Chapter 11 Inflammation and Infection Management My Nursing Test Banks

Chapter 11 Inflammation and Infection Management

MULTIPLE CHOICE

1.The nurse, assessing a clients leukocyte level, determines the amount to be within normal limits. Which of the following would indicate a normal level of leukocytes in the clients blood?

1.

14 to 18 g/dL

2.

4.6 to 6.2 million/mm3

3.

4500 to 11,000 mm3

4.

50 to 60 percent

ANS: 3

The normal amount of leukocytes or white blood cells in the blood is 4500 to 11,000 mm3. The value of 14 to 18 g/dL is the normal hemoglobin level. The value of 4.6 to 6.2 million/mm3 represents the normal amount of red blood cells. The value of 50 to 60 percent represents a normal neutrophil level.

PTS: 1 DIF: Analyze REF: Leukocytes

2.A clients complete blood count reveals a large amount of phagocytic cells present. The nurse realizes that this type of cell is most likely:

1.

basophils.

2.

eosinophils.

3.

monocytes.

4.

neutrophils.

ANS: 4

Monocytes are phagocytic but in a smaller amount than neutrophils. Basophils are stimulated by allergens and eosinophils by parasites. Neutrophils are the chief phagocytic cells and are present in larger numbers as a response to early inflammation.

PTS: 1 DIF: Analyze REF: Leukocytes

3.According to assessment findings, the nurse determines that a client is experiencing an inflammatory process. Which of the following did the nurse assess in this client?

1.

Redness, swelling, heat, and pain

2.

Reduced urine output

3.

Thirst

4.

Elevated blood pressure and slow heart rate

ANS: 1

The symptoms of the inflammatory process are redness, swelling, heat, and pain. Reduced urine output, thirst, elevated blood pressure, and slow heart rate are not symptoms of the inflammatory process.

PTS: 1 DIF: Analyze REF: Signs of Inflammation

4.A client is diagnosed with a bacterial infection. Which of the following is an example of this type of infection?

1.

Malaria

2.

Gastroenteritis

3.

Urinary tract infection

4.

Typhus

ANS: 3

Urinary tract infections are caused by bacteria. Malaria and gastroenteritis are caused by protozoa. Typhus is caused by rickettsia.

PTS: 1 DIF: Understand REF: Table 11-3 Types of Agents Causing Disease

5.A client is diagnosed with gastroenteritis. The nurse realizes that this illness occurs from which type of disease-causing organism?

1.

Bacteria

2.

Fungi

3.

Protozoa

4.

Viruses

ANS: 3

Protozoa are single-cell parasitic organisms that form cysts or spores. Diseases caused by protozoa include malaria and gastroenteritis. Hepatitis A, B, and C are examples of a disease caused by a virus. Pneumonia and urinary tract infections are examples of diseases caused by bacteria. Ringworm is an example of a disease caused by fungi.

PTS: 1 DIF: Analyze REF: Table 11-3 Types of Agents Causing Disease

6.A client has been diagnosed with Rocky Mountain spotted fever. The causative organism for this disease process is:

1.

bacteria.

2.

helminth.

3.

mycoplasma.

4.

rickettsia.

ANS: 4

Rocky Mountain spotted fever is caused by the infectious organism rickettsia. Disease processes from bacteria, helminths, and mycoplasma include urinary tract infections, tapeworm infection, and pneumonia, respectively.

PTS: 1 DIF: Understand REF: Table 11-3 Types of Agents Causing Disease

7.Which of the following will the nurse most likely assess in a client diagnosed with asthma?

1.

Wheezing and anxiety

2.

Barking cough and increased blood pressure

3.

Bradycardia and restlessness

4.

Anemia and hypoxia

ANS: 1

Common symptoms in asthma include wheezing, anxiety, cough, shortness of breath, tachycardia, restlessness, increased blood pressure, and hypoxia. Barking cough, bradycardia, and anemia are not common symptoms of asthma.

PTS: 1 DIF: Analyze REF: Asthma: An Allergic Disease

8.The nurse would expect that a client diagnosed with arthritis will be prescribed which of the following medications?

1.

Albuterol

2.

Furosemide

3.

Ibuprofen

4.

Nortriptyline

ANS: 3

Nonsteroidal anti-inflammatory drugs (NSAIDs) and cortisol drugs are common treatments for arthritis. Albuterol relaxes bronchial smooth muscle. Furosemide is a loop diuretic, and nortriptyline is an antidepressant.

PTS: 1 DIF: Analyze REF: Arthritis

9.A client is being admitted to a health care facility. Which type of precautions will the nurse implement at this time?

1.

Airborne

2.

Contact

3.

Droplet

4.

Standard

ANS: 4

Standard precautions are actions used with all clients. Transmission-based precautions such as airborne, contact, and droplet are used when a client is known or suspected of having a communicable disease.

PTS:1DIF:ApplyREF:Standard Precautions

10.A client diagnosed with tuberculosis is scheduled for a chest x-ray to be completed in the radiology department. Which of the following devices should be utilized when transporting this client?

1.

Face shield with mask and gown

2.

N-95 mask

3.

Surgical mask

4.

Patient does not need to wear a device

ANS: 3

For a client diagnosed with tuberculosis, transport out of the room should only be done when absolutely necessary and the client should wear a surgical mask during transport. A face shield, gown, or N-95 mask are not needed to transport this client.

PTS:1DIF:ApplyREF:Airborne Precautions

11.The nurse is preparing to administer medications to a client diagnosed with varicella. Which of the following personal protective equipment should the nurse use when entering the clients room?

1.

Face shield with mask and gown

2.

Gloves and gown

3.

A high-efficiency particulate air filter mask

4.

Surgical mask

ANS: 3

A high-efficiency particulate air filter mask is required personal protective equipment for the care of a client with varicella. A mask may be worn for clients on droplet precautions, and the gown and gloves are for a client on contact precautions.

PTS:1DIF:ApplyREF:Airborne Precautions

12.A client is diagnosed with venous leg ulcers. The nurse would expect that these wounds will heal by which of the following types of intention?

1.

Primary

2.

Secondary

3.

Tertiary

4.

Quaternary

ANS: 2

Primary intention type of healing occurs in wounds that are clean, and have little loss of tissue. Secondary intention occurs when a wound heals by spread of granulation tissue from the base of a wound. Venous leg ulcers heal by secondary intention. In tertiary intention, the wound must be sutured through several layers of granulation tissue in order to bring closure. Quaternary is not a type of wound healing.

PTS: 1 DIF: Analyze REF: Types of Wound Healing

13.The nurse is using the Braden Scale to determine a clients risk for developing a pressure ulcer. Which of the following areas are assessed with this scale?

1.

Home environment

2.

Finances

3.

Medications

4.

Friction and shear

ANS: 4

The Braden Scale is used to assess a clients risk for developing a pressure ulcer. This scale assesses the areas of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Home environment, finances, and medications are not assessed with the use of this scale.

PTS: 1 DIF: Apply REF: Table 11-7 Elements in Braden Pressure Scale

MULTIPLE RESPONSE

1.The nurse is identifying nursing diagnoses for a client experiencing inflammation. Which of the following diagnoses would be appropriate for this client? (Select all that apply.)

1.

Risk for infection

2.

Thermoregulation: Ineffective

3.

Ineffective coping

4.

Pain: Acute

5.

Nutrition: Imbalanced, less than body requirements

6.

Anxiety

ANS: 1, 2, 4, 5

Nursing diagnoses appropriate for a client experiencing inflammation include risk for infection; thermoregulation: ineffective; pain: acute; and nutrition: imbalanced, less than body requirements. Ineffective coping and anxiety are not diagnoses appropriate for a client with an inflammation.

PTS: 1 DIF: Apply REF: Nursing Response: Inflammation

2.The nurse is determining the route of transmission for an infectious organism. Which of the following are types of transmission routes? (Select all that apply.)

1.

Ingestion

2.

Vector-borne

3.

Common vehicle

4.

Airborne

5.

Droplet

6.

Contact

ANS: 2, 3, 4, 5, 6

There are five types of transmission routes: 1) contact, 2) droplet, 3) airborne, 4) common vehicle, and 5) vector-borne. Ingestion is not a type of transmission route.

PTS: 1 DIF: Analyze REF: Infectious Disease Control

3.The nurse is determining when gloves should be worn when providing client care. Which of the following situations would necessitate the wearing of gloves? (Select all that apply.)

1.

In contact with blood

2.

In contact with mucous membranes

3.

Delivering a meal tray

4.

Providing medications

5.

Measuring urine output

6.

Suctioning oral secretions

ANS: 1, 2, 5, 6

Gloves should be worn when in contact with blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and nonintact skin. Gloves are not needed when delivering a meal try or providing medications.

PTS:1DIF:Analyze

REF: Table 11-4 Summary of the Updated Centers for Disease Control and Prevention Isolation Guidelines

4.The nurse is concerned that a client will experience delayed wound healing when which of the following is assessed? (Select all that apply.)

1.

Prescribed a beta-blocker medication

2.

Poor appetite

3.

Ambulating in the room several times a day

4.

Age 85

5.

Prescribed steroids

6.

Skin warm and dry

ANS: 1, 2, 4, 5

Risk factors for delayed wound healing include ischemia, medications such as beta-blockers, smoking, exposure to cold, repetitive injury, altered nutrition infection, anti-inflammatory steroids, and older age. Ambulating in the room several times a day may encourage wound healing. Skin warm and dry will not delay wound healing.

PTS:1DIF:Analyze

REF: Table 11-6 Risk Factors for Delayed Wound Healing

5.The nurse is planning care for a client with a chronic wound. Which of the following principles should be reflected in this clients care?

1.

Debridement

2.

Restrict fluids

3.

Provide moist environment

4.

Prevent further injury

5.

Maintain on bed rest

6.

Nutrition

ANS: 1, 3, 4, 6

The four principles of chronic wound management include debridement, provide moist environment, prevent further injury, and nutrition. Restricting fluids and maintaining on bed rest are not principles of chronic wound management.

PTS: 1 DIF: Apply REF: Interventions: Wound Management

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