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 the nurse is most appropriate? 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 leaves the unit. d. Notify the primary health care provider that the client cannot leave the room. - answer-ANS: A - Clients in isolation will leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. 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 primary health care provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation. - answer-ANS: B -A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) a. Colonization b. Host c. Mode of transmission d. Portal of entry e. Reservoir f. Poor hygiene - answer-ANS: B, C, D, E - Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet (1 m) away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching clients' excretions or secretions. f. Cohorting clients who have infections caused by the same organism. - answer-ANS: D, E - Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues is infectious The nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) a. Appropriate drug b. Proper route of administration c. Standardized peak levels d. Sufficient dose e. Sufficient length of treatment f. Appropriate trough levels - answer-ANS: A, B, D, E -In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet (1 m) from the client at all times. c. Obtain specialized respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care. f. Assure client has a respirator for moving between departments. - answer-ANS: A, C -A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A nurse asks the supervisor why older adults are more prone to infection than other adults. What reasons does the supervisor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective f. Higher rates of chronic illness - answer-ANS: A, B, C, E, F -Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, fewer lymphocytes and antibodies, and higher rates of chronic illness. A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.) 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 armpits and groin. e. Provide a fan to help cool the client. f. Sponging the client with tepid water. - answer-ANS: B, C, F -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 will be administered only when the client is uncomfortable. A nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? (Select all that apply.) a. Administer prophylactic antibiotics. b. Monitor white blood cell count and differential. c. Screen all visitors for infections. d. Implement Transmission-Based Precautions. e. Promote sufficient nutritional intake. - answer-ANS: B, C, E Nursing interventions for clients at risk for infection include monitoring white blood cell count and differential, screening visitors for infections and infectious disease, and promoting sufficient nutritional intake. A nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? (Select all that apply.) a. Wear a gown when contact of clothing with body fluids is anticipated. b. Teach clients and visitors respiratory hygiene techniques. c. Obtain powered air purifying respirators for all staff members. d. Do not use alcohol-based hand rub between client contacts. e. Disinfect frequently touched surfaces in client-care areas. - answer-ANS: A, B, E -Infection control measures appropriate to all clients include hand hygiene with alcohol-based hand rub or soap between client contact, procedures for routine care, cleaning and disinfection of frequently contaminated surfaces, and wearing personal protective equipment when contamination is anticipated. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs. - answer-ANS: B This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found. - answer-ANS: C -Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation." - answer-ANS: C -A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin. - answer-ANS: B -For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush. - answer-ANS: B -Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82 × 109/L) c. Red blood cell count: 4.8/mm3 (4.8 × 1012/L) d. White blood cell count: 8700/mm3 (8.7 × 109/L) - answer-ANS: B -This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other signs of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths. - answer-ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best? a. Ensure that the client has adequate sedation. b. Find another qualified provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation. - answer-ANS: C -Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse would interrupt the intubation attempt and give the client oxygen. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure that all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube. - answer-ANS: C -When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate to the assistive personnel (AP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools. - answer-ANS: C -The client on mechanical ventilation needs frequent oral care, which can be delegated to the AP. The other actions fall within the scope of practice of the nurse. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on. - answer-ANS: D -The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately. - answer-ANS: A -The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause agitation. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room - answer-ANS: B -Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse would know and check the settings. A client is on mechanical ventilation and the client's spouse wonders why ranitidine is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation." - answer-ANS: D -Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them and p