Infection/Immune Flashcards
Which action should the nurse take to prevent infection and sepsis in a client with renal failure?
- Use clean technique when managing central lines.
- Provide oral hygiene every 8 hours.
- Inspect all body secretions.
- Record the client’s temperature once a day.
3
The nurse should carefully monitor clients with renal failure to prevent infection. Inspecting the color, odor, and appearance of all body secretions is a care priority for preventing infection and sepsis.
A 3-year-old client being treated for sepsis has begun bleeding from multiple sites. The nurse’s assessment reveals widespread petechiae and bleeding from the nose, mouth, and rectum. Laboratory results reveal a prolonged prothrombin time (PT), elevated d-dimer, and low platelet count. Which disorder should the nurse suspect?
- Von Willebrand disease.
- Disseminated intravascular coagulation.
- Hemophilia type A.
- Hypoplastic anemia.
2
- Decreased RBC count
* Low platelet count noted on CBC
* RBC fragments on the smear
* Prolonged prothrombin time (PT)
* Decreased fibrinogen level
* Elevated levels of fibrin degradation products (e.g., D-dimer)
When providing client education about the Zika virus, what should the nurse explain is the primary mode of transmission?
- Consuming contaminated food.
- Receiving a bite from an infected mosquito.
- Shaking hands with an infected person.
- Breathing in contaminated air.
2
The Zika virus is a type of flavivirus. It is transmitted through blood and body fluids, often through the bite of an infected mosquito.
A child is being treated with penicillin for bacterial pneumonitis. The nurse teaches the parent to monitor for signs of an allergic reaction to the new medication. Which sign is the parent most likely to observe?
- Skin rash.
- Nasal congestion.
- Diarrhea.
- Vomiting.
1
Adverse reactions to drugs are seen more often in the skin than in any other organ. Rashes are the most common manifestation of an allergic reaction to drugs in children.
A client is diagnosed with severe sepsis and admitted to the hospital. The nurse should anticipate which type of anti-infective medication to be initiated within one hour of the admission to treat which type of causative organism associated with sepsis?
- Parasitic.
- Retroviral virus.
- Anaerobic fungus.
- Gram-negative bacteria.
4
Gram-negative bacteria are the most common organism known to cause septic shock. If a sepsis diagnosis is suspected, then a broad spectrum antibiotic to treat against gram-negative bacteria is initiated within one hour of diagnosis, even before the causative organism is identified.
A client has been diagnosed with chlamydia. The nurse should anticipate that the client will need which medications?
- Cephalexin and Augmentin.
- Cefepime and azithromycin.
- Cefazolin and Augmentin.
- Ceftriaxone and azithromycin.
4
Treatments for sexually transmitted infections, such as chlamydia, are based upon guidelines provided by the Centers for Disease Control and Prevention (CDC). Ceftriaxone and azithromycin are used to treat uncomplicated chlamydia.
A mother of a two-month-old, asked the nurse what was the purpose of the administration the polio vaccine. The nurse should inform the mother that the polio vaccination series is supposed to help prevent which condition?
- Morbid obesity.
- Deteriorated mental state.
- Permanent paralysis.
- Metastatic cancer.
3
Poliomyelitis is a viral infection that affects the central nervous system. According to the World Health Organization, 1 in 200 cases of infections result in permanent paralysis. The recommended vaccination series for the inactivated poliovirus vaccine according to CDC for children is a total of four doses; one at 2 months; 4 months; between 6-8 months; and a booster given between 4-6 years old.
A pregnant client living in south Florida with concerns about the Zika virus asks the nurse “What could she do to minimize her chances of contracting the Zika virus?” Which prevention instructions could help the client from acquiring this virus?
- Practice safe sex methods while pregnant.
- Use insect repellent that contains DEET or Picaridin.
- Ensure to close eyes when spraying repellent on the face.
- If using sunscreen, spray the DEET repellent first, and then apply sunscreen.
- Once a week, empty and scrubbed any container that holds standing water from around the house.
1, 2, 5
In the U.S., the “Zika” virus is prevalent is south Florida and Brownsvile, Texas. The virus remains in an infected person’s blood for about a week. The virus has known to cause birth defects to fetuses of an infected mother. The most prevalent known birth defect is microcephaly. This virus can be spread through sexually contact. Pregnant mothers living in these areas of known prevalence should practice safe sex methods while pregnant or with anyone traveling from these areas. Insect repellents containing DEET or Picardin should be used. If planning to use sunscreen, applied sunscreen first, and then repellent spray applied afterwards. Do not spray repellent spray directly into the face, but spray into palms of hands and then apply to the face. Ensure to scrubbed and empty or remove any standing water containers from in and/or outside of the home.
A client who had been diagnosed positive for the human immunodeficiency virus (HIV) had developed oral thrush and their CD4+T-cell count dropped below less than 200cells/mm3 causing the healthcare provider to change their medical diagnosis to acquired immune deficiency syndrome (AIDS). After treatment of nystatin swish, the oral thrush cleared up and the client’s CD4+T-cell count returned back to above 200cells/mm3. Based on the client’s improvement of health status, the nurse suspects the healthcare provider to do what?
- Change the client’s medical diagnosis back to HIV+ status.
- Prescribe the client to continue the nystatin prophylactically.
- Make arrangements for the client to be transfer to Hospice Care.
- Continuation of the prescribed plan of care prior to the acquisition of thrush.
4
Once a client is diagnosed with HIV+ develops an opportunistic infection such as thrush and their CD4+T-cell drops below 200cells/mm3; their diagnosis is changed to AIDS. Once diagnosed with AIDS, even if the infection clears up and their CD4+T-cell returns back to be above 200cells/mm3, they keep the AIDS diagnosis. Client’s diagnosed with AIDS and who are compliant with their prescribed medication regime and don’t have any other medical issues may live for another 5-10 years or more.
When providing client education about the Zika virus, what should the nurse explain is the primary mode of transmission?
- Consuming contaminated food.
- Receiving a bite from an infected mosquito.
- Shaking hands with an infected person.
- Breathing in contaminated air.
2
The Zika virus is a type of flavivirus. It is transmitted through blood and body fluids, often through the bite of an infected mosquito.
A two year old client experiencing an anaphylactic reaction and respiratory distress with laryngeal spasms is being prepared for an endotracheal tube (ETT) placement. The healthcare provider has ordered 0.5mL of epinephrine 1:10,000 to be given STAT. The attempts to place an intravenous catheter were unsuccessful. What is another appropriate route to administer the epinephrine during this anaphylactic emergency?
- PO
- Interosseous
- IM
- SubQ
- Endotracheal tube
2, 3, 5
Ideally during an anaphylactic reaction intravenously administration of epinephrine would be the best route. In the event, an intravenous route is not available, epinephrine can be administered order of preference for faster absorption, tibial interosseous, followed by endotracheal tube after the dose has been diluted in 2.5mL of normal saline before being administered down the ETT. Intramuscularly would be your last option if no other access was available due to the slow absorption rate.
Which condition should the nurse identify as one that has been closely associated with acquired immune deficiency syndrome (AIDS)?
- Pneumonia
- Kaposi’s sarcoma.
- Diarrhea.
- Nausea.
2
Kaposi’s sarcoma is one of the various illnesses the CDC states must be present for a client to be diagnosed with AIDS.
The healthcare provider has prescribed lisinopril 5mg to be added to a client’s current medication plan of furosemide 60 mg PO BID to treat the client’s heart failure and edema. Which action is most important for the nurse do first related to the client’s new prescription for lisinopril?
- Reconcile the new prescription in the client’s electronic medical administration record.
- Review the client’s most recent serum potassium, magnesium, sodium and chloride levels.
- Check with the healthcare provider about reducing or discontinuing the dose of the diuretic before starting lisinopril.
- Assess the client’s blood pressure every four hours at the beginning of treatment and periodically when administered.
3
For clients already taking a diuretic, severe hypotension may occur with lisinopril, an antihypertensive. This results from hypovolemia associated with the effect of the diuretic. This may be prevented by either reducing the diuretic dose or discontinuing the diuretic for three days prior to beginning lisinopril therapy.
The nurse is working with the medical team to stabilize a client who is in shock. The nurse knows the physician will likely order a fluid challenge. Which action should the nurse take first?
- Establish two IV catheters.
- Begin warming IV fluids.
- Encourage the client to take fluids in orally.
- Obtain orthostatic blood pressures.
1
IV access is needed to provide fluid resuscitation to clients in shock. The nurse’s first action is to establish two IV catheters, one in a peripheral vein and one in a central vein.
The nurse is educating a client about the signs and symptoms of postpartum hemorrhage. Which information should the nurse provide?
- You may feel lightheaded.
- You may experience a headache.
- Your pulse may slow down.
- Your skin may feel hot or flushed.
1
Postpartum hemorrhage resulting in hypovolemic shock may result from persistent bleeding after birth. Lightheadedness is considered a mild symptom of hypovolemic shock.
