would not affect the ESR. Cultures and x-rays may be ordered, but not until the client has been thoroughly assessed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

20. The nurse works in a long-term care facility. Which resident does the nurse assess most carefully for manifestations of infection?

a.

Resident who has long-standing dementia

b.

Resident with incontinence

c.

Resident who eats a lot of sweets and little protein

d.

Resident whose family wont allow an influenza vaccination

ANS: B

All older clients are at increased risk for infection owing to age-related decreased immune function. Each of these clients has special reasons for being at increased risk. However, the one at highest risk is the client with incontinence because this is a chronic condition that is a daily problem, leaving his or her skin vulnerable to breakdown and bacterial entry. Poor perineal care also increases the risk for urinary tract infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

21. A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?

a.

Airborne

b.

Standard

c.

Contact

d.

Droplet

ANS: A

Chickenpox infection is transmitted via the airborne route. Clients with chickenpox must be placed on Airborne Precautions.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 442

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1. A client is admitted with infection and a high fever. Which assessments by the nurse take priority? (Select all that apply.)

a.

Blood pressure

b.

Mental status

c.

Pulse quality

d.

Respiratory effort

e.

Skin turgor

f.

Bowel sounds

ANS: A, B, C, E

Dehydration can accompany fever, especially if the client is sweating profusely. Blood pressure, pulse quality, and skin turgor are assessments of fluid status. Mental status changes can accompany fluid losses, especially in older clients.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is assessing a clients skin for local signs of infection. Which signs does the nurse assess for? (Select all that apply.)

a.

Fever

b.

Redness

c.

Warmth

d.

Pain

e.

Swelling

f.

Increased erythrocyte sedimentation rate (ESR)

ANS: B, C, D, E

Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and increased ESR are systemic signs of infection.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 444

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

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