Chapter 23 Flashcards
The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection?
Skin and mucous membranes
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?
Auditing staff members’ hand hygiene practices
A student nurse asks why brushing clients’ teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
“It mechanically removes biofilm on teeth.”
A client is admitted with possible sepsis. Which action should the nurse perform first?
Obtain specified cultures.
A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?
Consult with the provider about obtaining stool cultures.
A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a client’s bed linens. What action by the UAP requires intervention by the nurse?
Shaking dirty linens and placing them on the floor
A hospital unit is participating in a bioterrorism drill. A “client” is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the “client”?
Standard Precautions
Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?
Consistently using appropriate hand hygiene
A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?
Place the client on Airborne Precautions.
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?
Inform them that the infection is the issue, not the client.
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?
Prepare to administer vancomycin (Vancocin).
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?
Ensure that the radiology department is aware of the isolation precautions.
A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
Elevate the arm above the level of the heart.
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?
Notify the provider and request antibiotics.
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 best?
Assess the client frequently for worsening of his or her condition.
The student 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
B,C,D,E
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 away from any client who has an infection.
d. Use personal protective equipment as needed for client care.
e. Wear gloves when touching client excretions or secretions.
D,E
The student 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
A,B,D,E
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 from the client at all times.
c. Order specialized masks/respirators for caregiving.
d. Other than wearing gloves, no special actions are needed.
e. Wash hands with chlorhexidine after providing care.
A,C
A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor 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
A,B,C,E
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.
B,C
