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Med Surg II Exam 2 21,29,34
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  • Med Surg II
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  • Med Surg II

The nurse learning about infection discovers 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 - answer-ANS: D A nursing manager is concerned about the ...

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  • September 7, 2024
  • 14
  • 2024/2025
  • Exam (elaborations)
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  • Med Surg II

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Med Surg II Exam 2 21,29,34


The nurse learning about infection discovers 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 - answer-ANS: D

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would
best help
prevent these infections?
a. Auditing staff members' hand hygiene practices
b. Ensuring clients are placed in appropriate isolation
c. Establishing a policy to remove urinary catheters quickly
d. Teaching staff members about infection control methods - answer-ANS: A - All methods will help prevent infection;
however, health care workers' lack of hand hygiene is the biggest cause of health care-associated infections.

An assistive personnel asks why brushing client s' teeth with a toothbrush in the intensive care unit is important to
infection
control. What response by the registered nurse is best?
a. "It mechanically removes biofilm on teeth."
b. "It's easier to clean all surfaces with a brush."
c. "Oral care is important to all our clients."
d. "Toothbrushes last longer than oral swabs." - answer-Biofilms are a complex group of bacteria that function within a
slimy gel on surfaces such as teeth. Mechanical disruption is the best way to control them.

A client is admitted with possible sepsis. Which action will the nurse perform first?
a. Administer antibiotics.
b. Give an antipyretic.
c. Place the client in isolation.
d. Obtain specified cultures. - answer-ANS: D - Prior to administering antibiotics, the nurse obtains the prescribed
cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known.

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is
most
important?
a. Consult with the primary health care provider about obtaining stool cultures.
b. Delegate frequent perianal care to assistive personnel.
c. Place the client on NPO status until the diarrhea resolves.
d. Request a prescription for an antidiarrheal medication. - answer-ANS: A -Hospitalized clients who have three or more
stools a day for 2 or more days are suspected of having infection with Clostridium difficile.

A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort measures to a client with an
infection. What action by the AP requires intervention by the nurse?
a. Not using gloves while combing the client's hair
b. Rinsing the client's commode pan after use
c. Ordering an oscillating fan for the client

, d. Wearing gloves when providing perianal care - answer-ANS: C -Fans in client care areas are discouraged because they
can disperse airborne or droplet-borne pathogens.

A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the nurse is best?
a. Administer bowel cleansing as prescribed.
b. Educate the client on immunosuppressive drugs.
c. Inform the client he/she will drink a thick liquid.
d. Place a nasogastric tube to intermittent suction. - answer-ANS: A -The usual route of delivering an FMT is via
colonoscopy, so the client would have a bowel cleansing as prescribed for that procedure.

A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement
below indicates
the need to review this information?
a. "Methicillin-resistant Staphylococcus aureus can be hospital- or
community-acquired."
b. "Vancomycin-resistant Enterococcus can live on surfaces and be infectious for
weeks."
c. Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that
break down antibiotics."
d. "If you leave work wearing your scrubs, go directly home and wash them right
away." - answer-ANS: D -To help prevent the transmission of an MDRO, wear scrubs and change clothes before leaving
work. Keep work clothes separate from personal clothes.

The nurse caring for clients admitted for infectious diseases understands what information about emerging global
diseases and
bioterrorism?
a. Many infections are or could be spread by international travel.
b. Safer food preparation practices have decreased foodborne illnesses.
c. The majority of Americans have adequate innate immunity to smallpox.
d. Plague produces a mild illness and generally has a low mortality rate. - answer-ANS: A -Increased global travel has
resulted in the spread of many emerging diseases and has the potential to spread diseases caused by bioterrorism.

A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being
"contaminated" by the
client. What action by the nurse is best?
a. Explain to them that these precautions are mandated by law.
b. Show the family how to avoid spreading the disease.
c. Reassure the family that they will not get the infection.
d. Tell the family it is important that they visit the client. - answer-ANS: B -Visitors may be apprehensive about visiting a
client in Transmission-Based Precautions.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the
urine. What action by the nurse is most appropriate?
a. Prepare to administer vancomycin.
b. Strictly limit visitors to immediate family only.
c. Wash hands only after taking off gloves after care.
d. Wear a respirator when handling urine output. - answer-ANS: A -Vancomycin is one of a few drugs approved to treat
MRSA.

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What
action by

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