Deck 3 Module 9 Infection

Question 1

Which actions should the nurse take to help the client with bowel and bladder dysfunction reduce the risk of infection? Select all that apply.

A) Isolate the client using transmission-based precautions.
B) Monitor intake and output.
C) Provide hygienic care after episodes of incontinence.
D) Use standard precautions when handling linen after episodes of incontinence.
E) Limit fluid intake.

Answer 1

B) Monitor intake and output.
C) Provide hygienic care after episodes of incontinence.
D) Use standard precautions when handling linen after episodes of incontinence.

Rationale: Monitoring intake and output is important because it can help reveal whether a client is experiencing dehydration. Dehydration may lead to urinary stasis, which increases the risk of infection. Similarly, intake and output levels can help reveal urinary retention, which also heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an infection. In contrast, limiting fluid intake increases infection risk by putting the client at greater risk for dehydration. Isolating the client using transmission-based precautions is not necessary because these precautions are meant to prevent the spread of infection from the client to others, and this client is not currently experiencing infection.

Question 2

A nurse is planning an in-service on preventing infection for the staff nurses on a hospital’s medical-surgical unit. Which of the following should be the priority teaching point for this in-service?

A) Raising the temperature in each client’s room
B) Assessing vital signs once daily
C) Wearing a mask for client care
D) Performing hand hygiene

Answer 2

D) Performing hand hygiene

Rationale: Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Raising the temperature in a client’s room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.

Question 3

The nurse is assessing a client who is recovering following surgery. Which factor would increase this client’s susceptibility to infection?

A) Intact mucous membranes
B) Presence of an incision
C) Dry skin
D) Active bowel sounds

Answer 3

B) Presence of an incision

Rationale: This client has a surgical incision, so the body’s first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection.

Question 4

The nurse is caring for a client who is being discharged following abdominal surgery with an incision. Which instruction is most important for the nurse to teach this client regarding wound healing?

A) “Thoroughly irrigate the wound with hydrogen peroxide once a day.”
B) “Apply a lubricating lotion to the edges of the wound twice a day.”
C) “Add more fruits and vegetables to your diet.”
D) “Notify the healthcare provider if you notice swelling, warmth, or tenderness at the wound site.”

Answer 4

D) “Notify the healthcare provider if you notice swelling, warmth, or tenderness at the wound site.”

Rationale: A client being discharged with a surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.

Question 5

The nurse is caring for a client who is exhibiting signs of a systemic infection following surgery. Which diagnostic tests would the nurse anticipate being ordered? Select all that apply.

A) Serum electrolyte levels
B) Urinalysis
C) White blood cell differential
D) White blood cell count
E) Wound culture

Answer 5

B) Urinalysis
C) White blood cell differential
D) White blood cell count
E) Wound culture

Rationale: Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.

Question 6

The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of infection?

A) Place contaminated linens in a paper bag.
B) Use personal protective equipment (PPE).
C) Cover one’s cough by placing the mouth in the hand.
D) Wear sterile gloves for client care.

Answer 6

B) Use personal protective equipment (PPE).

Rationale: PPE, according to Occupational Safety and Health Administration (OSHA) standards, has to be used whenever the situation dictates and is a nursing measure to break a link in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Covering one’s mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. However, the cough should be covered in the elbow, not in the hand. Non-sterile gloves have to be worn when providing certain aspects of client care. The gloves should be changed between clients, and hands are to be washed.

Question 7

The nurse is teaching a child care class for mothers of young children. What should the nurse teach as being the most common mode of transmission of infectious disease?

A) Children who are playing board games
B) Children who are sitting together eating meals
C) Children who are playing with the same toy
D) Children who don’t wash their hands after using the bathroom

Answer 7

D) Children who don’t wash their hands after using the bathroom

Rationale: The fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission.

Question 8

A client is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this client? Select all that apply.

A) Encourage adequate fluid intake.
B) Monitor for allergic reaction.
C) Assess renal and liver function.
D) Assess pain level.
E) Monitor vital signs.

Answer 8

A) Encourage adequate fluid intake.
B) Monitor for allergic reaction.
C) Assess renal and liver function.
E) Monitor vital signs.

Rationale: Nursing interventions to support antibiotic therapy include encouraging adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. Although some clients may experience pain related to staph infection, antibiotics do not address pain, so assessment of pain levels is not related to administration of these medications.

Question 9

The healthcare provider prescribes a client to have peak and trough blood levels drawn to evaluate the therapeutic effect of an IV antibiotic. When should the nurse schedule the blood samples to be drawn? Select all that apply.

A) Prior to the discontinuing the antibiotic
B) A few minutes before the next scheduled dose of medication
C) During the infusion of the antibiotic
D) 30 minutes after the IV administration
E) 1 to 2 hours after the oral administration of the medication

Answer 9

B) A few minutes before the next scheduled dose of medication
D) 30 minutes after the IV administration

Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range–that is, the minimum and maximum blood levels at which the drug is effective–is known for a given drug. By measuring blood levels at the predicted peak (1-2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.

Question 10

A pregnant client tested positive for group B streptococcus during her 36-week checkup. For which intervention should the nurse prepare the client in order to prevent transmission of infection to the neonate?

A) Not breastfeeding the neonate during the first week after birth
B) Administration of antibiotics to the neonate after birth
C) Delivery by cesarean section
D) Administration of antibiotics to the client during labor

Answer 10

D) Administration of antibiotics to the client during labor

Rationale: Group B streptococcus (GBS) can be transmitted to the newborn during delivery. Administration of antibiotics during labor and delivery can prevent this transmission, so the nurse should prepare the mother for this intervention. GBS is not transmitted to the neonate through breastfeeding, antibiotics are not given to the neonate after birth, and a positive GBS test does not require cesarean delivery.

Question 11

A type of infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home is called a(n)

A) etiologic infection.
B) latent infection.
C) healthcare-associated infection.
D) hospital-associated infection.

Answer 11

C) healthcare-associated infection.

Rationale: A healthcare-associated infection, not a hospital-associated infection, is an infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home. Nurses must be diligent about hand hygiene and other safety practices to prevent healthcare-associated infections. A latent infection is an infection that is present but not active. All infections are etiologic; they are produced by a specific organism.

Question 12

Which agent can be used to destroy pathogens other than spores?

A) Antiseptic
B) Disinfectant
C) Sterilizing agent
D) Isolating agent

Answer 12

B) Disinfectant

Rationale: Disinfectants destroy pathogens other than spores. Antiseptics only inhibit the growth of some organisms. A sterilizing agent destroys all pathogens, including spores. Isolation is used to prevent the spread of infection but does not destroy any pathogens.

Question 13

Which client should the nurse anticipate will have the greatest psychosocial needs?

A) A client under standard precautions
B) A client taking antibiotics
C) A client under droplet precautions
D) A client in isolation

Answer 13

D) A client in isolation

Rationale: Clients requiring isolation precautions can develop psychosocial problems related to their separation from other people, including sensory deprivation and decreased self-esteem. The nurse will need to provide additional care for these clients to promote their psychosocial health. Clients taking antibiotics or under standard or droplet precautions may have psychosocial needs as well, but they will not be as severe as those of the client in isolation.

Question 14

The nurse is caring for a client with gangrene of the toe. Which collaborative intervention should the nurse anticipate preparing the client for?

A) Surgery
B) Debridement
C) Myringotomy
D) Wound irrigation

Answer 14

A) Surgery

Rationale: Surgical intervention is the primary collaborative treatment for gangrene. Wound irrigation and debridement are used to remove dead tissue and debris from a wound. They are not used for gangrenous infections. Myringotomy is used to remove infected inner ear drainage, not for infected toes.

Question 15

The nurse is caring for a client who is admitted with cellulitis of the foot. Which assessment findings support this diagnosis?

A) Blood urea nitrogen (BUN) and creatinine
B) Breath sounds
C) Blood cultures
D) Redness, pain, and edema at the site

Answer 15

D) Redness, pain, and edema at the site

Rationale: Classic signs of cellulitis are swelling, pain, redness, and edema at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot.

Question 16

The nurse is teaching a group of adolescents at a local high school about skin infections. Which students should the nurse identify as being at increased risk for developing cellulitis? Select all that apply.

A) A student who plucks her eyebrows
B) A student with diabetes
C) A student who is a member of the golf team
D) A student who squeezes pimples
E) A student who applies moisturizer on a daily basis

Answer 16

A) A student who plucks her eyebrows
B) A student with diabetes
D) A student who squeezes pimples

Rationale: The student who plucks her eyebrows risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes has a weakened immune system and increased risk for nerve damage and vascular changes in the extremities, which can lead to increased potential for skin injury and cellulitis. Non-contact sports like golf do not pose a risk for cellulitis. Keeping the skin well moisturized can protect against skin breakdown and thus reduce the risk for cellulitis.

Question 17

The nurse is caring for a client who is hospitalized for cellulitis of the foot. Which nursing diagnoses should the nurse use to plan this client’s care? Select all that apply.

A) Social Isolation related to skin infection
B) Impaired Skin Integrity related to skin infection
C) Acute Pain related to skin infection
D) Disturbed Sleep Pattern related to skin infection
E) Powerlessness related to inability to control the infection

Answer 17

B) Impaired Skin Integrity related to skin infection
C) Acute Pain related to skin infection

Rationale: Clients with cellulitis have Impaired Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given.

Question 18

The nurse is teaching a client with cellulitis about ways to promote healing and avoid future infections. Which client statements indicate that the teaching has been effective? Select all that apply.

A) “I should use antibiotic soap to cleanse my wound.”
B) “I must keep my wound completely dry between cleansings.”
C) “I should contact the doctor if I have a temperature of 99.5°F or higher.”
D) “I should avoid swimming in lakes when I have a wound.”
E) “I can stop taking antibiotics when the swelling subsides.”

Answer 18

A) “I should use antibiotic soap to cleanse my wound.”
D) “I should avoid swimming in lakes when I have a wound.”

Rationale: Clients with cellulitis should wash affected areas with antibacterial soap to prevent the spread of infection. They should also avoid swimming in lakes when wounded, as the water may be contaminated and could cause an infection. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered, not just until the swelling subsides. Wounds should be kept at a proper moisture level as instructed, because wet or moist wounds heal faster than dry wounds.

Question 19

A client receiving intravenous antibiotics for 3 days as treatment for cellulitis is being prepared for discharge. Which discharge order should the nurse anticipate for this client?

A) Low-sodium diet prescribed
B) Home healthcare aide for the client
C) Oral antibiotics to be continued at home
D) Orders for evaluation by physical therapy

Answer 19

C) Oral antibiotics to be continued at home

Rationale: Antibiotics should be taken for 10 days; therefore, the nurse anticipates oral antibiotics to be continued at home. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs physical therapy.

Question 20

The nurse is providing discharge instructions to a client recovering from cellulitis. Which client statement indicates that this teaching has been effective?

A) “I will monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site.”
B) “If the lesion looks healed, I will stop taking the antibiotics so that I will not develop resistance to antibiotics.”
C) “If pustules develop, I will squeeze the lesion to remove the pus.”
D) “Drainage from the site is an expected finding, and I should not be concerned.”

Answer 20

A) “I will monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site.”

Rationale: The client will need to be taught to monitor for the signs and symptoms of infection. Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. Changes in the color, amount, and odor from drainage are cause for concern and should be monitored. The physician must be notified if these symptoms occur. Pustules are never to be squeezed open, as there is risk of greater infection. Stopping antibiotics before the doses are complete causes resistance.

Question 21

When providing care to a client with a wound, which evidence-based interventions should the nurse anticipate carrying out? Select all that apply.

A) Keeping the wound dry
B) Only covering the wound if a scab forms
C) Ensuring that the wound remains moist
D) Keeping the wound covered
E) Teaching the client that proper wound management can reduce scarring

Answer 21

C) Ensuring that the wound remains moist
D) Keeping the wound covered
E) Teaching the client that proper wound management can reduce scarring

Rationale: Individuals with open wounds are more susceptible to contracting a skin infection, such as cellulitis. Many people believe that wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps maintain a moist environment, decreasing the chance of infection. Proper wound moisture management also reduces pain and improves the cosmetic outcome.

Question 22

On which region of the body would the nurse most expect to observe erysipelas?

A) Abdomen
B) Ankles
C) Neck
D) Back

Answer 22

B) Ankles

Rationale: Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders.

Question 23

The nurse is caring for a client who has been diagnosed with orbital cellulitis. Which assessment finding should the nurse anticipate?

A) Sunken eyes
B) Edema of the affected eye
C) Increased acuity of the affected eye
D) Elevated blood pressure

Answer 23

B) Edema of the affected eye

Rationale: Edema of the affected site is a common symptom of cellulitis. This may cause bulging eyes, not sunken eyes. The client may complain of decreased vision, not increased acuity of vision. Blood pressure is unrelated to orbital cellulitis.

Question 24

What organism is most commonly responsible for cellulitis?

A) Staphylococcus epidermidis
B) Streptococcus pneumoniae
C) Streptococcus viridans
D) Staphylococcus aureus

Answer 24

D) Staphylococcus aureus

Rationale: The most common causative organism of cellulitis is Staphylococcus aureus, followed by group A Streptococcus. The other bacteria produce other types of infections.

Question 25

A nurse caring for a client with cellulitis can expect to collaborate with which other member of the healthcare team?

A) Clinical psychologist
B) Social worker
C) Wound care specialist
D) Respiratory therapist

Answer 25

C) Wound care specialist

Rationale: Cellulitis is an acute bacterial infection of the dermis and underlying connective tissue. It usually occurs as a complication of a wound infection; thus, a wound care specialist is often used to promote a positive wound care plan. Social workers, clinical psychologists, and respiratory therapists are typically not involved in the care of most clients with cellulitis.

Question 26

The nurse is assessing a college student who presents with red, swollen eyes; photophobia; and yellowish drainage from the conjunctiva. Which question should the nurse ask the client first?

A) “Have you had extra caffeine this week?”
B) “Did you get sand in your eye recently?”
C) “Have you been exposed to HIV?”
D) “Have any of your friends experienced these symptoms?”

Answer 26

D) “Have any of your friends experienced these symptoms?”

Rationale: The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.

Question 27

When planning care for a client with trachoma, which potential complication should the nurse consider?

A) Scarring of the cornea
B) Eye muscle weakness
C) Damaged iris
D) Retinal detachment

Answer 27

A) Scarring of the cornea

Rationale: Trachoma is a chronic form of conjunctivitis that causes the formation of granulation tissue that is abraded by the lashes, leading to scarring of the cornea and eventual blindness. The other options are not potential complications to this type of conjunctivitis.

Question 28

The nurse is teaching a mother how to administer optical antibiotics to her child who has conjunctivitis. Which statement made by the mother indicates teaching has been effective?

A) “I will drop the medication onto the eyeball.”
B) “I will wait 10 seconds between drops.”
C) “I will wash my hands before instilling the medication.”
D) “I will rub the eye with a cotton ball after I administer the medication.”

Answer 28

C) “I will wash my hands before instilling the medication.”

Rationale: Teach the client to wash hands thoroughly before and after instilling eye medications. Handwashing is the single most important means of preventing transmission of infection. Medication is dropped into the lower conjunctival sac and should not be rubbed after instillation. The time between drops is 1 to 5 minutes, depending on the type of medication.

Question 29

The nurse is providing care for a pediatric client with bacterial conjunctivitis. Which interventions should the nurse use as part of the collaborative management of the client? Select all that apply.

A) Recommending dark sunglasses
B) Recommending removing contacts at night
C) Contacting the client's school nurse
D) Performing careful hand hygiene
E) Administering antiviral therapy

Answer 29

A) Recommending dark sunglasses
C) Contacting the client’s school nurse
D) Performing careful hand hygiene

Rationale: Dark glasses will help to reduce the photophobia that many clients with conjunctivitis experience. It is often appropriate for the nurse to contact the client’s school nurse to discuss increased prevention and student education. Careful hand hygiene is a standard method for managing the client with conjunctivitis. Antibiotics, not antiviral medications, are prescribed with conjunctivitis. Contacts should not be worn during conjunctivitis.

Question 30

The nurse is providing discharge instructions for a client who has acute conjunctivitis from Staphylococcus. Which should the nurse include when teaching this client? Select all that apply.

A) “It is OK to share makeup once the infection has resolved.”
B) “Do not share towels, makeup, or contact lenses with anyone else, as this can spread the infection.”
C) “You can soak your eyelids with a warm cloth to soften crusts and exudates that may form.”
D) “Wash your hands before cleansing the eye and administering eye drops.”
E) “You may go back to sharing towels when the infection is gone.”

Answer 30

B) “Do not share towels, makeup, or contact lenses with anyone else, as this can spread the infection.”
C) “You can soak your eyelids with a warm cloth to soften crusts and exudates that may form.”
D) “Wash your hands before cleansing the eye and administering eye drops.”

Rationale: Sharing supplies, such as towels, makeup, or contact lenses, is never a good idea even after the infection is cleared, due to potential for cross-contamination. Handwashing (hand hygiene) will minimize the risk of bringing in other organisms to an already infected eye. Soaking the lids with a warm cloth will soften the crusts from exudates that accompany the Staphylococcus infection. The action of rubbing one’s eyes can traumatize the eyes further and increase the risk of cross-contamination.

Question 31

The nurse is assessing a client who presents with purulent drainage and crusting of the eye. The nurse should recognize that these findings are most consistent with which type of infection?

A) Viral conjunctivitis
B) Allergic conjunctivitis
C) Bacterial conjunctivitis
D) Fungal conjunctivitis

Answer 31

C) Bacterial conjunctivitis

Rationale: The major difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting, whereas the discharge from viral conjunctivitis is serous (watery). Allergic conjunctivitis produces watery to thick drainage and is characterized by itching. Fungi do not cause conjunctivitis.

Question 32

Which term is commonly used by clients to describe conjunctivitis?

A) Stye
B) Pink eye
C) Red eye
D) Retinitis

Answer 32

B) Pink eye

Rationale: Clients commonly refer to conjunctivitis as “pink eye,” not red eye. Retinitis is a disease related to the retina, not the conjunctiva of the eye. Retinitis causes vision loss, not inflammation, redness, and discharge. A stye is a pimple-like infected oil gland on or near the edge of the eyelid.

Question 33

A client who uses extended-wear contact lenses should be taught measures for reducing the risk of which of the following conditions?

A) Conjunctivitis
B) Cataracts
C) Glaucoma
D) Macular degeneration

Answer 33

A) Conjunctivitis

Rationale: Individuals who use extended-wear contact lenses are at higher risk of developing conjunctivitis. Therefore, client teaching should include prevention of eye infections. These individuals are not at specific risk for other types of eye conditions, such as cataracts, glaucoma, or macular degeneration.

Question 34

A labor and delivery nurse is providing care for a neonate in the first few minutes after birth. One action the nurse will take to promote eye health and prevent conjunctivitis in the infant is administration of

A) oral tetracycline.
B) erythromycin as an eye ointment.
C) ceftriaxone as an eye drop.
D) parenteral acyclovir.

Answer 34

B) erythromycin as an eye ointment.

Rationale: Prevention of conjunctivitis in a newborn is provided by the administration of an antibiotic eye ointment, usually erythromycin. Tetracycline may be used instead of erythromycin immediately after birth, but it will be used as an eye ointment, not as an oral formulation. Ceftriaxone is only administered for a confirmed case of gonococcal conjunctivitis. Parenteral acyclovir is only administered for a confirmed case of conjunctivitis due to herpes simplex virus.

Question 35

The nurse is caring for a client who presents with acute malaise, muscle aches, and fever. Which additional assessment findings should the nurse recognize as consistent with influenza? Select all that apply.

A) No history of vaccinations within the past 12 months
B) Nonproductive cough
C) Hypotension
D) Difficulty urinating
E) Dizziness

Answer 35

A) No history of vaccinations within the past 12 months
B) Nonproductive cough

Rationale: Based on the presenting symptoms, the nurse would ask whether the client has had a seasonal flu shot or recently been exposed to the flu. Usually, the cough of a client with influenza is nonproductive. A productive cough may indicate a different diagnosis. Insufficient voiding, hypotension, and dizziness are not routine manifestations of influenza.

Question 36

The nurse is working in a primary care setting. Which clients should the nurse identify as being at high risk for influenza or its complications? Select all that apply.

A) A 25-year-old pregnant woman at 20 weeks’ gestation
B) A 65-year-old woman
C) A 3-year-old with cystic fibrosis
D) A 35-year-old man with a severe allergy to eggs
E) A 20-year-old healthcare worker

Answer 36

A) A 25-year-old pregnant woman at 20 weeks’ gestation
B) A 65-year-old woman
C) A 3-year-old with cystic fibrosis
E) A 20-year-old healthcare worker

Rationale: People at increased risk of influenza or its complications include infants, young children, pregnant women, and anyone age 50 or older. Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary diseases, are more susceptible as well. Healthcare workers have increased risk of exposure to influenza. A man with an allergy to eggs is not at increased risk for influenza or its complications.

Question 37

What information should the nurse include when teaching parents of pediatric clients about ways to decrease the spread of influenza? Select all that apply.

A) “Cover your cough” education
B) An explanation of appropriate hand hygiene
C) Methods for safe food preparation and storage
D) Where to obtain the influenza vaccine
E) The importance of withholding immunizations for children with compromised immune systems

Answer 37

A) “Cover your cough” education
B) An explanation of appropriate hand hygiene
D) Where to obtain the influenza vaccine

Rationale: Teaching children to wash their hands and to use respiratory etiquette helps control the growth and spread of microorganisms. The influenza vaccine can decrease each child’s susceptibility to influenza infection. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children.

Question 38

Which interventions should the nurse anticipate carrying out to promote effective breathing in a client with respiratory manifestations of the flu? Select all that apply.

A) Maintain adequate hydration.
B) Teach the client coughing and deep breathing.
C) Prepare the client for the possibility of a tracheostomy tube.
D) Keep the head of the bed elevated.
E) Administer antitussives during the day.

Answer 38

A) Maintain adequate hydration.
B) Teach the client coughing and deep breathing.
D) Keep the head of the bed elevated.

Rationale: Keeping the head of the bed elevated improves lung excursion and reduces the work of breathing. Coughing and deep breathing are essential for achieving airway clearance. Hydration thins the mucus and also aids in clearing the airway. Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance. Antitussives should be administered at night to promote sleep but should not be administered during the day to promote airway clearance through coughing.

Question 39

The nurse makes a home visit to a client recovering from influenza. Which client statements indicate that desired outcomes have been met? Select all that apply.

A) “I’m eating healthy foods now.”
B) “I went back to work.”
C) “I haven’t had chills since I left the hospital.”
D) “I slept the whole night without coughing.”
E) “I was able to take a walk today.”

Answer 39

C) “I haven’t had chills since I left the hospital.”
D) “I slept the whole night without coughing.”

Rationale: Desired outcomes for a client recovering from the flu include absence of symptoms of acute infection (such as fever and chills), resolution of respiratory symptoms, and resumption of normal sleep-rest patterns. The facts that the client has returned to work, is able to walk, and is eating a healthy diet do not indicate that the client’s flu has resolved.

Question 40

The nurse is reviewing diagnostic and laboratory studies performed for a client with influenza. Which result should the nurse recognize as being consistent with influenza?

A) Decreased white blood cell count
B) Increased BUN
C) Decreased sodium level
D) Fluid-filled lungs on chest x-ray

Answer 40

A) Decreased white blood cell count

Rationale: The white blood cell count of a client with influenza will typically be decreased. Laboratory tests for BUN and sodium levels are not usually associated with influenza. Unless the client with influenza develops complications, the chest x-ray is clear.

Question 41

Which interventions should the nurse incorporate into the plan of care for a client diagnosed with influenza? Select all that apply.

A) Placing droplet and contact precaution signs on the client’s room door
B) Placing the client in a negative air flow room
C) Placing a ventilator in the room
D) Notifying other departments of the diagnosis
E) Using appropriate PPE

Answer 41

A) Placing droplet and contact precaution signs on the client’s room door
E) Using appropriate PPE

Rationale: To prevent the spread of influenza, the client is placed in a private room with signs for droplet and contact precautions. It is important for healthcare workers to use appropriate PPE for these transmission-based precautions. Placing signs on the door is the way to notify other departments of precautions; no additional notification is needed. Negative air flow rooms are for diseases such as chickenpox, measles, and severe acute respiratory syndrome (SARS). There is no indication that this client will need a ventilator.

Question 42

Necrosis of respiratory epithelial cells and shedding of serous and ciliated cells of the respiratory tract produce which common symptom of influenza?

A) Malaise
B) Coryza
C) Cough
D) Rhinorrhea

Answer 42

D) Rhinorrhea

Rationale: Shedding of serous and ciliated cells of the respiratory tract leads to rhinorrhea, or a runny nose. Serous cells are replaced more rapidly than ciliated cells, leading to continued cough and coryza. Malaise is a general symptom of influenza and is not directly related to the shedding of cells from the respiratory tract.

Question 43

Because of the way the influenza virus is transmitted from person to person, nurses who are working with clients with influenza should implement

A) droplet precautions.
B) isolation precautions.
C) airborne precautions.
D) contact precautions.

Answer 43

A) droplet precautions.

Rationale: Influenza is spread through droplets when the client sneezes or coughs. Therefore, droplet precautions should be used. Isolation precautions limit the number of people who come in contact with the client and are used only for severe or life-threatening infections. Airborne precautions are used for tuberculosis and other infections that are airborne. Contact precautions are used when the nurse is at risk of contacting infected body fluids such as stool or wound drainage.

Question 44

Which oral antiviral drug that is commonly prescribed for influenza A and B works by preventing the release of newly formed virus?

A) Rimantadine (Flumadine)
B) Zanamivir (Relenza)
C) Oseltamivir (Tamiflu)
D) Amantadine (Symmetrel)

Answer 44

C) Oseltamivir (Tamiflu)

Rationale: Oseltamivir (Tamiflu) is an oral antiviral drug that is prescribed for influenza A and B. It works by preventing the release of newly formed virus. Zanamivir (Relenza) has a similar mechanism of action, but it is given via inhalation. Rimantadine (Flumadine) and amantadine (Symmetrel) are primarily used for prophylaxis of influenza. They are not recommended by the Centers for Disease Control and Prevention (CDC) for treatment of active influenza.

Question 45

What should the nurse recommend for a pregnant client who is concerned about a recent flu outbreak?

A) The nurse should recommend that the client receive the influenza vaccination.
B) The nurse should recommend that the client stay home until the influenza outbreak has ended.
C) The nurse should recommend that the client take amantadine (Symmetrel) prophylactically.
D) The nurse should recommend that the client eat foods that boost the immune system.

Answer 45

A) The nurse should recommend that the client receive the influenza vaccination.

Rationale: The influenza vaccine is the client’s best method of preventing influenza infection, and it has no indication of harm to the unborn child. Amantadine is a Category C drug and should not be given during pregnancy to prevent influenza. Although eating foods that boost the immune system is a good recommendation, it will not be as effective at preventing influenza in an exposed individual as the influenza vaccine. Recommending the client stay home for several weeks is not a practical method of prevention.

Question 46

The nurse is caring for a group of clients with influenza. Which client should the nurse identify as being at greatest risk for complications?

A) A 53-year-old woman
B) A 72-year-old man
C) A 35-year-old woman
D) A 12-year-old boy

Answer 46

B) A 72-year-old man

Rationale: Children under the age of 5 and older adults over the age of 65 are at highest risk of developing complications related to influenza infection. Older adults are more at risk because their immune defenses become weaker with age.

Question 47

The nurse is caring for a client who refuses treatment for otitis media. The nurse correctly teaches the client that she is at increased risk for developing which condition?

A) External otitis
B) Meningitis
C) Pneumonia
D) Influenza

Answer 47

B) Meningitis

Rationale: The bacterial infection from otitis media may migrate internally, leading to the development of bacterial meningitis. Otitis media is not known to cause external otitis. Otitis media does not cause pneumonia or influenza.

Question 48

The nurse is teaching the mother of an infant with otitis media to manage the associated fever and pain. Which instruction by the nurse is correct?

A) Swaddle the baby in blankets.
B) Feed the baby solid foods.
C) Administer acetaminophen.
D) Bathe the baby with cool water.

Answer 48

C) Administer acetaminophen.

Rationale: Swaddling the baby with blankets is not going to reduce the fever or help the pain. The baby may not be of the age to take solid foods. Acetaminophen will help reduce the child’s fever and reduce the pain. Bathing with cool water is not an appropriate intervention to reduce the fever of a baby.

Question 49

Which instruction should the nurse provide to an adolescent client with otitis media with regard to pain?

A) Apply a cold compress to the affected ear.
B) Report abrupt relief of pain immediately.
C) Continue plans for air travel.
D) Report increased pain when moving the outer ear.

Answer 49

B) Report abrupt relief of pain immediately.

Rationale: Abrupt relief of pain may mean that the tympanic membrane has perforated. Heat should be applied to dilate surrounding blood vessels and decrease swelling. The pain of otitis media is not aggravated by movement of the external ear. Drastic changes in barometric pressure can increase pain considerably, so clients are discouraged from traveling by air.

Question 50

The nurse correctly explains to a young mother that bottle-feeding an infant in the upright position may help to prevent which infectious health problem?

A) Choking
B) Aspiration
C) Sinus infection
D) Otitis media

Answer 50

D) Otitis media

Rationale: Infants and small children who are bottle-fed in a supine position have a greater probability of developing otitis media because the eustachian tube opens when the child sucks, and the horizontal angle provides easy access to the middle ear. Children are not prone to sinus infection during infancy as the result of feeding position. Although choking and aspiration can occur due to an improper position during bottle-feeding, they are not infectious health problems.

Question 51

A client has completed the full course of antibiotics prescribed to treat otitis media. Which primary manifestation of the disorder will be relieved as evidence that treatment has been effective?

A) Impaired hearing
B) Dizziness
C) Pain
D) Nausea and vomiting

Answer 51

C) Pain

Rationale: Ear pain is the most common symptom of otitis media that motivates the client to seek healthcare. Secondary symptoms associated with the disease include dizziness, impaired hearing, and nausea and vomiting.

Question 52

A toddler with otitis media is prescribed amoxicillin clavulanate 250 mg/5 mL three times daily by mouth for 10 days. What should the nurse teach the mother about this medication?

A) “It is OK to stop the antibiotic if the child begins to have side effects.”
B) “Give the antibiotic for the full 10 days as prescribed.”
C) “It is important to measure the prescribed dose in a household teaspoon.”
D) “Be sure to administer a loading dose of the medication when you get home.”

Answer 52

B) “Give the antibiotic for the full 10 days as prescribed.”

Rationale: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon could contain less than 5 mL, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.

Question 53

The nurse is teaching the parents of an infant who is diagnosed with acute otitis media. Which is the priority teaching point for these parents?

A) Administer a decongestant for nasal congestion.
B) Keep the baby in a flat position during sleep.
C) Administer acetaminophen to relieve pain and decrease fever.
D) Place the baby to sleep with a pacifier.

Answer 53

A) Administer a decongestant for nasal congestion.

Rationale: ) Parents are taught to administer acetaminophen to relieve the discomfort and decrease fever associated with acute otitis media. Decongestants are not recommended for treatment of acute otitis media. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended. Placing infants to sleep with a pacifier can increase the incidence of otitis media.

Question 54

The body structure that provides a route by which infections organisms can enter the middle ear to cause otitis media is the

A) nasopharynx.
B) eustachian tube.
C) tympanic membrane.
D) sinus cavity.

Answer 54

B) eustachian tube.

Rationale: The eustachian tube connects the middle ear with the nasopharynx, and this tube provides a route through which infectious organisms can enter the middle ear from the nose and throat. The nasopharynx and sinus cavity are structures in the nose and throat. They do not directly connect to the middle ear. The tympanic membrane separates the middle ear from the external auditory canal. It protects the middle ear from infectious organisms when it is intact.

Question 55

Which child has a risk factor for developing otitis media?

A) A 10-year-old child who plays baseball and soccer
B) A 14-year-old child who lives on a farm
C) A 5-year-old child who stays with her grandmother during summer break
D) An 18-month-old child who attends daycare while his parents work

Answer 55

D) An 18-month-old child who attends daycare while his parents work

Rationale: Risk factors for developing otitis media include being younger than age 2, participating in group care settings, having seasonal allergies, or being exposed to poor air quality. The 18-month-old child has two risk factors for developing otitis media. None of the other children have any of these risk factors.

Question 56

An older adult client is admitted with pneumonia. Which manifestations would the nurse expect to find when assessing this client? Select all that apply.

A) Hemoptysis
B) Increased appetite
C) Cough
D) Tachypnea
E) Fever

Answer 56

A) Hemoptysis
C) Cough
D) Tachypnea
E) Fever

Rationale: Common symptoms of pneumonia include fever, cough, tachypnea, and hemoptysis. Decreased appetite may accompany symptoms of pneumonia, not increased appetite.

Question 57

An older adult client asks the nurse what can be done to decrease the risk of developing pneumonia. Which responses by the nurse are most appropriate? Select all that apply.

A) “Once per day, you should eat yogurt that is supplemented with L. casei immunitas cultures.”
B) “Eliminating habits like smoking can help.”
C) “You can get the pneumonia vaccination, which may help decrease your risk in the future.”
D) “Avoiding alcohol will reduce your risk.”
E) “There is nothing you can do to decrease your risk of pneumonia in the future.”

Answer 57

B) “Eliminating habits like smoking can help.”
C) “You can get the pneumonia vaccination, which may help decrease your risk in the future.”
D) “Avoiding alcohol will reduce your risk.”

Rationale: Both smoking and alcohol consumption increase the risk of pneumonia. Smoking injures tissues in the airways and decreases the action of the cilia. Alcohol interferes with the actions of macrophages. Avoiding smoking and alcohol will decrease the risk of pneumonia. Pneumonia vaccines can also decrease the risk of developing the disease in the future. L. casei immunitas cultures have not been proven to support immune function. Telling the client that it is not possible to decrease the risk of pneumonia is incorrect.

Question 58

The nurse is caring for a client with pneumonia. Which intervention should the nurse include in this client’s plan of care to promote effective airway clearance?

A) Perform chest percussion every 4 hours and prn.
B) Administer the pneumococcal vaccine prior to discharge.
C) Limit fluid intake to 1000 mL per day.
D) Provide the client with smoking cessation education.

Answer 58

A) Perform chest percussion every 4 hours and prn.

Rationale: Chest percussion can help clear secretions. Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a client with pneumonia; however, they would be aligned with a different nursing diagnosis. Patients with pneumonia are encouraged to increase fluid intake.

Question 59

The nurse is providing discharge teaching to a client recovering from pneumonia. Which client statement indicates that additional teaching is needed?

A) “I can’t get the influenza vaccine due to my allergy to eggs.”
B) “I will get the influenza vaccine every year.”
C) “I will get the pneumococcal vaccine every fall.”
D) “The pneumococcal vaccine protects against bacterial pneumonia.”

Answer 59

C) “I will get the pneumococcal vaccine every fall.”

Rationale: Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. Because the pneumococcal vaccine is made of antigens from 23 types of pneumococcus, a type of bacteria, it only protects against bacterial pneumonias.

Question 60

Which intervention should the nurse carry out to manage fever in a client with pneumonia? Select all that apply.

A) Increase the temperature of the room environment to prevent shivering.
B) Administer antipyretic medications.
C) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance.
D) Use ice packs and a tepid bath every 2 hours.
E) Promote frequent rest periods to increase energy reserve

Answer 60

B) Administer antipyretic medications.
E) Promote frequent rest periods to increase energy reserve.

Rationale: The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance.

Question 61

The nurse is caring for a client who develops a fever and productive cough after abdominal surgery. Which orders should the nurse expect from the healthcare provider? Select all that apply.

A) Sputum cultures
B) Antibiotics
C) Chest physiotherapy
D) Bronchial washing for culture
E) Isolation precautions

Answer 61

A) Sputum cultures
B) Antibiotics
C) Chest physiotherapy

Rationale: The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not included in routine testing for this scenario. The client likely has an infectious disease that is not contagious. Isolation precautions are usually not ordered for noncontagious infections.

Question 62

Which of the following is not one of the four distinct patterns of pneumonia?

A) Lobar pneumonia
B) Bronchopneumonia
C) Alveolar pneumonia
D) Interstitial pneumonia

Answer 62

C) Alveolar pneumonia

Rationale: The four distinct patterns of pneumonia are lobar pneumonia, bronchopneumonia, interstitial pneumonia, and miliary pneumonia. Alveolar pneumonia is not a typical pattern for pneumonia.

Question 63

Which type of pneumonia rarely occurs in individuals with normal immune function?

A) Pneumonia caused by the influenza virus
B) Pneumonia caused by Pneumocystis jiroveci
C) Pneumonia caused by Mycoplasma pneumoniae
D) Pneumonia caused by Streptococcus pneumoniae

Answer 63

B) Pneumonia caused by Pneumocystis jiroveci

Rationale: Individuals who are significantly immunocompromised are at significant risk of developing pneumonia caused by Pneumocystis jiroveci. Immunity to P. jiroveci is nearly universal, except in those who are immunocompromised. The influenza virus, Mycoplasma pneumoniae, and Streptococcus pneumonia are all common causes of pneumonia in the general population.

Question 64

The provider has ordered fluid administration for a pediatric client with pneumonia. The client weighs 81.6 lb (37 kg). The nurse should expect to administer ________ mL of fluid per day for this client.

Answer 64

1840

Explanation: Administer 100 mL/kg/day for the first 10 kg, 50 mL/kg/day for the second 10 kg, and 20 mL/kg/day for all additional body weight over 20 kg. Therefore, this client should receive (10 kg × 100 mL) + (10 kg × 50 mL) + (17 kg × 20 mL) = 1000 mL + 500 mL + 340 mL = 1840 mL/day.

Question 65

What is the primary rationale for maintaining adequate hydration in clients with pneumonia?

A) It helps maintain urine output to clear toxins from the blood.
B) It helps increase blood pressure to maintain perfusion to vital organs.
C) It helps keep the mucus membranes moist to prevent further infection.
D) It helps keep the airway clear by making secretions easier to expectorate.

Answer 65

D) It helps keep the airway clear by making secretions easier to expectorate.

Rationale: Maintaining adequate hydration can help in all four of these areas depending on the nature of the client’s condition. However, for clients with pneumonia, the most important reason to maintain adequate hydration is that this helps keep secretions in the lungs thin, which makes them easier to expectorate. This helps keep the airway clear, which is a priority for clients with pneumonia.

Question 66

A client is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this client? Select all that apply.

A) Tachycardia
B) Pain
C) Edema
D) Hypotension
E) Fever

Answer 66

A) Tachycardia
D) Hypotension
E) Fever

Rationale: Fever, tachycardia, and hypotension are common symptoms of a systemic infection. Edema and pain are symptoms of a local infection.

Question 67

The nurse is providing teaching on preventing sepsis. Which should the nurse include as a major risk factor for the development of this health problem?

A) Pneumococcal bacteria
B) Leukocytosis on the complete blood count
C) Undiagnosed urinary tract infection
D) Elevated temperature

Answer 67

C) Undiagnosed urinary tract infection

Rationale: Sepsis is an entire-body inflammatory process. Sepsis is most often the result of gram-positive infections from Staphylococcus and Streptococcus bacteria but may also follow gram-negative bacterial infections such as Pseudomonas, Escherichia coli, and Klebsiella. A portal of entry for sepsis is the urinary system. Leukocytosis occurs with sepsis if the client is able to mount an immune response. An elevated temperature is a manifestation of sepsis.

Question 68

A 1-month-old infant is admitted to the hospital with a temperature of 102°F. What is the rationale for a complete septic workup?

A) Absence of sweat glands
B) Immature immune system
C) Inadequate red blood cells
D) Poor lung elasticity

Answer 68

B) Immature immune system

Rationale: A child less than 3 months of age with a temperature higher than 100.4°F should be evaluated for sepsis because the child is at increased risk secondary to an immature immune system. The child is not evaluated for sepsis because of the absence of sweat glands, inadequate red blood cells, or poor lung elasticity.

Question 69

A nurse is caring for a client with septicemia. What assessment by the nurse best addresses the potential for ineffective peripheral perfusion?

A) Monitor heart rate every hour.
B) Assess temperature every 4 hours.
C) Monitor pupil reactions every 8 hours.
D) Monitor for cyanosis.

Answer 69

D) Monitor for cyanosis.

Rationale: Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but a change in skin color will alert the nurse immediately of decreased tissue perfusion.

Question 70

The nurse is caring for an older adult client who developed sepsis from a pressure ulcer while residing in a long-term care facility. The family asks how they can help prevent this from happening again in the future. Which response by the nurse is best?

A) Alert the staff when the client’s IV runs dry.
B) Help the nurse with dressing changes.
C) Assist the client to the bathroom so there is not a fall.
D) Assist the client with meals to obtain optimal nourishment.

Answer 70

D) Assist the client with meals to obtain optimal nourishment.

Rationale: Poor nutritional status and a slow-functioning immune system contribute to the risk for sepsis in the older client. The family can help by assisting and encouraging the client to take in the proper nourishment needed. The family is not responsible for IV or dressing changes. Assisting the client to the bathroom should be done by the staff who are responsible for client safety.

Question 71

Which finding supports the nurse’s evaluation that an older adult client with sepsis has maintained a normal mental status?

A) The client is agitated.
B) The client has a Glasgow coma score of 4.
C) The client responds to questions appropriately.
D) The client’s pupils are fixed and dilated.

Answer 71

C) The client responds to questions appropriately.

Rationale: A client who responds to questions appropriately is alert and oriented. Restlessness or agitation in a client with sepsis can be a sign that the client’s condition is deteriorating. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent.

Question 72

The nurse is admitting a client to the intensive care unit. Earlier, the client presented to the emergency department in early septic shock. Given this information, which assessment findings should the nurse anticipate? Select all that apply.

A) Normal blood pressure
B) Rapid and deep respirations
C) Shallow respirations
D) Warm and flushed skin
E) Lethargic mental status
F) Decreased urine output

Answer 72

A) Normal blood pressure
B) Rapid and deep respirations
D) Warm and flushed skin

Rationale: Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock.

Question 73

List the pathophysiology concepts related to the onset of sepsis in sequential order.

A) Macrophage-producing cytokines are released.
B) Endotoxin released by microorganisms sets off an out-of-control inflammatory process.
C) Neutrophils arrive and multiply, occluding capillaries.
D) Vasodilation with increased capillary permeability and fluid leak.

Answer 73

B) Endotoxin released by microorganisms sets off an out-of-control inflammatory process.
A) Macrophage-producing cytokines are released.
D) Vasodilation with increased capillary permeability and fluid leak.
C) Neutrophils arrive and multiply, occluding capillaries.

Rationale: The pathophysiology of sepsis occurs as follows: Endotoxin released by microorganisms sets off an out-of-control inflammatory process; macrophage-producing cytokines are released; vasodilation with increased capillary permeability and fluid leak; neutrophils arrive and multiply, occluding capillaries.

Question 74

One method of preventing sepsis in hospitalized clients is

A) using aseptic techniques when inserting a catheter.
B) placing clients with infections in negative airflow rooms.
C) using airborne precautions when assessing clients.
D) teaching proper techniques for using tampons.

Answer 74

A) using aseptic techniques when inserting a catheter.

Rationale: One risk factor for developing sepsis is not using aseptic techniques and good hand washing techniques when inserting a catheter. Following standard guidelines for using aseptic and hand washing techniques when inserting or removing a catheter can help prevent sepsis. Not all clients who are at risk for sepsis need to be placed in a negative airflow room or require airborne precautions during assessment. Teaching proper techniques for using tampons will help prevent sepsis, but this is more appropriate for clients in the community rather than hospitalized clients.

Question 75

Which diagnostic test result is consistent with a diagnosis of septic shock?

A) A blood pH that is higher than normal
B) A hematocrit that is higher than normal
C) A PaCO2 that is lower than normal
D) A potassium level that is lower than normal

Answer 75

B) A hematocrit that is higher than normal

Rationale: During septic shock, fluid leaks from the intravascular to the extravascular spaces, causing hemoglobin and hematocrit concentrations that are higher than normal. During septic shock, the blood pH will be lower than normal (indicating acidosis), and the PaCO2 and potassium level will increase.

Question 76

The nurse is preparing to assess an older adult client admitted with tuberculosis. Which assessment finding does the nurse anticipate?

A) Night sweats
B) Swollen lymph nodes
C) Cough
D) Hemoptysis

Answer 76

C) Cough

Rationale: Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers. Night sweats, swollen lymph nodes, and hemoptysis are more common in younger adults but are not considered presenting symptoms of tuberculosis in the older adult.

Question 77

An adolescent client is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, which potential risk should the nurse include when planning care for this client?

A) Pneumothorax
B) Atelectasis
C) Renal failure
D) Reduced peristalsis

Answer 77

A) Pneumothorax

Rationale: This client was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax. Patients with TB are not at particular risk for atelectasis, renal failure, or reduced peristalsis.

Question 78

The nurse in an inner city clinic is providing a health screening for a homeless client with a history of drug abuse. The client has a chronic nonproductive cough. For which should the nurse expect to screen this client?

A) Herpes zoster
B) Sickle cell disease
C) Sick sinus syndrome
D) Tuberculosis

Answer 78

D) Tuberculosis

Rationale: The homeless client who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this client for TB. There is no evidence to support the need to screen the client for sickle cell disease, herpes zoster, or sick sinus syndrome.
B) The homeless client who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this client for TB. There is no evidence to support the need to screen the client for sickle cell disease, herpes zoster, or sick sinus syndrome.

Question 79

The nurse is planning care for a client recently diagnosed with tuberculosis (TB). The client lives alone in an apartment and will continue treatment at home. When reviewing the client’s history, the nurse notes that the client has had trouble complying with medication regimens in the past. Which nursing diagnosis is a priority for this client?

A) Ineffective Health Management
B) Deficient Knowledge
C) Ineffective Breathing Pattern
D) Risk for Injury

Answer 79

A) Ineffective Health Management

Rationale: The treatment regimen for tuberculosis requires that the client take many medications, maintain nutrition, and be aware of potential side effects. Given the complexity of this regimen and the client’s history of noncompliance, the client is at risk for ineffective treatment in the home. The client may have a knowledge deficit, but the priority is the health management. Since the client is being treated in the home, there is not much risk for ineffective breathing. The client does not appear to be at risk for injury.

Question 80

An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB). The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most appropriate response by the nurse?

A) “Different medication is used in the second PPD.”
B) “The treatment for TB is 6 months of medication, and we want to make sure the first results of the first PPD were accurate.”
C) “The first PPD was not interpreted in the correct time frame of 48-72 hours.”
D) “There is an increased risk for a false-negative response for people who work in long-term care facilities. The two-step process is recommended to accurately screen for TB.”

Answer 80

D) “There is an increased risk for a false-negative response for people who work in long-term care facilities. The two-step process is recommended to accurately screen for TB.”

Rationale: PPD testing is done in a two-step process for people who work in long-term care facilities because of the risk of false-negative responses. Treatment for TB for 6 months is not a reason to complete the PPD twice. PPD testing is not done twice because different medication is used. Evaluating the test at the wrong interval is not the reason that the PPD is done twice for long-term care facility employees.

Question 81

The nurse has provided teaching on multidrug treatment to a client with tuberculosis. Which statement by the client indicates that the teaching was effective?
A) “Multiple drugs are necessary to develop immunity to tuberculosis.”
B) “Multiple drugs are necessary because I became infected from an immigrant.”
C) “Multiple drugs will be required as long as I am contagious.”
D) “Multiple drugs are necessary because of the risk of resistance.”

Answer 81

D) “Multiple drugs are necessary because of the risk of resistance.”
Answer: D

Rationale: Tuberculosis bacilli are likely to develop resistance to one drug, so multiple drugs must be used. Treatment must be continued long after the client is no longer contagious. There is no indication that the client contracted TB from an immigrant. Drugs to treat tuberculosis do not cause immunity to the disease.

Question 82

The nurse is caring for a client who is admitted to the unit with tuberculosis (TB). Which type of isolation room is most appropriate?

A) Single-door room with positive airflow (air flows out of the room)
B) Isolation room with an anteroom and negative airflow (air flows into the room)
C) Isolation room with an anteroom and normal airflow
D) Single-door room with normal airflow

Answer 82

B) Isolation room with an anteroom and negative airflow (air flows into the room)

Rationale: Patients with airborne infections such as meningococcemia, severe acute respiratory syndrome (SARS), or TB are placed in an isolation room with an anteroom and negative pressure airflow. Air flows into the room and is vented in a special manner to prevent the organism from entering the rest of the unit. Positive flow rooms are used for those clients who are immunosuppressed so that microorganisms from the unit are not drawn into the room. Single-door isolation with normal airflow might be used for a client with droplet or wound infection. Single-door rooms are not equipped to have positive or negative airflow.

Question 83

The charge nurse for a medical-surgical unit is notified that a client with tuberculosis (TB) is being transported to the unit. Which actions for infection prevention are the most appropriate in this circumstance? Select all that apply.

A) Stock the client’s supply cart at the beginning of each shift.
B) Wear a respirator and gown when caring for the client.
C) Have the client wear a mask when coming from admissions.
D) Perform hand hygiene only after leaving the room.
E) Test all staff members for TB immediately.

Answer 83

B) Wear a respirator and gown when caring for the client.
C) Have the client wear a mask when coming from admissions

Rationale: HEPA-filtered respirators and gowns should be worn when caring for clients who do not reliably cover their mouths when coughing. When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask. Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next healthcare provider. Hand hygiene should be performed before and after client care. Clinical staff receive TB testing annually. There is no reason to test all staff members at this time.

Question 84

A nurse is caring for a client with tuberculosis (TB) who is taking rifampin for treatment of the disease. Which nursing interventions are appropriate for this client? Select all that apply.

A) Administer the medication with meals to reduce gastrointestinal side effects.
B) Record a baseline visual examination before initiating therapy.
C) Administer the medication on an empty stomach.
D) Administer the medication by deep intramuscular injection into a large muscle mass.
E) Monitor complete blood count (CBC), liver function studies, and renal function studies for evidence of toxicity.

Answer 84

C) Administer the medication on an empty stomach.
E) Monitor complete blood count (CBC), liver function studies, and renal function studies for evidence of toxicity.

Rationale: Rifampin is an oral antituberculosis medication that should be administered on an empty stomach. The nurse should monitor the CBC, liver function studies, and renal function studies. A baseline visual examination before therapy is necessary with ethambutol, another antituberculosis medication.

Question 85

The nurse caring for a client at risk for tuberculosis (TB) should include which symptoms of the disease when educating the client? Select all that apply.

A) Fatigue
B) Low-grade morning fever
C) Productive cough that later turns to a dry, hacking cough
D) Weight loss
E) Night sweats

Answer 85

A) Fatigue
D) Weight loss
E) Night sweats

Rationale: Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, diminished appetite, low-grade afternoon fever, and night sweats are common. A dry cough develops, which later becomes productive of purulent and/or blood-tinged sputum. It is often at this stage that the client first seeks medical attention.

Question 86

A client with a previously healed tuberculosis lesion experiences lesion rupture that leads to active disease. Which type of tuberculosis does this client have?

A) Miliary tuberculosis
B) Extrapulmonary tuberculosis
C) Reactivation tuberculosis
D) Cavitation tuberculosis

Answer 86

C) Reactivation tuberculosis

Rationale: When a previously healed tuberculosis lesion ruptures and initiates active disease, this is called reactivation tuberculosis. This reactivation may or may not lead to extrapulmonary tuberculosis (tuberculosis outside the lungs) or to miliary tuberculosis (the spread of tuberculosis through the blood to the rest of the body). Cavitation is a process by which a bubble or cavity is formed from tuberculosis infection. It is not a type of tuberculosis.

Question 87

The infecting organism that causes tuberculosis is

A) Micrococcus tuberculosis.
B) Microbacterium tuberculosis.
C) Mycoplasma tuberculosis.
D) Mycobacterium tuberculosis.

Answer 87

D) Mycobacterium tuberculosis.

Rationale: Tuberculosis is caused by the bacterium Mycobacterium tuberculosis. Micrococcus, Microbacterium, and Mycoplasma are all other forms of bacteria, but they do not cause tuberculosis.

Question 88

An adult client is admitted to the hospital with a diagnosis of kidney stones. The healthcare provider prescribes IV fluids, x-rays, blood work, and a Foley catheter for the client. The nurse is caring for the client 3 days after admission and documents morning vital signs of 101°F, heart rate 92, respirations 25, and blood pressure 120/80. The urinary output has decreased, and the urine is cloudy and dark amber. Based on this data, which conclusion by the nurse is the most appropriate?

A) The client has passed the kidney stones.
B) The client is in acute renal failure.
C) The client has developed a respiratory infection.
D) The client has a probable urinary tract infection.

Answer 88

D) The client has a probable urinary tract infection.

Rationale: The client has developed a urinary tract infection that was not present upon admission. This is a healthcare-associated infection (HAI) and is likely due to poor technique when placing the Foley catheter. There is no evidence of a respiratory infections, renal failure, or the passage of kidney stones.

Question 89

The nurse for a urology clinic is planning an in-service about urinary infections for a group of novice nurses. Which statement should the nurse include in the presentation?

A) Men are most likely to experience descending urinary tract infections.
B) Straight catheterization is the only way to evaluate for the presence of a urinary tract infection.
C) Women require a shorter course of antibiotic therapy to manage a urinary tract infection than men.
D) The rate of urinary tract infections is similar between men and women.

Answer 89

C) Women require a shorter course of antibiotic therapy to manage a urinary tract infection than men.

Rationale: Men will usually be prescribed a longer course of therapy to manage a urinary tract infection. They have a longer urethra and typically experience more complicated urinary tract infections than women. Descending infections are less common than ascending infections of the urinary tract. A clean-catch midstream specimen is a reliable means to obtain a urine specimen to check for the presence of infection. Women have a higher rate of urinary tract infection than men.

Question 90

The nurse is providing teaching to the family of an older adult client with a urinary tract infection (UTI). Which common early symptom that is likely to occur in older adults should the nurse stress?

A) Urinary urgency
B) Blood in the urine
C) Urinary frequency
D) Alteration in cognition

Answer 90

D) Alteration in cognition

Rationale: ) The early manifestations of UTI are different for older adults than for younger adults. Older adult clients are often asymptomatic until changes in cognition occur.

Question 91

Which question best helps the nurse establish a common cause of recurrent urinary tract infections (UTIs) in a preadolescent female client?

A) “When was your last UTI?”
B) “How often do you shower?”
C) “Do you have a family history of urinary problems?”
D) “In what direction do you wipe after a bowel movement?”

Answer 91

D) “In what direction do you wipe after a bowel movement?”

Rationale: The most important teaching to provide females is always to wipe the perianal/genital area from front to back. Escherichia coli are the most common microorganisms responsible for urinary tract infections and can easily be dragged into the urethral orifice by wiping from the anus to the urethra after defecation. Females do have a shorter urethra compared with males and are more susceptible to urinary tract infections for this reason. Personal hygiene practices, such as cleansing after a bowel movement, are a priority teaching instruction to include for this client. Urinary tract infections are not associated with families or genetics.

Question 92

The nurse is providing teaching to parents about urinary tract infections (UTIs) in preschool children. The nurse should inform the parents that which of the following are common symptoms of UTI in this age group? Select all that apply.

A) Urinary urgency
B) Elevated blood pressure
C) Dysuria
D) Fever
E) Headache

Answer 92

A) Urinary urgency
C) Dysuria
D) Fever

Rationale: Clinical manifestations of a UTI in a preschool-age child include fever, urgency, and dysuria. Headache and elevated blood pressure are not clinical manifestations of a UTI for a preschool-age child.

Question 93

The nurse is providing discharge teaching for a client diagnosed with a urinary tract infection (UTI). The client is prescribed a 3-day course of oral trimethoprim-sulfamethoxazole (TMP-SMZ). Which client statement indicates that teaching has been effective?

A) “I will return within 10 days for a follow-up urine culture.”
B) “I will practice Kegel exercises on a daily basis.”
C) “I will increase my intake of fluids, especially citrus juice.”
D) “I will only wear 100% cotton underwear.”

Answer 93

A) “I will return within 10 days for a follow-up urine culture.”

Rationale: It is essential to validate eradication of infection with a follow-up culture that is negative. Doing Kegel exercises and wearing cotton underwear are both useful in prevention of future urinary tract infections, but they are not the best evaluation of effectiveness of teaching. Citrus juices will not increase acidity of urine and therefore are not recommended when a client has a UTI.

Question 94

The healthcare provider prescribes an indwelling urinary catheter for a client with urinary retention. Which intervention, along with strict aseptic technique, will decrease the risk of infection for this procedure?

A) Irrigating the catheter with sterile saline on a daily basis
B) Instructing the client to void around the catheter
C) Using an anesthetic lubricating gel during insertion
D) Inflating the balloon while the catheter is in the urethra

Answer 94

C) Using an anesthetic lubricating gel during insertion

Rationale: Unless contraindicated, the additional step of using an anesthetic lubricating gel promotes comfort and protects fragile urethral tissues from trauma, and therefore reduces risk for a catheter-associated UTI. Irrigating the catheter should not be done because it can introduce infection by allowing bacteria to enter the closed urinary drainage system. Although voiding around the catheter will decrease bladder spasms, it will not help reduce infection. The balloon is not inflated until the catheter is in the bladder, in order to prevent trauma to the urethra and therefore decrease the risk of infection.

Question 95

The nurse in an urgent care center assesses a 40-year-old adult client who presents with a fever of 101.2°F and complaints of painful urination. What should the nurse ask to elicit further data that indicate cystitis?

A) “Do you have any symptoms of menopause?”
B) “How long have you had a fever, and have you had chills with this?”
C) “Do you have any upper abdominal pain or cramping?”
D) “What color is your urine?”

Answer 95

D) “What color is your urine?”

Rationale: The classic symptoms of cystitis include dysuria or painful urination, urinary frequency and urgency, and bloody urine or hematuria. A 40-year-old client who presents with a fever and painful urination is not experiencing symptoms of menopause. Asking about fever and chills is not specific to suspected cystitis and does not elicit information related to urinary symptoms. Pain from cystitis is typically suprapubic, not upper abdominal

Question 96

The most common type of upper urinary tract infection that results from bacteria ascending to the kidney from the lower respiratory tract is

A) urethritis.
B) prostatitis.
C) pyelonephritis.
D) cystitis.

Answer 96

C) pyelonephritis.

Rationale: Pyelonephritis is inflammation of the renal pelvis and parenchyma. This is the most common upper urinary tract infection. Urethritis (inflammation of the urethra), cystitis, inflammation of the urinary bladder), and prostatitis (inflammation of the prostate gland) are all lower urinary tract infections.

Question 97

The most common source for bacteria that cause a urinary tract infection is

A) a catheter.
B) the mucous membranes of the perineal area.
C) the hands.
D) clothing such as underwear.

Answer 97

B) the mucous membranes of the perineal area.

Rationale: Pathogens usually enter the urinary tract by ascending from the mucous membranes of the perineal area into the lower urinary tract. The hands and clothing are potential sources of bacteria that cause a UTI, but they are not the most common. The presence of a catheter is a risk factor for development of a UTI, but the source of bacteria is still often the mucous membranes of the perineal tract or some other source, not the catheter itself.

Question 98

A mother brings in her 6-year-old daughter with signs and symptoms of fever, reduced voiding, uncontrolled voiding, and pain during urination. The daughter is diagnosed with a urinary tract infection. Which nursing outcome is most appropriate for this client?

A) The client’s bilirubin levels will remain within normal limits.
B) The client will report no episodes of enuresis.
C) The client will remain afebrile for 12 hours prior to discharge.
D) The client will void at least 300 mL of urine over 24 hr.
Answer: B

Answer 98

B) The client will report no episodes of enuresis.

Rationale: Children who are potty trained often develop enuresis, or involuntary passage of urine, during a urinary tract infection. An appropriate nursing outcome would be that the child would recover enough from the infection that the child no longer experiences enuresis. An outcome related to bilirubin levels would be more appropriate for a neonate, not a school-aged child. The client should be afebrile for 24 hours prior to discharge, not 12 hours. The client should be voiding 500 to 1000 mL of urine in 24 hours, depending on weight. Only voiding 300 mL of urine would be cause for concern.